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last updated: 2026-03-12_132215
file_name: _archive-combined-files_regulatory_954k.md
category: regulatory
subcategory: NA
gfile_url: **FLAGGED - TBD user-facing Google-hosted public file URL**
words:
tokens:
CONTENT
# _archive-combined-files_regulatory_954k (122 files, 954,035 tokens)
METADATA
last updated: 2026-03-10_105727
file_name: _archive-combined-files_fda-euas_45k.md
category: regulatory
subcategory: fda-euas
gfile_url: **FLAGGED - TBD user-facing Google-hosted public file URL**
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# _archive-combined-files_fda-euas_45k (2 files, 45,416 tokens)
# 725 _context-commentary_regulatory-fda-euas.md
METADATA
last updated: 2026-02-26 RT
file_name: _context-commentary_regulatory-fda-euas.md
category: regulatory
subcategory: fda-euas
words: 502
tokens: 725
CONTENT
## Context
An Emergency Use Authorization (EUA) is a mechanism through which the FDA can authorize the use of unapproved medical products — or unapproved uses of approved products — during a declared public health emergency. During the COVID-19 pandemic, EUAs were the primary pathway by which diagnostic tests reached the market. The EUA process differs from the standard FDA authorization pathways (510(k), PMA, De Novo) in several key respects:
- **Speed**: EUAs are designed for rapid review during emergencies, with timelines measured in weeks rather than months or years
- **Evidence threshold**: EUAs require the FDA to determine that the product "may be effective" based on available evidence, a lower bar than the "reasonable assurance of safety and effectiveness" required for standard authorizations
- **Temporary status**: EUAs are valid only for the duration of the declared emergency and can be revised or revoked
- **Conditions of authorization**: EUA-holders must meet ongoing conditions, including labeling requirements, adverse event reporting, and sometimes performance monitoring
Each EUA includes an Instructions for Use (IFU) document that specifies the authorized specimen types, testing procedures, performance characteristics, interpretation criteria, and conditions of authorization. Some EUAs also include an EUA Summary providing the FDA's review of the submission data.
This subcategory contains a selection of EUA documents that were relevant to FloodLAMP's work — not a comprehensive collection of COVID-19 diagnostic EUAs (of which there were hundreds). The files here were included because FloodLAMP reviewed them during development, because they represent comparable technologies (particularly LAMP-based or isothermal assays), or because they illustrate specific aspects of the EUA landscape. The collection includes IFUs and EUA summaries from tests spanning RT-PCR, isothermal amplification, CRISPR-based detection, and home collection kits.
Two files merit specific mention:
- **Detectachem MobileDetect-BIO BCC19 Test Kit** — This was the EUA most similar to what FloodLAMP was developing: a colorimetric LAMP-based SARS-CoV-2 test designed for point-of-care use. FloodLAMP's assays appeared to achieve significantly higher sensitivity and overall performance than the Detectachem test based on the published performance data.
- **SalivaDirect** (documented primarily in the open-euas subcategory) — Notable as the first and essentially only "open" EUA, meaning the protocol was made freely available for other labs to adopt. The open-euas subcategory covers this in detail.
The CDC's own RT-PCR Diagnostic Panel IFU is also included as a reference document — it was the original FDA-authorized COVID-19 test in the United States and provides a baseline example of an EUA IFU at the highest complexity level.
For broader analysis and commentary on the FDA's EUA process during the pandemic, see the reg-articles-misc subcategory, which includes articles and reports examining how the process functioned. For FloodLAMP's own FDA submissions and correspondence, see the fl-fda-submissions and fl-fda-correspondence subcategories.
Also see the following file, which is an AI generated report sourcing retrospectives on FDA EUAs during the COVID-19 pandemic.
regulatory/reg-articles-misc/_AI_fda-eua-covid-retrospectives_post2022_report.md
## Commentary
See other regulatory subcategories for commentary. FloodLAMP's assessments and lessons learned regarding the EUA process are addressed there where they can be grounded in specific documents and experiences.
# 44,009 2020-12-01_CDC EUA IFU - CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel.md
METADATA
last updated: 2026-03-03 BA fixed html and other glaring issues
file_name: 2020-12-01_CDC EUA IFU - CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel.md
file_date: 2020-12-01
title: CDC EUA IFU - CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel
category: regulatory
subcategory: fda-euas
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license: Public Domain
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notes:
summary_short: The CDC “2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel” EUA Instructions for Use detail how CLIA high-complexity laboratories perform, analyze, and report the CDC N1/N2/RP RT-PCR assay for SARS-CoV-2 across authorized respiratory specimen types. It provides end-to-end workflows for reagent prep, nucleic acid extraction options, ABI 7500 Fast Dx run setup, controls/interpretation rules, and performance characteristics (including LoD and specificity). It also includes appendices for heat-treatment as an extraction alternative and for pooled testing (up to 4 specimens) with guidance on implementation and ongoing monitoring.
CONTENT
***INTERNAL TITLE:*** CDC 2019-Novel Coronavirus (2019-nCoV)
Real-Time RT-PCR Diagnostic Panel
**For Emergency Use Only**
**Instructions for Use**
**Catalog \# 2019-nCoVEUA-01**
**1000 reactions**
For *In-vitro* Diagnostic (IVD) Use
Rx Only
Centers for Disease Control and Prevention
Division of Viral Diseases
1600 Clifton Rd NE
Atlanta GA 30329
CDC-006-00019, Revision: 06 CDC/DDID/NCIRD/ Division of Viral Diseases Effective: 12/01/2020
## Table of Contents
Intended Use ............................................................................................... 3
Summary and Explanation............................................................................. 4
Principles of the Procedure ........................................................................... 4
Materials Required (Provided)....................................................................... 6
Materials Required (But Not Provided) ........................................................... 7
Warnings and Precautions ........................................................................... 10
Reagent Storage, Handling, and Stability...................................................... 12
Specimen Collection, Handling, and Storage................................................. 12
Specimen Referral to CDC ........................................................................... 13
Reagent and Controls Preparation................................................................ 13
General Preparation ................................................................................... 14
Nucleic Acid Extraction................................................................................ 14
Assay Set Up............................................................................................... 16
Create a Run Template on the Applied Biosystems 7500 Fast Dx Real-time PCR
Instrument (Required if no template exists).................................................. 21
Defining the Instrument Settings .................................................................. 27
Running a Test............................................................................................ 29
Interpretation of Results and Reporting ........................................................ 35
2019-nCoV rRT-PCR Diagnostic Panel Results Interpretation Guide ................ 38
Quality Control............................................................................................ 39
Limitations .................................................................................................. 39
Conditions of Authorization for the Laboratory............................................. 40
Performance Characteristics........................................................................ 42
Disposal...................................................................................................... 52
References .................................................................................................. 52
Revision History .......................................................................................... 53
Contact Information, Ordering, and Product Support .................................... 53
Appendix A: Heat Treatment Alternative to Extraction .................................. 54
Appendix B: Pooled Specimen Preparation and Processing ........................... 58
Appendix C: Implementation and Monitoring of Pooled Specimen Testing..... 67
## Intended Use
The CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel is a real-time RT-PCR test intended for the qualitative detection of nucleic acid from SARS-CoV-2 in upper and lower respiratory specimens (such as nasopharyngeal or oropharyngeal swabs, sputum, lower respiratory tract aspirates, bronchoalveolar lavage, and nasopharyngeal wash/aspirate or nasal aspirate) collected from individuals suspected of COVID-19 by their healthcare provider(1).
This test is also for the qualitative detection of nucleic acid from the SARS-CoV-2 in pooled samples containing up to four of the individual upper respiratory swab specimens (nasopharyngeal (NP), oropharyngeal (OP), NP/OP combined, or nasal swabs) that were collected using individual vials containing transport media from individuals suspected of COVID-19 by their healthcare provider. Negative results from pooled testing should not be treated as definitive. If a patient’s clinical signs and symptoms are inconsistent with a negative result or results are necessary for patient management, then the patient should be considered for individual testing. Specimens included in pools with a positive, inconclusive, or invalid result must be tested individually prior to reporting a result. Specimens with low viral loads may not be detected in sample pools due to the decreased sensitivity of pooled testing.
Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, that meet the requirements to perform high complexity tests.
Results are for the identification of SARS-CoV-2 RNA. SARS-CoV-2 RNA is generally detectable in upper and lower respiratory specimens during infection. Positive results are indicative of active infection with SARS-CoV-2 but do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for treatment or other patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
Testing with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel is intended for use by trained laboratory personnel who are proficient in performing real-time RT-PCR assays. The CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel is only for use under a Food and Drug Administration’s Emergency Use Authorization.
(1) For this EUA, a healthcare provider includes, but is not limited to, physicians, nurses, pharmacists, technologists, laboratory directors, epidemiologists, or any other practitioners or allied health professionals.
## Summary and Explanation
An outbreak of pneumonia of unknown etiology in Wuhan City, Hubei Province, China was initially reported to WHO on December 31, 2019. Chinese authorities identified a novel coronavirus (2019-nCoV, also referred to as SARS-CoV-2), which has resulted in millions of confirmed human infections globally. Cases of asymptomatic infection, mild illness, severe illness, and deaths have been reported.
The CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel is a molecular *in vitro* diagnostic test that aids in the detection and diagnosis of SARS-CoV-2 infection and is based on widely used nucleic acid amplification technology. The product contains oligonucleotide primers and dual-labeled hydrolysis probes (TaqMan®) and control material used in rRT-PCR for the *in vitro* qualitative detection of 2019- nCoV RNA in respiratory specimens.
The term “qualified laboratories” refers to laboratories in which all users, analysts, and any person reporting results from use of this device should be trained to perform and interpret the results from this procedure by a competent instructor prior to use.
## Principles of the Procedure
The oligonucleotide primers and probes for detection of 2019-nCoV were selected from regions of the virus nucleocapsid (N) gene. The panel is designed for specific detection of SARS-CoV-2 (two primer/probe sets). An additional primer/probe set to detect the human RNase P gene (RP) in control samples and clinical specimens is also included in the panel.
RNA isolated and purified from upper and lower respiratory specimens is reverse transcribed to cDNA and subsequently amplified in the Applied Biosystems 7500 Fast Dx Real-Time PCR Instrument with SDS version 1.4 software. In the process, the probe anneals to a specific target sequence located between the forward and reverse primers. During the extension phase of the PCR cycle, the 5’ nuclease activity of Taq polymerase degrades the probe, causing the reporter dye to separate from the quencher dye, generating a fluorescent signal. With each cycle, additional reporter dye molecules are cleaved from their respective probes, increasing the fluorescence intensity. Fluorescence intensity is monitored at each PCR cycle by Applied Biosystems 7500 Fast Dx Real-Time PCR System with SDS version 1.4 software.
Detection of viral RNA not only aids in the diagnosis of illness but also provides epidemiological and surveillance information.
### Summary of Preparation and Testing Process
```mermaid
flowchart TD
subgraph receipt["Upon receipt of rRT-PCR Panel reagents"]
A["Resuspend primer/probe mix,
aliquot and store at ≤ −20°C"]
B["Resuspend and aliquot nCoVPC,
store at −70°C"]
end
subgraph sample["Upon obtaining sample"]
C["Extract sample RNA
and HSC RNA"]
D["Prepare master mix
(15 µL)"]
E["Prepare rRT-PCR
plate (5 µL RNA)"]
F["Run assay on
ABI 7500Fast Dx"]
G["Analyze data"]
H["Report results"]
end
A --> C
B --> C
C --> D --> E --> F --> G --> H
```
## Materials Required (Provided)
Note: CDC will maintain on its website a list of commercially available lots of primer and probe sets and/or positive control materials that are acceptable alternatives to the CDC primer and probe set and/or positive control included in the Diagnostic Panel. Only material distributed through the CDC International Reagent Resource and specific lots of material posted to the CDC website are acceptable for use with this assay under CDC’s Emergency Use Authorization.
This list of acceptable alternative lots of primer and probe materials and/or positive control materials will be available at: https://www.cdc.gov/coronavirus/2019-nCoV/lab/virus-requests.html
### Primers and Probes:
**Catalog \#2019-nCoVEUA-01 Diagnostic Panel Box \#1:**
| *Reagent Label* | *Part #* | *Description* | *Quantity /Tube* | *Reactions /Tube* |
| --------------- | ----------------- | --------------------------------------- | ---------------- | ----------------- |
| 2019-nCoV_N1 | RV202001 RV202015 | 2019-nCoV_N1 Combined Primer/Probe Mix | 22.5 nmol | 1000 |
| 2019-nCoV_N2 | RV202002 RV202016 | 2019-nCoV_N2 Combined Primer/Probe Mix | 22.5 nmol | 1000 |
| RP | RV202004 RV202018 | Human RNase P Combined Primer/Probe Mix | 22.5 nmol | 1000 |
||
### Positive Control (either of the following products are acceptable):
#### Catalog \#2019-nCoVEUA-01 Diagnostic Panel Box \#2:
| *Reagent Label* | *Part #* | *Description* | *Quantity* | *Notes* |
| -------------- | -------- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------- | ---------------------------------- |
| nCoVPC | RV202005 | 2019-nCoV Positive Control (nCoVPC) for use as a positive control with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel procedure. The nCoVPC contains noninfectious positive control material supplied in a dried state and must be resuspended before use. nCoVPC consists of *in vitro* transcribed RNA. nCoVPC will yield a positive result with each assay in the 2019-nCoV Real-Time RT-PCR Diagnostic Panel including RP. | 4 tubes | Provides (800) 5 µL test reactions |
||
#### Catalog \#VTC-04 CDC 2019-nCoV Positive Control (nCoVPC)
| *Reagent Label* | *Part #* | *Description* | *Quantity* | *Notes* |
| -------------- | -------- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------- | ---------------------------------- |
| nCoVPC | RV202005 | 2019-nCoV Positive Control (nCoVPC) for use as a positive control with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel procedure. The nCoVPC contains noninfectious positive control material supplied in a dried state and must be resuspended before use. nCoVPC consists of *in vitro* transcribed RNA. nCoVPC will yield a positive result with each assay in the 2019-nCoV Real-Time RT-PCR Diagnostic Panel including RP. | 4 tubes | Provides (800) 5 µL test reactions |
||
## Materials Required (But Not Provided)
### Human Specimen Control (HSC)
| Description | Quantity | CDC Catalog No. |
| -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------- | --------------- |
| Manufactured by CDC. For use as a nucleic acid extraction procedural control to demonstrate successful recovery of nucleic acid as well as extraction reagent integrity. The HSC consists of noninfectious (beta Propiolactone treated) cultured human cell material supplied as a liquid suspended in 0.01 M PBS at pH 7.2-7.4. | 10 vials x 500 µL | KT0189 |
||
Acceptable alternatives to HSC:
• Negative human specimen material: Laboratories may prepare a volume of human specimen material (e.g., human sera or pooled leftover negative respiratory specimens) to extract and run alongside clinical samples as an extraction control. This material should be prepared in sufficient volume to be used across multiple runs. Material should be tested prior to use as the extraction control to ensure it generates the expected results for the HSC listed in these instructions for use.
• Contrived human specimen material: Laboratories may prepare contrived human specimen materials by suspending any human cell line (e.g., A549, Hela, or 293) in PBS. This material should be prepared in sufficient volume to be used across multiple runs. Material should be tested prior to use as the extraction control to ensure it generates the expected results for the HSC listed in these instructions for use.
CDC will maintain on its website a list of commercially alternative extraction controls, if applicable, that are acceptable for use with this assay under CDC’s Emergency Use Authorization, at: https://www.cdc.gov/coronavirus/2019-nCoV/lab/virus-requests.html
### rRT-PCR Enzyme Mastermix Options
| Reagent | Quantity | Catalog No. |
| --------------------------------------------------- | ----------------------------- | ----------- |
| Quantabio qScript XLT One-Step RT-qPCR ToughMix | 100 x 20 μL rxns (1 x 1 mL) | 95132-100 |
| Quantabio qScript XLT One-Step RT-qPCR ToughMix | 2000 x 20 μL rxns (1 x 20 mL) | 95132-02K |
| Quantabio qScript XLT One-Step RT-qPCR ToughMix | 500 x 20 μL rxns (5 x 1 mL) | 95132-500 |
| Quantabio UltraPlex 1-Step ToughMix (4X) | 100 x 20 µL rxns (500 µL) | 95166-100 |
| Quantabio UltraPlex 1-Step ToughMix (4X) | 500 x 20 μL rxns (5 x 500 µL) | 95166-500 |
| Quantabio UltraPlex 1-Step ToughMix (4X) | 1000 x 20 μL rxns (1 x 5 mL) | 95166-01K |
| Promega GoTaq® Probe 1- Step RT-qPCR System | 200 x 20 μL rxns (2 mL) | A6120 |
| Promega GoTaq® Probe 1- Step RT-qPCR System | 1250 x 20 μL rxns (12.5 mL) | A6121 |
| Thermofisher TaqPath™ 1-Step RT-qPCR Master Mix, CG | 1000 reactions | A15299 |
| Thermofisher TaqPath™ 1-Step RT-qPCR Master Mix, CG | 2000 reactions | A15300 |
||
### RNA Extraction Options
For each of the kits listed below, CDC has confirmed that the external lysis buffer is effective for inactivation of SARS-CoV-2.
| Instrument/Manufacturer | Extraction Kit | Catalog No. |
| ------------------------------- | ------------------------------------------------ | ------------------------------------------------------------------------------------------------------------------------- |
| QIAGEN | (2)QIAmp DSP Viral RNA Mini Kit | 50 extractions (61904) |
| QIAGEN | (2)QIAamp Viral RNA Mini Kit | 50 extractions (52904) 250 extractions (52906) |
| QIAGEN EZ1 Advanced XL | (2)EZ1 DSP Virus Kit | 48 extractions (62724) Buffer AVL (19073 or 19089) EZ1 Advanced XL DSP Virus Card (9018703) |
| QIAGEN EZ1 Advanced XL | (2)EZ1 Virus Mini Kit v2.0 | 48 extractions (955134) Buffer AVL (19073 or 19089) EZ1 Advanced XL Virus Card v2.0 (9018708) |
| Roche MagNA Pure 24 | (2)MagNA Pure 24 Total NA Isolation Kit | 96 extractions (07 658 036 001) External Lysis Buffer (06 374 913 001, 12 239 469 103, 03 246 779 001 or 03 246 752 001) |
| Roche MagNA Pure 96 | (2)DNA and Viral NA Small Volume Kit | 576 extractions (06 543 588 001) External Lysis Buffer (06 374 913 001, 12 239 469 103, 03 246 779 001 or 03 246 752 001) |
| (1)Roche MagNA Pure LC | (2)Total Nucleic Acid Kit | 192 extractions (03 038 505 001) |
| (1)Roche MagNA Pure Compact | (2)Nucleic Acid Isolation Kit I | 32 extractions (03 730 964 001) |
| Promega Maxwell® RSC 48 and Maxwell® CSC 48 | (3)Maxwell® RSC Viral Total Nucleic Acid Purification Kit | 48 extractions (AS1330) 144 extractions (ASB1330) |
| (1)QIAGEN QIAcube | (2)QIAmp DSP Viral RNA Mini Kit | 50 extractions (61904) |
| (1)QIAGEN QIAcube | (2)QIAamp Viral RNA Mini Kit | 50 extractions (52904) 250 extractions (52906) |
| (1, 3)bioMérieux NucliSENS® easyMAG® and (1, 3)bioMérieux EMAG® (Automated magnetic extraction reagents sold separately. Both instruments use the same reagents and disposables, with the exception of tips.) | | EasyMAG® Magnetic Silica (280133) EasyMAG® Lysis Buffer (280134) EasyMAG® Lysis Buffer, 2 mL (200292) EasyMAG® Wash Buffers 1,2, and 3 (280130, 280131, 280132) EasyMAG® Disposables (280135) Biohit Pipette Tips (easyMAG® only) (280146) EMAG®1000μL Tips (418922) |
||
(1)Equivalence and performance of these extraction platforms for extraction of viral RNA were demonstrated with the CDC Human Influenza Virus Real-Time RT-PCR Diagnostic Panel (K190302). Performance characteristics of these extraction platforms with 2019-nCoV (SARS CoV-2) have not been demonstrated.
(2) CDC has confirmed that the external lysis buffer used with this extraction method is effective for inactivation of SARS CoV-2.
(3) CDC has compared the concentration of inactivating agent in the lysis buffer used with this extraction method and has determined the concentration to be within the range of concentrations found effective in inactivation of SARS-CoV-2.
Alternative to Extraction:
If a laboratory cannot access adequate extraction reagents to support testing demand due to the global shortage of reagents, CDC has evaluated a heat treatment procedure for upper respiratory specimens using the Quantabio UltraPlex 1-Step ToughMix (4X), CG. Though performance was comparable, this method has been evaluated with a limited number of clinical specimens and a potential reduction in sensitivity due to carryover of inhibitory substances or RNA degradation cannot be ruled out. It should only be used when a jurisdiction determines that the testing need is great enough to justify the risk of a potential loss of sensitivity. Heat-treated specimens generating inconclusive or invalid results should be extracted with an authorized extraction method prior to retesting. Details and procedure for the heat treatment alternative to extraction may be found in Appendix A.
## Equipment and Consumables Required (But Not Provided)
- Vortex mixer
- Microcentrifuge
- Micropipettes (2 or 10 μL, 200 μL and 1000 μL)
- Multichannel micropipettes (5-50 μL)
- Racks for 1.5 mL microcentrifuge tubes
- 2 x 96-well -20°C cold blocks
- 7500 Fast Dx Real-Time PCR Systems with SDS 1.4 software (Applied Biosystems; catalog \#4406985 or \#4406984)
- Extraction systems (instruments): QIAGEN EZ1 Advanced XL, QIAGEN QIAcube, Roche MagNA Pure 24, Roche MagNA Pure 96, Promega Maxwell® RSC 48, Roche MagNA Pure LC, Roche MagNA Pure Compact, bioMérieux easyMAG, and bioMérieux EMAG
- Molecular grade water, nuclease-free
- 10% bleach (1:10 dilution of commercial 5.25-6.0% hypochlorite bleach)
- DNA*Zap*(TM) (Ambion, cat. \#AM9890) or equivalent
- RNase AWAY™ (Fisher Scientific; cat. \#21-236-21) or equivalent
- Disposable powder-free gloves and surgical gowns
- Aerosol barrier pipette tips
- 1.5 mL microcentrifuge tubes (DNase/RNase free)
- 0.2 mL PCR reaction plates (Applied Biosystems; catalog \#4346906 or \#4366932)
- MicroAmp Optical 8-cap Strips (Applied Biosystems; catalog \#4323032)
Qualifying Alternative Components:
If a laboratory modifies this test by using unauthorized, alternative components (e.g., extraction methods or PCR instruments), the modified test is not authorized under this EUA. FDA’s Policy for Diagnostic Tests for Coronavirus Disease-2019 during the Public Health Emergency, updated May 11, 2020, does not change this. As part of this policy, FDA does not intend to object when a laboratory modifies an EUA-authorized test, which could include using unauthorized components, without obtaining an EUA or EUA amendment, where the modified test is validated using a bridging study to the EUA-authorized test.
## Warnings and Precautions
- For *in vitro* diagnostic use (IVD).
- This test has not been FDA cleared or approved; this test has been authorized by FDA under an EUA for use by laboratories certified under CLIA, 42 U.S.C. § 263a, that meet requirements to perform high complexity tests.
- This test has been authorized only for the detection of nucleic acid from SARS CoV-2, not for any other viruses or pathogens.
- This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostic tests for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
- Follow standard precautions. All patient specimens and positive controls should be considered potentially infectious and handled accordingly.
- Do not eat, drink, smoke, apply cosmetics or handle contact lenses in areas where reagents and human specimens are handled.
- Handle all specimens as if infectious using safe laboratory procedures. Refer to Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with 2019- nCoV https://www.cdc.gov/coronavirus/2019-nCoV/lab-biosafety-guidelines.html.
- Specimen processing should be performed in accordance with national biological safety regulations.
- If infection with 2019-nCoV is suspected based on current clinical and epidemiological screening criteria recommended by public health authorities, specimens should be collected with appropriate infection control precautions.
- Performance characteristics have been determined with human upper respiratory specimens and lower respiratory tract specimens from human patients with signs and symptoms of respiratory infection.
- Perform all manipulations of live virus samples within a Class II (or higher) biological safety cabinet (BSC).
- Use personal protective equipment such as (but not limited to) gloves, eye protection, and lab coats when handling kit reagents while performing this assay and handling materials including samples, reagents, pipettes, and other equipment and reagents.
- Amplification technologies such as PCR are sensitive to accidental introduction of PCR product from previous amplifications reactions. Incorrect results could occur if either the clinical specimen or the real-time reagents used in the amplification step become contaminated by accidental introduction of amplification product (amplicon). Workflow in the laboratory should proceed in a unidirectional manner.
- Maintain separate areas for assay setup and handling of nucleic acids.
- Always check the expiration date prior to use. Do not use expired reagents. Do not substitute or mix reagents from different kit lots or from other manufacturers.
- Change aerosol barrier pipette tips between all manual liquid transfers.
- During preparation of samples, compliance with good laboratory techniques is essential to minimize the risk of cross-contamination between samples and the inadvertent introduction of nucleases into samples during and after the extraction procedure. Proper aseptic technique should always be used when working with nucleic acids.
- Maintain separate, dedicated equipment (e.g., pipettes, microcentrifuges) and supplies (e.g., microcentrifuge tubes, pipette tips) for assay setup and handling of extracted nucleic acids.
- Wear a clean lab coat and powder-free disposable gloves (not previously worn) when setting up assays.
- Change gloves between samples and whenever contamination is suspected.
- Keep reagent and reaction tubes capped or covered as much as possible.
- Primers, probes (including aliquots), and enzyme master mix must be thawed and maintained on a cold block at all times during preparation and use.
- Work surfaces, pipettes, and centrifuges should be cleaned and decontaminated with cleaning products such as 10% bleach, DNA*Zap*™, or RNase AWAY(™) to minimize risk of nucleic acid contamination. Residual bleach should be removed using 70% ethanol.
- RNA should be maintained on a cold block or on ice during preparation and use to ensure stability.
- Dispose of unused kit reagents and human specimens according to local, state, and federal regulations.
## Reagent Storage, Handling, and Stability
- Store all dried primers and probes and the positive control, nCoVPC, at 2-8°C until re-hydrated for use. Store liquid HSC control materials at ≤ -20°C.
Note: Storage information is for CDC primer and probe materials obtained through the International Reagent Resource. If using commercial primers and probes, please refer to the manufacturer’s instructions for storage and handling.
- Always check the expiration date prior to use. Do not use expired reagents.
- Protect fluorogenic probes from light.
- Primers, probes (including aliquots), and enzyme master mix must be thawed and kept on a cold block at all times during preparation and use.
- Do not refreeze probes.
- Controls and aliquots of controls must be thawed and kept on ice at all times during preparation and use.
## Specimen Collection, Handling, and Storage
Inadequate or inappropriate specimen collection, storage, and transport are likely to yield false test results. Training in specimen collection is highly recommended due to the importance of specimen quality. CLSI MM13-A may be referenced as an appropriate resource.
- Collecting the Specimen
- Refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID 19 https://www.cdc.gov/coronavirus/2019-nCoV/guidelines-clinical-specimens.html
- Follow specimen collection device manufacturer instructions for proper collection methods.
- Swab specimens should be collected using only swabs with a synthetic tip, such as nylon or Dacron(®), and an aluminum or plastic shaft. Calcium alginate swabs are unacceptable and cotton swabs with wooden shafts are not recommended. Place swabs immediately into sterile tubes containing 1-3 mL of appropriate transport media, such as viral transport media (VTM).
- Transporting Specimens
- Specimens must be packaged, shipped, and transported according to the current edition of the International Air Transport Association (IATA) Dangerous Goods Regulation. Follow shipping regulations for UN 3373 Biological Substance, Category B when sending potential 2019-nCoV specimens. Store specimens at 2-8°C and ship overnight to CDC on ice pack. If a specimen is frozen at -70°C or lower, ship overnight to CDC on dry ice.
- Storing Specimens
- Specimens can be stored at 2-8°C for up to 72 hours after collection.
- If a delay in extraction is expected, store specimens at -70°C or lower.
- Extracted nucleic acid should be stored at -70°C or lower.
## Specimen Referral to CDC
For state and local public health laboratories:
- Ship all specimens overnight to CDC.
- Ship frozen specimens on dry ice and non-frozen specimens on cold packs.
- Refer to the International Air Transport Association (IATA - www.iata.org) for requirements for shipment of human or potentially infectious biological specimens. Follow shipping regulations for UN 3373 Biological Substance, Category B when sending potential 2019-nCoV specimens.
- Prior to shipping, notify CDC Division of Viral Diseases (see contact information below) that you are sending specimens.
- Send all samples to the following recipient:
Centers for Disease Control and Prevention c/o STATT
Attention: Unit 66 1600 Clifton Rd., Atlanta, GA 30329-4027
Phone: (404) 639-3931
**The emergency contact number for CDC Emergency Operations Center (EOC) is** **770-488-7100.**
All other laboratories that are CLIA certified and meet requirements to perform high complexity testing:
- Please notify your state and/or local public health laboratory for specimen referral and confirmatory testing guidance.
## Reagent and Controls Preparation
NOTE: Storage information is for materials obtained through the CDC International Reagent Resource.
If using commercial products for testing, please refer to the manufacturer’s instructions for storage, handling, and preparation instructions.
### Primer and Probe Preparation:
1\) Upon receipt, store dried primers and probes at 2-8°C.
2\) Precautions: These reagents should only be handled in a clean area and stored at appropriate temperatures (see below) in the dark. Freeze-thaw cycles should be avoided. Maintain cold when thawed.
3\) Using aseptic technique, suspend dried reagents in 1.5 mL of nuclease-free water and allow to rehydrate for 15 min at room temperature in the dark.
4\) Mix gently and aliquot primers/probe in 300 μL volumes into 5 pre-labeled tubes. Store a single, working aliquot of primers/probes at 2-8°C in the dark. Store remaining aliquots at ≤ -20°C in a non-frost-free freezer. Do not refreeze thawed aliquots (stable for up to 4 months at 2-8°C).
### 2019-nCoV Positive Control (nCoVPC) Preparation:
1\) Precautions: This reagent should be handled with caution in a dedicated nucleic acid handling area to prevent possible contamination. Freeze-thaw cycles should be avoided. Maintain on ice when thawed.
2\) Resuspend dried reagent in each tube in 1 mL of nuclease-free water to achieve the proper concentration. Make single use aliquots (approximately 30 μL) and store at ≤ -70°C.
3\) Thaw a single aliquot of diluted positive control for each experiment and hold on ice until adding to plate. Discard any unused portion of the aliquot.
### Human Specimen Control (HSC) (not provided):
1\) Human Specimen Control (HSC) or one of the listed acceptable alternative extraction controls must be extracted and processed with each specimen extraction run.
2\) Refer to the Human Specimen Control (HSC) package insert for instructions for use.
### No Template Control (NTC) (not provided):
1\) Sterile, nuclease-free water
2\) Aliquot in small volumes
3\) Used to check for contamination during specimen extraction and/or plate set-up
## General Preparation
### Equipment Preparation
Clean and decontaminate all work surfaces, pipettes, centrifuges, and other equipment prior to use.
Decontamination agents should be used including 10% bleach, 70% ethanol, and DNA*zap*™, or RNase AWAY(™) to minimize the risk of nucleic acid contamination.
### Nucleic Acid Extraction
**NOTE: The extraction instructions below are for use when testing individual specimens ONLY. When pooling specimens, refer to Appendix B for modified extraction instructions.**
Performance of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel is dependent upon the amount and quality of template RNA purified from human specimens. The following commercially available RNA extraction kits and procedures have been qualified and validated for recovery and purity of RNA for use with the panel:
### Qiagen QIAamp®DSP Viral RNA Mini Kit or QIAamp®Viral RNA Mini Kit
Recommendation(s): Utilize 100 μL of sample and elute with 100 μL of buffer or utilize 140 μL of sample and elute with 140 μL of buffer.
### Qiagen EZ1 Advanced XL
Kit: Qiagen EZ1 DSP Virus Kit and Buffer AVL (supplied separately) for offboard lysis
Card: EZ1 Advanced XL DSP Virus Card
Recommendation(s): Add 120 μL of sample to 280 μL of pre-aliquoted Buffer AVL (total input sample volume is 400 μL). Proceed with the extraction on the EZ1 Advanced XL. Elution volume is 120 μL.
Kit: Qiagen EZ1 Virus Mini Kit v2.0 and Buffer AVL (supplied separately) for offboard lysis
Card: EZ1 Advanced XL Virus Card v2.0
Recommendation(s): Add 120 μL of sample to 280 μL of pre-aliquoted Buffer AVL (total input sample volume is 400 μL). Proceed with the extraction on the EZ1 Advanced XL. Elution volume is 120 μL.
### Roche MagNA Pure 96
Kit: Roche MagNA Pure 96 DNA and Viral NA Small Volume Kit
Protocol: Viral NA Plasma Ext LysExt Lys SV 4.0 Protocol or Viral NA Plasma Ext Lys SV Protocol
Recommendation(s): Add 100 μL of sample to 350 μL of pre-aliquoted External Lysis Buffer (supplied separately) (total input sample volume is 450 μL). Proceed with the extraction on the MagNA Pure 96.
(**Internal Control = None)**. Elution volume is 100 μL.
### Roche MagNA Pure 24
Kit: Roche MagNA Pure 24 Total NA Isolation Kit
Protocol: Pathogen 1000 2.0 Protocol
Recommendation(s): Add 100 µL of sample to 400 µL of pre-aliquoted External Lysis Buffer (supplied separately) (total input sample volume is 500 µL). Proceed with the extraction on the MagNA Pure 24.
(**Internal Control = None**). Elution volume is 100 µL.
### Promega Maxwell® RSC 48 and Maxwell® CSC 48
Kit: Promega Maxwell® Viral Total Nucleic Acid Purification Kit
Protocol: Viral Total Nucleic Acid
Recommendation(s): Add 120 µL of sample to 330 µL of pre-aliquoted External Lysis Buffer (300 µL Lysis Buffer plus 30 µL Proteinase K; supplied within the kit) (total input volume is 450 µL). Proceed with the extraction on the Maxwell® RSC 48. Elution volume is 75 µL.
Equivalence and performance of the following extraction platforms were demonstrated with the CDC Human Influenza Virus Real-Time RT-PCR Diagnostic Panel (K190302) and based on those data are acceptable for use with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
### QIAGEN QIAcube
Kit: QIAGEN QIAamp® DSP Viral RNA Mini Kit or QIAamp® Viral RNA Mini Kit
Recommendations: Utilize 140 μL of sample and elute with 100 μL of buffer.
### Roche MagNA Pure LC
Kit: Roche MagNA Pure Total Nucleic Acid Kit
Protocol: Total NA External\_lysis
Recommendation(s): Add 100 μL of sample to 300 μL of pre-aliquoted TNA isolation kit lysis buffer (total input sample volume is 400 μL). Elution volume is 100 μL.
### Roche MagNA Pure Compact
Kit: Roche MagNA Pure Nucleic Acid Isolation Kit I
Protocol: Total\_NA\_Plasma100\_400
Recommendation(s): Add 100 μL of sample to 300 μL of pre-aliquoted TNA isolation kit lysis buffer (total input sample volume is 400 μL). Elution volume is 100 μL.
### bioMérieux NucliSENS® easyMAG® Instrument
Protocol: General protocol (not for blood) using “Off-board Lysis” reagent settings.
Recommendation(s): Add 100 μL of sample to 1000 μL of pre-aliquoted easyMAG lysis buffer (total input sample volume is 1100 μL). Incubate for 10 minutes at room temperature.
Elution volume is 100 μL.
### bioMérieux EMAG® Instrument
Protocol: Custom protocol: **CDC Flu V1** using “Off-board Lysis” reagent settings.
Recommendation(s): Add 100 μL of samples to 2000 μL of pre-aliquoted easyMAG lysis buffer (total input sample volume is 2100 μL). Incubate for 10 minutes at room temperature. Elution volume is 100 μL. The custom protocol, **CDC Flu V1**, is programmed on the bioMérieux EMAG**®** instrument with the assistance of a bioMérieux service representative. Installation verification is documented at the time of installation. Laboratories are recommended to retain a record of the step-by-step verification of the bioMérieux custom protocol installation procedure.
Manufacturer’s recommended procedures (except as noted in recommendations above) are to be followed for sample extraction. HSC must be included in each extraction batch.
***Disclaimer: Names of vendors or manufacturers are provided as examples of suitable product sources. Inclusion does not imply endorsement by the Centers for Disease Control and Prevention**.*
## Assay Set Up
### Reaction Master Mix and Plate Set Up
Note: Plate set-up configuration can vary with the number of specimens and workday organization. NTCs and nCoVPCs must be included in each run.
1\) In the reagent set-up room clean hood, place rRT-PCR buffer, enzyme, and primer/probes on ice or cold-block. Keep cold during preparation and use.
2\) Mix buffer, enzyme, and primer/probes by inversion 5 times.
3\) Centrifuge reagents and primers/probes for 5 seconds to collect contents at the bottom of the tube, and then place the tube in a cold rack.
4\) Label one 1.5 mL microcentrifuge tube for each primer/probe set.
5\) Determine the number of reactions (N) to set up per assay. It is necessary to make excess reaction mix for the NTC, nCoVPC, HSC (if included in the rRT-PCR run), and RP reactions and for pipetting error. Use the following guide to determine N:
- If number of samples (n) including controls equals 1 through 14, then N = n + 1
- If number of samples (n) including controls is 15 or greater, then N = n + 2
6\) For each primer/probe set, calculate the amount of each reagent to be added for each reaction mixture (N = \# of reactions).
### Thermo Fisher TaqPath™ 1-Step RT-qPCR Master Mix
| Step # | Reagent | Vol. of Reagent Added per Reaction |
| ------ | ------------------------- | --------------------------------- |
| 1 | Nuclease-free Water | N x 8.5 µL |
| 2 | Combined Primer/Probe Mix | N x 1.5 µL |
| 3 | TaqPath(TM | N x 5.0 µL |
| | Total Volume | N x 15.0 µL |
||
### Promega GoTaq® Probe 1- Step RT-qPCR System
| Step # | Reagent | Vol. of Reagent Added per Reaction |
| ------ | ------------------------------------- | ---------------------------------- |
| 1 | Nuclease-free Water | N x 3.1 µL |
| 2 | Combined Primer/Probe Mix | N x 1.5 µL |
| 3 | GoTaq Probe qPCR Master Mix with dUTP | N x 10.0 µL |
| 4 | Go Script RT Mix for 1-Step RT-qPCR | N x 0.4 µL |
| | Total Volume | N x 15.0 µL |
||
### Quantabio qScript XLT One-Step RT-qPCR ToughMix
| Step # | Reagent | Vol. of Reagent Added per Reaction |
| ------ | ----------------------------------------- | ---------------------------------- |
| 1 | Nuclease-free Water | N x 3.5 µL |
| 2 | Combined Primer/Probe Mix | N x 1.5 µL |
| 3 | qScript XLT One-Step RT-qPCR ToughMix(2X) | N x 10.0 µL |
| | Total Volume | N x 15.0 µL |
||
### Quantabio UltraPlex 1-Step ToughMix (4X)
| Step # | Reagent | Vol. of Reagent Added per Reaction |
| ------ | ------------------------------ | --------------------------------- |
| 1 | Nuclease-free Water | N x 8.5 µL |
| 2 | Combined Primer/Probe Mix | N x 1.5 µL |
| 3 | UltraPlex 1-Step ToughMix (4X) | N x 5.0 µL |
| | Total Volume | N x 15.0 µL |
||
7\) Dispense reagents into each respective labeled 1.5 mL microcentrifuge tube. After addition of the reagents, mix reaction mixtures by pipetting up and down. ***Do not vortex***.
8\) Centrifuge for 5 seconds to collect contents at the bottom of the tube, and then place the tube in a cold rack.
9\) Set up reaction strip tubes or plates in a 96-well cooler rack.
10\) Dispense 15 µL of each master mix into the appropriate wells going across the row as shown below (**Figure 1**):
**Figure 1: Example of Reaction Master Mix Plate Set-Up**
| **A** | **1** | **2** | **3** | **4** | **5** | **6** | **7** | **8** | **9** | **10** | **11** | **12** |
|----|------|------|------|------|------|------|------|------|------|------|------|------|
| | N1 | N1 | N1 | N1 | N1 | N1 | N1 | N1 | N1 | N1 | N1 | N1 |
| **B** | N2 | N2 | N2 | N2 | N2 | N2 | N2 | N2 | N2 | N2 | N2 | N2 |
| **C** | RP | RP | RP | RP | RP | RP | RP | RP | RP | RP | RP | RP |
| **D** | | | | | | | | | | | | |
| **E** | | | | | | | | | | | | |
| **F** | | | | | | | | | | | | |
| **G** | | | | | | | | | | | | |
| **H** | | | | | | | | | | | | |
||
11\) Prior to moving to the nucleic acid handling area, prepare the No Template Control (NTC) reactions for column \#1 in the assay preparation area.
12\) Pipette 5 µL of nuclease-free water into the NTC sample wells (**Figure 2**, column 1). Securely cap NTC wells before proceeding.
13\) Cover the entire reaction plate and move the reaction plate to the specimen nucleic acid handling area.
### Nucleic Acid Template Addition
1\) Gently vortex nucleic acid sample tubes for approximately 5 seconds.
2\) Centrifuge for 5 seconds to collect contents at the bottom of the tube.
3\) After centrifugation, place extracted nucleic acid sample tubes in the cold rack.
4\) Samples should be added to columns 2-11 (column 1 and 12 are for controls) to the specific assay that is being tested as illustrated in **Figure 2**. Carefully pipette 5.0 µL of the first sample into all the wells labeled for that sample (i.e. Sample “S1” down column \#2). *Keep other sample wells covered during addition. Change tips after each addition.*
5\) Securely cap the column to which the sample has been added to prevent cross contamination and to ensure sample tracking.
6\) Change gloves often and when necessary to avoid contamination.
7\) Repeat steps \#4 and \#5 for the remaining samples.
8\) If necessary, add 5 µL of Human Specimen Control (HSC) extracted sample to the HSC wells
(**Figure 2**, column 11). Securely cap wells after addition. NOTE: Per CLIA regulations, HSC must be tested at least once per day.
9\) Cover the entire reaction plate and move the reaction plate to the positive template control handling area.
### Assay Control Addition
1\) Pipette 5 µL of nCoVPC RNA to the sample wells of column 12 (**Figure 2**)**.** Securely cap wells after addition of the control RNA.
***NOTE:** If using 8-tube strips,label the TAB of each strip to indicate sample position. **DO NOT *** ***LABEL THE TOPS OF THE REACTION TUBES!***
*2)* Briefly centrifuge reaction tube strips for 10-15 seconds. After centrifugation return to cold rack.
***NOTE**: If using 96-well plates,centrifuge plates for 30 seconds at 500 x g, 4*°*C*.
**Figure 2. 2019-nCoV rRT-PCR Diagnostic Panel: Example of Sample and Control Set-up**
| | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11(a ) | 12 |
| - | --- | -- | -- | -- | -- | -- | -- | -- | -- | -- | --------------- | ------- |
| A | NTC | S1 | S2 | S3 | S4 | S5 | S6 | S7 | S8 | S9 | S10 | nCoV PC |
| B | NTC | S1 | S2 | S3 | S4 | S5 | S6 | S7 | S8 | S9 | S10 | nCoV PC |
| C | NTC | S1 | S2 | S3 | S4 | S5 | S6 | S7 | S8 | S9 | S10 | nCoV PC |
| D | | | | | | | | | | | | |
| E | | | | | | | | | | | | |
| F | | | | | | | | | | | | |
| G | | | | | | | | | | | | |
| H | | | | | | | | | | | | |
||
(a)Replace the sample in this column with extracted HSC if necessary
## Create a Run Template on the Applied Biosystems 7500 Fast Dx Real-time PCRInstrument (Required if no template exists)
If the template already exists on your instrument, please proceed to the **RUNNING A TEST** section.
1\) Launch the Applied Biosystems 7500 Fast Dx Real-time PCR Instrument by double clicking on the Applied Biosystems 7500 Fast Dx System icon on the desktop.
2\) A new window should appear, select **Create New Document** from the menu.
**Figure 3. New Document Wizard Window**
_Screenshot of a "New Document Wizard" pop-up dialog in the ABI 7500 SDS software (v1.4) where users configure the "Define Document" step. It includes fields for Assay (set to "Standard Curve (Absolute Quantitation)"), Container ("96-Well Clear"), Template ("Blank Document"), and Operator ("Training User"). A callout highlights that the Run Mode must be changed to Standard 7500._
3\) The **New Document Wizard** screen in **Figure 3** will appear. Select:
a\. Assay: **Standard Curve (Absolute Quantitation)**
b\. Container: **96-Well Clear**
c\. Template: **Blank Document**
d\. Run Mode: **Standard 7500**
e\. Operator: ***Your Name***
f\. Comments: **SDS v1.4**
g\. Plate Name: ***Your Choice***
4\) After making selections click **Next** at the bottom of the window.
**Figure 4. Creating New Detectors**
_Screenshot of the "Select Detectors" screen in the ABI 7500 SDS software showing the detector setup interface with a "New Detector" button and fields for detector configuration._
NOTE: ROX is the default passive reference. This will be changed to “none” in step 12.
5\) After selecting next, the ***Select Detectors*** screen (**Figure 4**) will appear.
6\) Click the **New Detector** button (see **Figure 4**).
7\) The **New Detector** window will appear (**Figure 5**). A new detector will need to be defined for each primer and probe set. Creating these detectors will enable you to analyze each primer and probe set individually at the end of the reaction.
**Figure 5. New Detector Window**
_Screenshot of the "New Detector" dialog box with fields for Name, Description, Reporter Dye (FAM), Quencher Dye ((none)), and Color selection._
8\) Start by creating the N1 Detector. Include the following:
a\. Name: **N1**
b\. Description: *leave blank*
c\. Reporter Dye: **FAM**
d\. Quencher Dye: **(none)**
e\. Color: *to change the color of the detector indicator do the following:*
⇒ Click on the color square to reveal the color chart
⇒ Select a color by clicking on one of the squares
⇒ After selecting a color click **OK** to return to the New Detector screen
f\. Click the **OK** button of the New Detector screen to return to the screen shown in **Figure 4**. 9) Repeat step 6-8 for each target in the panel.
| **Name** | **Reporter Dye** | **Quencher Dye** |
|----------|------------------|------------------|
| N1 | FAM | (none) |
| N2 | FAM | (none) |
| RP | FAM | (none) |
||
10\) After each Detector is added, the **Detector Name**, **Description**, **Reporter** and **Quencher** fields will become populated in the **Select Detectors** screen (**Figure 6**).
11\) Before proceeding, the newly created detectors must be added to the document. To add the new detectors to the document, click **ADD** (see **Figure 6**). Detector names will appear on the right-hand side of the **Select Detectors** window (**Figure 6**).
**Figure 6. Adding New Detectors to Document**
_Two side-by-side screenshots of the "Select Detectors" screen showing the process of adding newly created detectors (N1, N2, RP) to the document using the ADD button. Detector names appear on the right-hand side after being added._
12\) Once all detectors have been added, select **(none)** for **Passive Reference** at the top right-hand drop-down menu (**Figure 7**).
**Figure 7. Select Passive Reference**
_Screenshot of the "Select Detectors" screen with the Passive Reference dropdown menu highlighted and set to "(none)" in the upper right corner._
**Passive reference should be set to “(none)” as described above.**
13)Click **Next** at the bottom of the **Select Detectors** window to proceed to the **Set Up Sample Plate** window (**Figure 8**).
14)In the **Set Up Sample Plate** window (**Figure 8**), use your mouse to select row A from the lower portion of the window, in the spreadsheet (see **Figure 8**).
15)In the top portion of the window, select detector **N1**. A check will appear next to the detector you have selected (**Figure 8**). You will also notice the row in the spreadsheet will be populated with a colored “U” icon to indicate which detector you’ve selected.
16)Repeat step 14-15 for each detector that will be used in the assay.
**Figure 8. Sample Plate Set-up**
_Screenshot of the "Set Up Sample Plate" window showing detector assignment to plate rows, with detector checkboxes in the upper portion and the plate spreadsheet below._
17\) Select **Finish** after detectors have been assigned to their respective rows. (**Figure 9**).
**Figure 9. Finished Plate Set-up**
_Screenshot of the completed "Set Up Sample Plate" window showing all detectors (N1, N2, RP) assigned to their respective plate rows with "Finish" button visible._
18\) After clicking “Finish”, there will be a brief pause allowing the Applied Biosystems 7500 Fast Dx to initialize. This initialization is followed by a clicking noise. ***Note: The machine must be turned on for initialization.***
19\) After initialization, the **Plate** tab of the Setup (**Figure 10)** will appear.
20)Each well of the plate should contain colored U icons that correspond with the detector labels that were previously chosen. To confirm detector assignments, select **Tools** from the file menu, then select **Detector Manager.**
**Figure 10. Plate Set-up Window**
_Screenshot of the Plate tab in the ABI 7500 software showing the 96-well plate layout with colored "U" icons indicating detector assignments for each well._
21\) The Detector Manager window will appear (**Figure 11**).
**Figure 11. Detector Manager Window**
_Screenshot of the Detector Manager window listing detectors N1, N2, and RP, each with Reporter set to FAM and Quencher set to (none)._
22)Confirm all detectors are included and that each target has a **Reporter** set to **FAM** and the **Quencher** is set to **(none)**.
23)If all detectors are present, select **Done**. The detector information has been created and assigned to wells on the plate.
## Defining the Instrument Settings
1\) After detectors have been created and assigned, proceed to instrument set up.
2\) Select the **Instrument** tab to define thermal cycling conditions.
3\) Modify the thermal cycling conditions as follows (**Figure 12**):
**Thermo Fisher TaqPath™ 1-Step RT-qPCR Master Mix, CG**
a\. In Stage 1, Set to 2 min at **25°C**; **1 Rep**.
b\. In Stage 2, Set to 15 min at **50°C**; **1 Rep**.
c\. In Stage 3, Set to 2 min at **95°C, 1 Rep.**
d\. In Stage 4, Step 1 set to **3 sec** at **95°C**.
e\. In Stage 4, Step 2 set to **30 sec** at **55.0°C.**
f\. In Stage 4, Reps should be set to **45.**
g\. Under **Settings** (**Figure 12**), bottom left-hand box, change volume to 20 µL.
h\. Under **Settings**, **Run Mode** selection should be **Standard 7500**.
i\. Step 2 of Stage 4 should be highlighted in yellow to indicate data collection (see **Figure 12**).
**OR** **Quantabio qScript(TM) XLT One-Step RT-qPCR ToughMix or UltraPlex 1-Step ToughMix (4X)**
a\. In Stage 1, Set to 10 min at **50°C**; **1 Rep**.
b\. In Stage 2, Set to 3 min at **95°C, 1 Rep.**
c\. In Stage 3, Step 1 set to **3 sec** at **95°C**.
d\. In Stage 3, Step 2 set to **30 sec** at **55.0°C.**
e\. In Stage 3, Reps should be set to **45.**
f\. Under **Settings** (**Figure 12**), bottom left-hand box, change volume to 20 µL. g. Under **Settings**, **Run Mode** selection should be **Standard 7500**.
h\. Step 2 of Stage 3 should be highlighted in yellow to indicate data collection (see **Figure 12**).
**OR** **Promega GoTaq® Probe 1-Step RT-qPCR System**
a\. In Stage 1, Set to 15 min at **45°C**; **1 Rep**.
b\. In Stage 2, Set to 2 min at **95°C, 1 Rep.**
c\. In Stage 3, Step 1 set to **3 sec** at **95°C**. d. In Stage 3, Step 2 set to **30 sec** at **55.0°C.** e. In Stage 3, Reps should be set to **45.**
f\. Under **Settings** (**Figure 12**), bottom left-hand box, change volume to 20 µL. g. Under **Settings**, **Run Mode** selection should be **Standard 7500**.
h\. Step 2 of Stage 3 should be highlighted in yellow to indicate data collection (see **Figure 12**).
**Figure 12. Instrument Window**
_Screenshot of the Instrument tab showing the thermal cycling protocol with multiple stages, temperature/time settings, and the Settings panel with reaction volume (20 uL) and Run Mode (Standard 7500) configuration._
4\) After making changes to the **Instrument** tab, the template file is ready to be saved. To save the template, select **File** from the top menu, then select **Save As**. Since the enzyme options have different instrument settings, it is recommended that the template be saved with a name indicating the enzyme option.
5\) Save the template as **2019-nCoV Dx Panel TaqPath** or **2019-nCoV Dx Panel Quanta** or **2019-** **nCoV Dx Panel Promega** as appropriate in the desktop folder labeled “***ABI Run Templates***” (*you must create this folder*). Save as type should be SDS Templates (\*.sdt) (**Figure 13**).
**Figure 13. Saving Template**
_Screenshot of the "Save As" dialog box for saving the run template as an SDS Templates (.sdt) file in the "ABI Run Templates" folder._
## Running a Test
1\) Turn on the ABI 7500 Fast Dx Real-Time PCR Instrument.
2\) Launch the Applied Biosystems 7500 Fast Dx Real-time PCR System by double clicking on the 7500 Fast Dx System icon on the desktop.
3\) A new window should appear, select **Open Existing Document** from the menu. 4) Navigate to select your ABI Run Template folder from the desktop.
5\) Double click on the appropriate template file (**2019-nCoV Dx Panel TaqPath** or **2019-nCoV Dx Panel Quanta** or **2019-nCoV Dx Panel Promega)**
6\) There will be a brief pause allowing the Applied Biosystems 7500 Fast Dx Real-Time PCR Instrument to initialize. This initialization is followed by a clicking noise. ***Note: The machine must be turned on for initialization.***
**Figure 14. Plate Set-up Window**
_Screenshot of the plate map showing the 96-well plate layout with pre-configured detector labels and control positions loaded from the template._
7\) After the instrument initializes, a plate map will appear (**Figure 14**). The detectors and controls should already be labeled as they were assigned in the original template.
8\) Click the **Well Inspector** icon (magnifying glass toolbar button) from the top menu.
9\) Highlight specimen wells of interest on the plate map.
10\) Type sample identifiers to **Sample Name** box in the **Well Inspector** window (**Figure 15**).
**Figure 15. Labeling Wells**
_Screenshot of the plate setup with the Well Inspector window open, showing the Sample Name field for entering specimen identifiers for highlighted wells._
11\) Repeat steps 9-10 until all sample identifiers are added to the plate setup.
12\) Once all specimen and control identifiers are added click the **Close** button on the **Well Inspector** window to return to the **Plate** set up tab.
13\) Click the **Instrument** tab at the upper left corner.
14\) The reaction conditions, volumes, and type of 7500 reaction should already be loaded (**Figure 16**).
**Figure 16. Instrument Settings**
_Screenshot of the Instrument tab displaying the thermal cycling protocol graph with temperature stages, timing parameters, and data collection settings for the RT-PCR run._
15\) Ensure settings are correct (refer to the *Defining Instrument Settings*).
16\) Before proceeding, the run file must be saved; from the main menu, select **File,** then **Save As**. Save in appropriate run folder designation.
17\) Load the plate into the plate holder in the instrument. Ensure that the plate is properly aligned in the holder.
18\) Once the run file is saved, click the **Start** button. *Note: The run should take approximately 1 hour and 20 minutes to complete.*
## Data Analysis
1\) After the run has completed, select the **Results** tab at the upper left corner of the software. 2) Select the **Amplification Plot** tab to view the raw data (**Figure 17**).
**Figure 17. Amplification Plot Window**
_Screenshot of the Amplification Plot window showing fluorescence growth curves for all samples, with labeled interface elements: (a) sample selector checkbox, (b) Data dropdown set to Delta Rn vs. Cycle, (c) Detector dropdown, (d) Line Color dropdown, and (e) Manual Ct analysis settings._
3\) Start by highlighting all the samples from the run; to do this, click on the upper left-hand box **(a)** of the sample wells (**Figure 17**). All the growth curves should appear on the graph.
4\) On the right-hand side of the window **(b)**, the **Data** drop down selection should be set to **Delta Rn vs. Cycle**.
5\) Select **N1** from **(c)**, the **Detector** drop down menu, using the downward arrow.
a\. Please note that each detector is analyzed individually to reflect different performance profiles of each primer and probe set.
6\) In the **Line Color** drop down **(d)**, **Detector Color** should be selected.
7\) Under **Analysis Settings** select **Manual Ct (e)**.
**b.** Do not change the **Manual Baseline** default numbers.
8\) Using the mouse, click and drag the red threshold line until it lies within the exponential phase of the fluorescence curves and above any background signal (**Figure 18)**.
**Figure 18. Amplification Plot**
_Screenshot of the amplification plot showing fluorescence curves with annotations indicating the exponential PCR phase, background noise region, and the threshold line positioned within the exponential phase above background signal._
9\) Click the **Analyze** button in the lower right corner of the window. The red threshold line will turn to green, indicating the data has been analyzed.
10\) Repeat steps 5-9 to analyze results generated for each set of markers (N1, N2, RP). 11) Save analysis file by selecting **File** then **Save As** from the main menu.
12\) After completing analysis for each of the markers, select the **Report** tab above the graph to display the Ct values (**Figure 19**). To filter report by sample name in ascending or descending order, simply click on **Sample Name** in the table.
**Figure 19. Report**
_Screenshot of the Report tab displaying a table of Ct values for each sample organized by detector (N1, N2, RP), with columns for Well, Sample Name, Detector, Ct, and other result fields._
## Interpretation of Results and Reporting
**Extraction and Positive Control Results and Interpretation**
**No Template Control (NTC)**
The NTC consists of using nuclease-free water in the rRT-PCR reactions instead of RNA. The NTC reactions for all primer and probe sets should not exhibit fluorescence growth curves that cross the threshold line. If any of the NTC reactions exhibit a growth curve that crosses the cycle threshold, sample contamination may have occurred. Invalidate the run and repeat the assay with strict adherence to the guidelines.
**2019-nCoV Positive Control (nCoVPC)**
The nCoVPC consists of in vitro transcribed RNA. The nCoVPC will yield a positive result with the following primer and probe sets: N1, N2, and RP.
**Human Specimen Control (HSC) (Extraction Control)**
When HSC is run with the CDC 2019-nCoV rRT-PCR Diagnostic Panel (see previous section on Assay Set Up), the HSC is used as a nucleic acid extraction procedural control to demonstrate successful recovery of nucleic acid as well as extraction reagent integrity. The HSC control consists of noninfectious cultured human cell (A549) material. Purified nucleic acid from the HSC should yield a positive result with the RP primer and probe set and negative results with all 2019-nCoV markers.
**Expected Performance of Controls Included in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel**
| Control Type | External Control Name | Used to Monitor | 2019 nCoV_N1 | 2019 nCoV_N2 | RP | Expected Ct Values |
| ----------- | -------------------- | ------------------------------------------------------------------------------------ | ----------- | ----------- | -- | ------------------ |
| Positive | nCoVPC | Substantial reagent failure including primer and probe integrity | + | + | + | < 40.00 Ct |
| Negative | NTC | Reagent and/or environmental contamination | - | - | - | None detected |
| Extraction | HSC | Failure in lysis and extraction procedure, potential contamination during extraction | - | - | + | < 40.00 Ct |
||
**If any of the above controls do not exhibit the expected performance as described, the assay may have been set up and/or executed improperly, or reagent or equipment malfunction could have occurred. Invalidate the run and re-test.**
**RNase P (Extraction Control)**
- All clinical samples should exhibit fluorescence growth curves in the RNase P reaction that cross the threshold line within 40.00 cycles (< 40.00 Ct), thus indicating the presence of the human RNase P gene. Failure to detect RNase P in any clinical specimens may indicate:
- Improper extraction of nucleic acid from clinical materials resulting in loss of RNA and/or RNA degradation.
- Absence of sufficient human cellular material due to poor collection or loss of specimen integrity.
- Improper assay set up and execution.
- Reagent or equipment malfunction.
- If the RP assay does not produce a positive result for human clinical specimens, interpret as follows:
- If the 2019-nCoV N1 and N2 are positive even in the absence of a positive RP, the result should be considered valid. It is possible, that some samples may fail to exhibit RNase P growth curves due to low cell numbers in the original clinical sample. A negative RP signal does not preclude the presence of 2019-nCoV virus RNA in a clinical specimen.
- If all 2019-nCoV markers AND RNase P are negative for the specimen, the result should be considered invalid for the specimen. If residual specimen is available, repeat the extraction procedure and repeat the test. If all markers remain negative after re-test, report the results as invalid and a new specimen should be collected if possible*.*
**2019-nCoV Markers (N1 and N2)**
• When all controls exhibit the expected performance, a specimen is considered negative if all 2019-nCoV marker (N1, N2) cycle threshold growth curves DO NOT cross the threshold line within 40.00 cycles (< 40.00 Ct) AND the RNase P growth curve DOES cross the threshold line within 40.00 cycles (< 40.00 Ct).
• When all controls exhibit the expected performance, a specimen is considered positive for 2019- nCoV if all 2019-nCoV marker (N1, N2) cycle threshold growth curves cross the threshold line within 40.00 cycles (< 40.00 Ct). The RNase P may or may not be positive as described above, but the 2019-nCoV result is still valid.
• When all controls exhibit the expected performance and the growth curves for the 2019-nCoV markers (N1, N2) AND the RNase P marker DO NOT cross the cycle threshold growth curve within 40.00 cycles (< 40.00 Ct), the result is invalid. The extracted RNA from the specimen should be re tested. If residual RNA is not available, re-extract RNA from residual specimen and re-test. If the re-tested sample is negative for all markers and RNase P, the result is invalid and collection of a new specimen from the patient should be considered.
• When all controls exhibit the expected performance and the cycle threshold growth curve for any one marker (N1 or N2, but not both markers) crosses the threshold line within 40.00 cycles (< 40.00 Ct) the result is inconclusive. The extracted RNA should be retested. If residual RNA is not available, re-extract RNA from residual specimen and re-test. If the same result is obtained, report the inconclusive result. Consult with your state public health laboratory or CDC, as appropriate, to request guidance and/or to coordinate transfer of the specimen for additional analysis.
• If HSC is positive for N1 or N2, then contamination may have occurred during extraction or sample processing. Invalidate all results for specimens extracted alongside the HSC. Re-extract specimens and HSC and re-test.
## 2019-nCoV rRT-PCR Diagnostic Panel Results Interpretation Guide
The table below lists the expected results for the 2019-nCoV rRT-PCR Diagnostic Panel. If a laboratory obtains unexpected results for assay controls or if inconclusive or invalid results are obtained and cannot be resolved through the recommended re-testing, please contact CDC for consultation and possible specimen referral. See pages 13 and 53 for referral and contact information.
| 2019nCoV_N1 | 2019nCoV_N2 | RP | ResultInterpretation(a ) | Report | Actions |
| ------------------------------------------ | ----------- | -- | --------------------------------- | ------------------ | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| + | + | ± | 2019-nCoV detected | Positive 2019-nCoV | Report results to CDC and sender. |
| If only one of the two targets is positive | | ± | Inconclusive Result | Inconclusive | Repeat testing of nucleic acid and/or re-extract and repeat rRT-PCR. If the repeated result remains inconclusive, contact your State Public Health Laboratory or CDC for instructions for transfer of the specimen or further guidance. |
| - | - | + | 2019-nCoV not detected | Not Detected | Report results to sender. Consider testing for other respiratory viruses.(b) |
| - | - | - | Invalid Result | Invalid | Repeat extraction and rRT-PCR. If the repeated result remains invalid, consider collecting a new specimen from the patient. |
||
**(a)Laboratories should report their diagnostic result as appropriate and in compliance with their specific reporting system.**
**(b)Optimum specimen types and timing for peak viral levels during infections caused by 2019-nCoV have not been determined. Collection of multiple specimens from the same patient may be necessary to detect the virus. The** **possibility of a false negative result should especially be considered if the patient’s recent exposures or clinical**
**presentation suggest that 2019-nCoV infection is possible, and diagnostic tests for other causes of illness (e.g., other respiratory illness) are negative. If 2019-nCoV infection is still suspected, re-testing should be considered**
**in consultation with public health authorities.**
## Quality Control
• Quality control requirements must be performed in conformance with local, state, and federal regulations or accreditation requirements and the user’s laboratory’s standard quality control procedures. For further guidance on appropriate quality control practices, refer to 42 CFR 493.1256.
• Quality control procedures are intended to monitor reagent and assay performance. • Test all positive controls prior to running diagnostic samples with each new kit lot to ensure all reagents and kit components are working properly.
• Good laboratory practice (cGLP) recommends including a positive extraction control in each nucleic acid isolation batch.
• Although HSC is not included with the 2019-nCov rRT-PCR Diagnostic Panel, the HSC extraction control must proceed through nucleic acid isolation per batch of specimens to be tested. • Always include a negative template control (NTC) and the appropriate positive control (nCoVPC) in each amplification and detection run. All clinical samples should be tested for human RNase P gene to control for specimen quality and extraction.
## Limitations
• All users, analysts, and any person reporting diagnostic results should be trained to perform this procedure by a competent instructor. They should demonstrate their ability to perform the test and interpret the results prior to performing the assay independently.
• Performance of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel has only been established in upper and lower respiratory specimens (such as nasopharyngeal or oropharyngeal swabs, sputum, lower respiratory tract aspirates, bronchoalveolar lavage, and nasopharyngeal wash/aspirate or nasal aspirate).
• Negative results do not preclude 2019-nCoV infection and should not be used as the sole basis for treatment or other patient management decisions. Optimum specimen types and timing for peak viral levels during infections caused by 2019-nCoV have not been determined. Collection of multiple specimens (types and time points) from the same patient may be necessary to detect the virus.
• A false-negative result may occur if a specimen is improperly collected, transported or handled.
False-negative results may also occur if amplification inhibitors are present in the specimen or if inadequate numbers of organisms are present in the specimen.
• Positive and negative predictive values are highly dependent on prevalence. False-negative test results are more likely when prevalence of disease is high. False-positive test results are more likely when prevalence is moderate to low.
• Do not use any reagent past the expiration date.
• If the virus mutates in the rRT-PCR target region, 2019-nCoV may not be detected or may be detected less predictably. Inhibitors or other types of interference may produce a false-negative result. An interference study evaluating the effect of common cold medications was not performed.
• Test performance can be affected because the epidemiology and clinical spectrum of infection caused by 2019-nCoV is not fully known. For example, clinicians and laboratories may not know
the optimum types of specimens to collect, and, during the course of infection, when these specimens are most likely to contain levels of viral RNA that can be readily detected. • Detection of viral RNA may not indicate the presence of infectious virus or that 2019-nCoV is the causative agent for clinical symptoms.
• The performance of this test has not been established for monitoring treatment of 2019-nCoV infection.
• The performance of this test has not been established for screening of blood or blood products for the presence of 2019-nCoV.
• This test cannot rule out diseases caused by other bacterial or viral pathogens.
## Conditions of Authorization for the Laboratory
The CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Letter of Authorization, along with the authorized Fact Sheet for Healthcare Providers, the authorized Fact Sheet for Patients, and authorized labeling are available on the FDA website: https://www.fda.gov/medical devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro diagnostics-euas.
However, to assist clinical laboratories using the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel
(“your product” in the conditions below), the relevant Conditions of Authorization are listed below:
• Authorized laboratories using your product will include with test result reports, all authorized
Fact Sheets available on the CDC website. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
• Authorized laboratories using your product will use your product as outlined in the authorized labeling available on the CDC website. Deviations from the authorized procedures, including the authorized RT-PCR instruments, authorized extraction methods, authorized clinical specimen types, authorized control materials, authorized other ancillary reagents and authorized materials required to use your product are not permitted under this authorization.
• Authorized laboratories that receive the commercially manufactured and distributed primer and probe sets identified as acceptable on the CDC website for use with your product, and are not able to obtain the authorized Human Specimen Control and authorized Positive Control for 2019- nCoV (NCoVPC) materials described in your product’s authorized labeling, may use appropriate materials identified as acceptable materials on the CDC website for use with your product.
• Authorized laboratories that receive your product will notify the relevant public health authorities of their intent to run your product prior to initiating testing.
• Authorized laboratories using your product will have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
• Authorized laboratories will collect information on the performance of your product and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and CDC (respvirus@cdc.gov) any suspected occurrence of false positive or false negative results and
significant deviations from the established performance characteristics of the test of which they become aware.
• Authorized laboratories using specimen pooling strategies when testing patient specimens with your product will include with negative test result reports for specific patients whose specimen(s) were the subject of pooling, a notice that pooling was used during testing and that “Patient specimens with low viral loads may not be detected in sample pools due to the decreased sensitivity of pooled testing.”
• Authorized laboratories implementing pooling strategies for testing patient specimens must use the “Implementation and Monitoring of Pooled Specimen Testing” available in the authorized labeling to evaluate the appropriateness of continuing to use such strategies based on the recommendations in the protocol.
• Authorized laboratories will keep records of specimen pooling strategies implemented including type of strategy, date implemented, and quantities tested, and test result data generated as part of the Protocol for Monitoring of Specimen Pooling Testing Strategies. For the first 12 months from the date of their creation, such records will be made available to FDA within 48 business hours (2 business days) for inspection upon request, and will be made available within a reasonable time after 12 months from the date of their creation.
• Authorized laboratories will report adverse events, including problems with your products performance or results, to MedWatch by submitting the online FDA Form 3500
(https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.home) or by calling 1-800-FDA-1088.
• All laboratory personnel using the test must be appropriately trained in RT-PCR techniques and use appropriate laboratory and personal protective equipment when handling this kit and use the test in accordance with the authorized labeling.
• CDC, IRR, manufacturers and distributors of commercial materials identified as acceptable on the CDC website, and authorized laboratories using your product will ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
## Performance Characteristics
***Analytical Performance:***
*Limit of Detection (LoD):*
LoD studies determine the lowest detectable concentration of 2019-nCoV at which approximately 95% of all (true positive) replicates test positive. The LoD was determined by limiting dilution studies using characterized samples.
The analytical sensitivity of the rRT-PCR assays contained in the CDC 2019 Novel Coronavirus (2019- nCoV) Real-Time RT-PCR Diagnostic Panel were determined in Limit of Detection studies. Since no quantified virus isolates of the 2019-nCoV were available for CDC use at the time the test was developed and this study conducted, assays designed for detection of the 2019-nCoV RNA were tested with characterized stocks of in vitro transcribed full length RNA (N gene; GenBank accession: MN908947.2) of known titer (RNA copies/µL) spiked into a diluent consisting of a suspension of human A549 cells and viral transport medium (VTM) to mimic clinical specimen. Samples were extracted using the QIAGEN EZ1 Advanced XL instrument and EZ1 DSP Virus Kit (Cat# 62724) and manually with the QIAGEN DSP Viral
RNA Mini Kit (Cat# 61904). Real-Time RT-PCR assays were performed using the Thermo Fisher Scientific TaqPath™ 1-Step RT-qPCR Master Mix, CG (Cat# A15299) on the Applied Biosystems™ 7500 Fast Dx Real
Time PCR Instrument according to the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel instructions for use.
A preliminary LoD for each assay was determined testing triplicate samples of RNA purified using each extraction method. The approximate LoD was identified by extracting and testing 10-fold serial dilutions of characterized stocks of in vitro transcribed full-length RNA. A confirmation of the LoD was determined using 3-fold serial dilution RNA samples with 20 extracted replicates. The LoD was determined as the lowest concentration where ≥ 95% (19/20) of the replicates were positive.
**Table 4. Limit of Detection Confirmation of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel with QIAGEN EZ1 DSP**
| Targets | 2019-nCoV_N1 | | | 2019-nCoV_N2 | | |
| ----------------------------- | ----------------- | ----------------- | ------------------ | ----------------- | ----------------- | ------------------ |
| RNA Concentration(1) | 10 (0.5) | 10 (0.0) | 10 (-0.5) | 10 (0.5) | 10 (0.0) | 10 (-0.5) |
| Positives/Total | 20/20 | 19/20 | 13/20 | 20/20 | 17/20 | 9/20 |
| Mean Ct(2) | 32.5 | 35.4 | NA | 35.8 | NA | NA |
| Standard Deviation (Ct) | 0.5 | 0.8 | NA | 1.3 | NA | NA |
||
(1)Concentration is presented in RNA copies/µL
(2)Mean Ct reported for dilutions that are ≥ 95% positive. Calculations only include positive results. NA not applicable
**Table 5. Limit of Detection Confirmation CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel with QIAGEN QIAmp DSP Viral RNA Mini Kit**
| Targets | 2019-nCoV_N1 | | | 2019-nCoV_N2 | | | |
| ----------------------------- | ----------------- | ----------------- | ------------------ | ----------------- | ----------------- | ------------------ | ------------------ |
| RNA Concentration(1) | 10 (0.5) | 10 (0.0) | 10 (-0.5) | 10 (0.5) | 10 (0.0) | 10 (-0.5) | 10 (-1.0) |
| Positives/Total | 20/20 | 20/20 | 6/20 | 20/20 | 20/20 | 20/20 | 8/20 |
| Mean Ct(2) | 32.0 | 32.8 | NA | 33.0 | 35.4 | 36.2 | NA |
| Standard Deviation (Ct) | 0.7 | 0.8 | NA | 1.4 | 0.9 | 1.9 | NA |
||
(1)Concentration is presented in RNA copies/µL
(2)Mean Ct reported for dilutions that are ≥ 95% positive. Calculations only include positive results. NA not applicable
**Table 6. Limit of Detection of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel**
| Virus | Material | Limit of Detection (RNA copies/∝L) | |
| ---------------------- | --------------------- | ---------------------------------- | ---------------------------- |
| | | QIAGEN EZ1Advanced XL | QIAGEN DSP ViralRNA Mini Kit |
| 2019 Novel Coronavirus | N Gene RNA Transcript | 10(0.5) | 10(0) |
||
FDA Sensitivity Evaluation: The analytical sensitivity of the test will be further assessed by evaluating an FDA-recommended reference material using an FDA developed protocol if applicable and/or when available.
*FDA SARS-CoV-2 Reference Panel Testing*
The evaluation of sensitivity and MERS-CoV cross-reactivity was performed using reference material (T1), blinded samples and a standard protocol provided by the FDA. The study included a range finding study and a confirmatory study for LoD. Blinded sample testing was used to establish specificity and to confirm the LoD. Samples were extracted using the QIAGEN EZ1 Advanced XL with the QIAGEN EZ1 DSP Virus Kit.
Extracted samples were then tested using the 2019-nCoV Real-Time RT-PCR Diagnostic Panel on the Applied BioSystems 7500 Fast Dx Real-Time PCR Instrument using the ThermoFisher TaqPath™ 1-Step
RT-qPCR Master Mix. The results are summarized in Table 7.
**Table 7: Summary of LoD Confirmation Result using the FDA SARS-CoV-2 Reference Panel**
| Reference Materials Provided by FDA | Specimen Type | Product LoD | CrossReactivity |
| ----------------------------------- | ------------- | ----------- | --------------- |
| SARS-CoV-2 | NP swab | N/A | |
| MERS-CoV | | N/A | ND |
||
NDU/mL = RNA NAAT detectable units/mL
N/A: Not applicable
ND: Not detected
*In Silico Analysis of Primer and Probe Sequences:*
The oligonucleotide primer and probe sequences of the CDC 2019 nCoV Real-Time RT-PCR Diagnostic Panel were evaluated against 31,623 sequences available in the Global Initiative on Sharing All Influenza
Data (GISAID, https://www.gisaid.org) database as of June 20, 2020, to demonstrate the predicted inclusivity of the 2019-nCoV Real-Time RT-PCR Diagnostic Panel. Nucleotide mismatches in the primer/probe regions with frequencies > 0.1% are shown below. With the exception of one nucleotide mismatch with frequency > 1% (2.00%) at the third position of the N1 probe, the frequency of all mismatches was < 1%, indicating that prevalence of the mismatches were sporadic. Only one sequence
(0.0032%) had two nucleotide mismatches in the N1 probe, and one other sequence from a different isolate (0.0032%) had two nucleotide mismatches in the N1 reverse primer. No sequences were found to have more than one mismatch in any N2 primer/probe region. The risk of these mismatches resulting in a significant loss in reactivity causing a false negative result is extremely low due to the design of the primers and probes, with melting temperatures > 60°C and with annealing temperature at 55°C that can tolerate up to two mismatches.
**Table 8. In Silico Inclusivity Analysis of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Among**
**31,623 Genome Sequences Available from GISAID as of June 20, 2020**
| Primer/probe | N1 probe | N1 reverse | | N2 probe |
| ---------------------- | -------- | ---------- | ---- | -------- |
| Location (5'>3') | 3 | 15 | 21 | 13 |
| Mismatch Nucleotide | C>T | G>T | T>C | C>T |
| Mismatch No. | 632 | 34 | 71 | 46 |
| Mismatch Frequency (%) | 2.00 | 0.11 | 0.22 | 0.15 |
||
*Specificity/Exclusivity Testing: In Silico Analysis*
BLASTn analysis queries of the 2019-nCoV rRT-PCR assays primers and probes were performed against public domain nucleotide sequences. The database search parameters were as follows: 1) The nucleotide collection consists of GenBank+EMBL+DDBJ+PDB+RefSeq sequences, but excludes EST, STS, GSS, WGS,
TSA, patent sequences as well as phase 0, 1, and 2 HTGS sequences and sequences longer than 100Mb; 2) The database is non-redundant. Identical sequences have been merged into one entry, while preserving the accession, GI, title and taxonomy information for each entry; 3) Database was updated on 10/03/2019; 4) The search parameters automatically adjust for short input sequences and the expect threshold is 1000; 5) The match and mismatch scores are 1 and -3, respectively; 6) The penalty to create and extend a gap in an alignment is 5 and 2 respectively.
2019-nCoV\_N1 Assay:
Probe sequence of 2019-nCoV rRT-PCR assay N1 showed high sequence homology with SARS coronavirus and Bat SARS-like coronavirus genome. However, forward and reverse primers showed no sequence homology with SARS coronavirus and Bat SARS-like coronavirus genome. Combining primers and probe, there is no significant homologies with human genome, other coronaviruses or human microflora that would predict potential false positive rRT-PCR results.
2019-nCoV\_N2 Assay:
The forward primer sequence of 2019-nCoV rRT-PCR assay N2 showed high sequence homology to Bat
SARS-like coronaviruses. The reverse primer and probe sequences showed no significant homology with human genome, other coronaviruses or human microflora. Combining primers and probe, there is no prediction of potential false positive rRT-PCR results.
In summary, the 2019-nCoV rRT-PCR assay N1 and N2, designed for the specific detection of 2019-nCoV, showed no significant combined homologies with human genome, other coronaviruses, or human microflora that would predict potential false positive rRT-PCR results.
In addition to the *in silico* analysis, several organisms were extracted and tested with the CDC 2019-nCoV
Real-Time RT-PCR Diagnostic Panel to demonstrate analytical specificity and exclusivity. Studies were performed with nucleic acids extracted using the QIAGEN EZ1 Advanced XL instrument and EZ1 DSP Virus Kit. Nucleic acids were extracted from high titer preparations (typically ≥ 10(5) PFU/mL or ≥ 10(6) CFU/mL). Testing was performed using the Thermo Fisher Scientific TaqPath™ 1-Step RT-qPCR Master
Mix, CG on the Applied Biosystems™ 7500 Fast Dx Real-Time PCR instrument. The data demonstrate that the expected results are obtained for each organism when tested with the CDC 2019-nCoV Real-Time RT PCR Diagnostic Panel.
**Table 9. Specificity/Exclusivity of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel**
| Virus | Strain | Source | 2019- nCoV_ N1 | 2019- nCoV_ N2 | Final Result |
| --------------------------- | ------ | ----------------- | -------------- | -------------- | ------------ |
| Human coronavirus | 229E | Isolate | 0/3 | 0/3 | Neg. |
| Human coronavirus | OC43 | Isolate | 0/3 | 0/3 | Neg. |
| Human coronavirus | NL63 | clinical specimen | 0/3 | 0/3 | Neg. |
| Human coronavirus | HKU1 | clinical specimen | 0/3 | 0/3 | Neg. |
| MERS-coronavirus | | Isolate | 0/3 | 0/3 | Neg. |
| SARS-coronavirus | | Isolate | 0/3 | 0/3 | Neg. |
| bocavirus | - | clinical specimen | 0/3 | 0/3 | Neg. |
| *Mycoplasma pneumoniae* | | Isolate | 0/3 | 0/3 | Neg. |
| *Streptococcus* | | Isolate | 0/3 | 0/3 | Neg. |
| Influenza A(H1N1) | | Isolate | 0/3 | 0/3 | Neg. |
| Influenza A(H3N2) | | Isolate | 0/3 | 0/3 | Neg. |
| Influenza B | | Isolate | 0/3 | 0/3 | Neg. |
| Human adenovirus, type 1 | Ad71 | Isolate | 0/3 | 0/3 | Neg. |
| Human metapneumovirus | - | Isolate | 0/3 | 0/3 | Neg. |
| respiratory syncytial virus | Long A | Isolate | 0/3 | 0/3 | Neg. |
| rhinovirus | | Isolate | 0/3 | 0/3 | Neg. |
| parainfluenza 1 | C35 | Isolate | 0/3 | 0/3 | Neg. |
| parainfluenza 2 | Greer | Isolate | 0/3 | 0/3 | Neg. |
| parainfluenza 3 | C-43 | Isolate | 0/3 | 0/3 | Neg. |
| parainfluenza 4 | M-25 | Isolate | 0/3 | 0/3 | Neg. |
||
*Endogenous Interference Substances Studies*:
The CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel uses conventional well-established nucleic acid extraction methods and based on our experience with CDC’s other EUA assays, including the CDC Novel
Coronavirus 2012 Real-time RT-PCR Assay for the presumptive detection of Middle East Respiratory
Syndrome Coronavirus (MERS-CoV) and the CDC Human Influenza Virus Real-Time RT-PCR Diagnostic Panel-Influenza A/H7 (Eurasian Lineage) Assay for the presumptive detection of novel influenza A (H7N9) virus that are both intended for use with a number of respiratory specimens, we do not anticipate interference from common endogenous substances.
*Specimen Stability and Fresh-frozen Testing:*
To increase the likelihood of detecting infection, CDC recommends collection of lower respiratory and upper respiratory specimens for testing. If possible, additional specimen types (e.g., stool, urine) should be collected and should be stored initially until decision is made by CDC whether additional specimen sources should be tested. Specimens should be collected as soon as possible once a PUI is identified regardless of symptom onset. Maintain proper infection control when collecting specimens. Store specimens at 2-8°C and ship overnight to CDC on ice pack. Label each specimen container with the patient’s ID number (e.g., medical record number), unique specimen ID (e.g., laboratory requisition number), specimen type (e.g., nasal swabs) and the date the sample was collected. Complete a CDC
Form 50.34 for each specimen submitted.
***Clinical Performance:***
As of February 22, 2020, CDC has tested 2071 respiratory specimens from persons under investigation
(PUI) in the U.S. using the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel. Specimen types include bronchial fluid/wash, buccal swab, nasal wash/aspirate, nasopharyngeal swab, nasopharyngeal/throat swab, oral swab, sputum, oropharyngeal (throat) swab, swab (unspecified), and throat swab.
**Table 10: Summary of CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Data Generated by Testing Human Respiratory Specimens Collected from PUI Subjects in the U.S.**
| Specimen Type | 2019 nCoVNegative | 2019 nCoVPositive | Inconclusive | Invalid | Total |
| ------------------------------ | ----------------- | ----------------- | ------------ | ------- | ----- |
| Bronchialfluid/wash | 2 | 0 | 0 | 0 | 2 |
| Buccal swab | 5 | 1 | 0 | 0 | 6 |
| Nasalwash/aspirate | 6 | 0 | 0 | 0 | 6 |
| Nasopharyngeal swab | 927 | 23 | 0 | 0 | 950 |
| Nasopharyngeal swab/throatswab | 4 | 0 | 0 | 0 | 4 |
| Oral swab | 476 | 9 | 0 | 0 | 485 |
| Pharyngeal(throat) swab | 363 | 10 | 0 | 1 | 374 |
| Sputum | 165 | 5 | 0 | 0 | 170 |
| Swab(unspecified)(1 ) | 71 | 1 | 0 | 0 | 72 |
| Tissue (lung) | 2 | 0 | 0 | 0 | 2 |
| Total | 2021 | 49 | 0 | 1 | 2071 |
||
(1)Actual swab type information was missing from these upper respiratory tract specimens.
Two thousand twenty-one (2021) respiratory specimens of the 2071 respiratory specimens tested negative by the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel. Forty-nine (49) of the 2071 respiratory specimens tested positive by the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel. Only one specimen (oropharyngeal (throat) swab) was invalid. Of the 49 respiratory specimens that tested positive by the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel, seventeen (17) were confirmed by genetic sequencing and/or virus culture (positive percent agreement = 17/17, 95% CI: 81.6%-100%)
During the early phase of the testing, a total of 117 respiratory specimens collected from 46 PUI subjects were also tested with two analytically validated real-time RT-PCR assays that target separate and independent regions of the nucleocapsid protein gene of the 2019-nCoV, N4 and N5 assays. The nucleocapsid protein gene targets for the N4 and N5 assays are different and independent from the nucleocapsid protein gene targets for the two RT-PCR assays included in the CDC 2019-nCoV Real-Time
RT-PCR Diagnostic Panel, N1 and N2. Any positive result from the N4 and/or the N5 assay was further investigated by genetic sequencing.
Performance of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel testing these 117 respiratory specimens was estimated against a composite comparator. A specimen was considered comparator negative if both the N4 and the N5 assays were negative. A specimen was considered comparator positive when the N4 and/or the N5 assay generated a positive result, and the comparator positive result(s) were further investigated and confirmed to be 2019-nCoV RNA positive by genetic sequencing.
**Table 11: Percent Agreement of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel with the Composite Comparator**
| CDC 2019-nCoV Panel Result | Composite Comparator Result | |
| -------------------------- | --------------------------- | -------- |
| | Positive | Negative |
| Positive | 13(1) | 0 |
| Inconclusive | 0 | 0 |
| Negative | 0 | 104 |
||
(1)Composite comparator results were available for 13 of 49 CDC 2019-nCoV Panel positive specimens only.
Positive percent agreement = 13/13 = 100% (95% CI: 77.2% - 100%)
Negative percent agreement = 104/104 = 100% (95% CI: 96.4% - 100%)
***Enzyme Master Mix Evaluation:***
The limit of detection equivalence between the Thermo Fisher TaqPath™ 1-Step RT-qPCR Master Mix and the following enzyme master mixes was evaluated: Quantabio qScript XLT One-Step RT-qPCR ToughMix, Quantabio UltraPlex 1-Step ToughMix (4X), and Promega GoTaq® Probe 1- Step RT-qPCR System. Serial dilutions of 2019 novel coronavirus (SARS CoV-2) transcript were tested in triplicate with the CDC 2019-nCoV Real-time RT-PCR Diagnostic Panel using all four enzyme master mixes. Both manufactured versions of oligonucleotide probe, BHQ and ZEN, were used in the comparison. The lowest detectable concentration of transcript at which all replicates tested positive using the Quantabio qScript XLT One-Step RT-qPCR ToughMix and Quantabio UltraPlex 1-Step ToughMix (4X) was similar to that observed for the Thermo Fisher TaqPath™ 1-Step RT-qPCR Master Mix. The lowest detectable concentration of transcript when using the Promega GoTaq® Probe 1- Step RT-qPCR System was one dilution above that observed for the other candidates when evaluated with the BHQ version of the CDC assays. The candidate master mixes all performed equivalently or at one dilution below the Thermo
Fisher TaqPath™ 1-Step RT-qPCR Master Mix when evaluated with the ZEN version of the CDC assays.
**Table 12: Limit of Detection Comparison for Enzyme Master Mixes – BHQ Probe Summary Results**
| Copy Number | Thermo Fisher TaqPath™ 1-Step RT qPCR Master Mix | | Quantabio qScript XLT One-Step RT-qPCR ToughMix | | Quantabio UltraPlex 1- Step ToughMix (4X) | | Promega GoTaq® Probe 1- Step RT-qPCR System | |
| ----------- | ------------------------------------------------ | ------------- | ----------------------------------------------- | ------------- | ----------------------------------------- | ------------- | ------------------------------------------- | ------------- |
| | 2019- nCoV_N1 | 2019- nCoV_N2 | 2019- nCoV_N1 | 2019- nCoV_N2 | 2019- nCoV_N1 | 2019- nCoV_N2 | 2019- nCoV_N1 | 2019- nCoV_N2 |
| 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | |
| 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | |
| 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 2/3 | |
| 2/3 | 0/3 | 1/3 | 1/3 | 1/3 | 1/3 | 0/3 | 0/3 | |
||
**Table 13: Limit of Detection Comparison for Enzyme Master Mixes – ZEN Probe Summary Results**
| Copy Number | Thermo Fisher TaqPath™ 1-Step RT qPCR Master Mix | | Quantabio qScript XLT One-Step RT-qPCR ToughMix | | Quantabio UltraPlex 1- Step ToughMix (4X) | | Promega GoTaq® Probe 1- Step RT-qPCR System | |
| ----------- | ------------------------------------------------ | ------------- | ----------------------------------------------- | ------------- | ----------------------------------------- | ------------- | ------------------------------------------- | ------------- |
| | 2019- nCoV_N1 | 2019- nCoV_N2 | 2019- nCoV_N1 | 2019- nCoV_N2 | 2019- nCoV_N1 | 2019- nCoV_N2 | 2019- nCoV_N1 | 2019- nCoV_N2 |
| 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | |
| 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | |
| 3/3 | 2/3 | 3/3 | 3/3 | 3/3 | 2/3 | 3/3 | 3/3 | |
| 1/3 | 1/3 | 0/3 | 0/3 | 0/3 | 1/3 | 1/3 | 1/3 | |
||
Retrospective positive (18) and negative (17) clinical respiratory specimens were extracted using the QIAGEN EZ1 Advanced XL instrument and EZ1 DSP Virus Kit and were tested with the CDC 2019-nCoV Real-time RT-PCR Diagnostic Panel using the Quantabio qScript XLT One-Step RT-qPCR ToughMix,
Quantabio UltraPlex 1-Step ToughMix (4X), and Promega GoTaq® Probe 1- Step RT-qPCR System master mixes. All three enzyme master mixes performed equivalently, demonstrating 100% positive and 100% negative agreement with expected results and a 95% confidence interval of 82.4%-100% and 81.6%- 100%, respectively.
**Table 14: Clinical Comparison – Retrospective Study Summary Results**
| CDC 2019-nCoV Real-time RT PCR Diagnostic Panel Result | Quantabio qScript XLT One-Step RT-qPCR ToughMix | | Quantabio UltraPlex 1-Step ToughMix (4X) | | Promega GoTaq® Probe 1- Step RT-qPCR System | |
| ------------------------------------------------------ | ----------------------------------------------- | -------- | ---------------------------------------- | -------- | ------------------------------------------- | -------- |
| | Positive | Negative | Positive | Negative | Positive | Negative |
| Positive | 18 | 0 | 18 | 0 | 18 | 0 |
| Negative | 0 | 17 | 0 | 17 | 0 | 17 |
||
***Roche MagNA Pure 24 and MagNA Pure 96 Extraction Platform Evaluation:***
Performance of the 2019-CoV Real-time RT-PCR Diagnostic Panel using the Roche MagNA Pure 24 and MagNA Pure 96 extraction platforms was compared to performance with an authorized extraction method. Serial dilutions of quantified inactivated SARS-CoV-2 virus (USA-WA1/2020; 100 RNA copies/µL) in lysis buffer were added to pooled negative upper respiratory tract specimen matrix. Five samples of each dilution were extracted in parallel with the QIAGEN EZ1 Advanced XL (EZ1 DSP Virus Kit Cat# 62724) and the Roche MagNA Pure 24 (MagNA Pure 24 Total NA Isolation Kit Cat# 07658036001) and Roche
MagNA Pure 96 (MagNA Pure 96 DNA and Viral Nucleic Acid Small Volume Kit Cat# 06543588001) extraction platforms and evaluated using the 2019-nCoV Real-Time RT-PCR Diagnostic Panel and ThermoFisher TaqPath™ 1-Step RT-qPCR Master Mix. The observed LoD was defined as the lowest concentration at which 100% (5 out of 5 total) of all replicates tested positive for both primer/probe sets
(N1 and N2) in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel. The acceptance criteria for
equivalence were defined as demonstrating an observed LoD either at the same endpoint or within a 3- fold dilution. The results showed that both the MagNA Pure 24 and MagNA Pure 96 extraction platforms performed equivalently or within one 3-fold dilution of the LoD observed when using the QIAGEN EZ1
Advanced XL extraction platform.
**Table 15. Limit of Detection Comparison between the QIAGEN EZ1 Advanced XL, Roche MagNA Pure 96, and Roche MagNA Pure 24 Extraction Platforms using the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel**
| Platform | Parameter | 2019-nCoV_N1 Assay | | | 2019-nCoV_N2 Assay | | | ObservedLoD(1 ) |
| ---------------------- | ------------------- | ------------------ | ---------------- | ---------------- | ------------------ | ---------------- | ---------------- | ------------------------ |
| QIAGEN EZ1 Advanced XL | RNA copies/µL | 10(1.0) | 10(0.5) | 10(0.0) | 10(1.0) | 10(0.5) | 10(0.0) | 10(0.5) |
| | # pos./total | 5/5 | 5/5 | 5/5 | 5/5 | 5/5 | 3/5 | |
| | Mean Ct(2) | 34.0 | 35.0 | 36.3 | 33.9 | 36.6 | NA | |
| | Std. Deviation | 0.2 | 0.8 | 0.2 | 0.4 | 0.9 | NA | |
| Roche MagNA Pure 96 | RNA copies/µL | 10(1.0) | 10(0.5) | 10(0.0) | 10(1.0) | 10(0.5) | 10(0.0) | 10(0.5) |
| | # pos./total | 5/5 | 5/5 | 5/5 | 5/5 | 5/5 | 2/5 | |
| | Mean Ct(2) | 33.3 | 34.6 | 36.1 | 33.2 | 35.7 | NA | |
| | Std. Deviation | 0.5 | 0.5 | 0.3 | 0.3 | 0.4 | NA | |
| Roche MagNA Pure 24 | RNA copies/µL | 10(1.0) | 10(0.5) | 10(0.0) | 10(1.0) | 10(0.5) | 10(0.0) | 10(1.0) |
| | # pos./total | 5/5 | 3/5 | 3/5 | 5/5 | 5/5 | 5/5 | |
| | Mean Ct(2) | 34.4 | NA | NA | 35.2 | 36.9 | 36.2 | |
| | Std. Deviation | 0.6 | NA | NA | 0.5 | 1.0 | 0.8 | |
||
(1)Concentration is presented in RNA copies/µL. The observed LoD is the lowest concentration where both assays showed 100% positive detection.
(2)Mean Ct reported for dilutions that show 100% positivity. Calculations only include positive results. NA = not applicable
Previously characterized clinical remainder specimens (14 positive and 15 negative) were extracted using both the Roche MagNA Pure 96 and MagNA Pure 24 extraction platforms and evaluated using the 2019- nCoV Real-Time RT-PCR Diagnostic Panel and Thermo Fisher TaqPath™ 1-Step RT-qPCR Master Mix. Acceptance criteria for clinical equivalence was defined as demonstrating 100% concurrence with qualitative results shown with the authorized comparator method (QIAGEN EZ1 Advanced XL). Results from this study showed 100% concurrence with the comparator method for both the Roche MagNA Pure 96 and Roche MagNA Pure 24 extraction platforms when used with the CDC 2019-nCoV Real-Time RT PCR Diagnostic panel.
**Table 16. Clinical Comparison Results – Retrospective Study Results**
| Test Platform | TestPlatformResult | QIAGEN EZ1Advanced XL Result | | Positive % Agreement (CI)(1 ) | Negative % Agreement (CI)(1 ) |
| ------------------- | ------------------ | ---------------------------- | -------- | -------------------------------------- | -------------------------------------- |
| | | Positive | Negative | | |
| Roche MagNA Pure 96 | Positive | 14 | 0 | 100.0 (78.5 – 100.0) | 100.0 (79.6 – 100.0) |
| | Negative | 0 | 15 | | |
| Roche MagNA Pure 24 | Positive | 14 | 0 | 100.0 (78.5 – 100.0) | 100.0 (79.6 – 100.0) |
| | Negative | 0 | 15 | | |
||
(1)CI = 95% confidence interval
***Promega Maxwell® RSC 48 Extraction Platform Evaluation:***
Performance of the 2019-CoV Real-time RT-PCR Diagnostic Panel using the Promega Maxwell® RSC 48 extraction platform was compared to performance with an authorized extraction method. Serial dilutions of quantified inactivated SARS-CoV-2 virus (USA-WA1/2020; 100 RNA copies/µL) in VTM were added to pooled negative upper respiratory tract specimen matrix. Five samples of each dilution were extracted in parallel with the QIAGEN EZ1® Advanced XL (EZ1 DSP Virus Kit Cat# 62724) and the Promega
Maxwell® RSC 48 (Promega Maxwell® Viral Total Nucleic Acid Purification Kit Cat# AS1330) extraction platforms and evaluated using the 2019-nCoV Real-Time RT-PCR Diagnostic Panel and ThermoFisher TaqPath™ 1-Step RT-qPCR Master Mix. The observed LoD was defined as the lowest concentration at which 100% (5 out of 5 total) of all replicates tested positive for both primer/probe sets (N1 and N2) in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel. The acceptance criteria for equivalence were defined as demonstrating an observed LoD either at the same endpoint or within a 3-fold dilution. The results showed that the performance of the Maxwell® RSC 48 extraction platform performed equivalently or within one 3-fold dilution of the LoD observed when using the QIAGEN EZ1® Advanced XL extraction platform.
**Table 17. Limit of Detection Comparison Between the QIAGEN EZ1® Advanced XL and Promega Maxwell® RSC 48 Extraction Platforms Using the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel**
| Platform | Parameter | 2019-nCoV_N1 Assay | | | 2019-nCoV_N2 Assay | | | ObservedLoD(1 ) |
| ----------------------- | ------------------- | ------------------ | ---------------- | ----------------- | ------------------ | ---------------- | ----------------- | ------------------------ |
| QIAGEN EZ1® Advanced XL | RNA copies/µL | 10(0.5) | 10(0.0) | 10(-0.5) | 10(0.5) | 10(0.0) | 10(-0.5) | 10 (0.0) |
| | # pos./total | 5/5 | 5/5 | 0/5 | 5/5 | 5/5 | 3/5 | |
| | Mean Ct(2) | 32.27 | 33.80 | NA | 35.13 | 36.41 | NA | |
| | Std. Deviation | 0.81 | 0.40 | NA | 0.81 | 0.40 | NA | |
| Promega Maxwell® RSC 48 | RNA copies/µL | 10(0.5) | 10(0.0) | 10(-0.5) | 10(0.5) | 10(0.0) | 10(-0.5) | 10 (0.0) |
| | # pos./total | 5/5 | 5/5 | 3/5 | 5/5 | 5/5 | 5/5 | |
| | Mean Ct(2) | 31.11 | 32.97 | NA | 31.89 | 33.95 | 35.17 | |
| | Std. Deviation | 0.24 | 0.34 | NA | 0.24 | 0.35 | 0.65 | |
||
(1)Concentration is presented in RNA copies/µL. The observed LoD is the lowest concentration where both assays showed 100% positive detection.
(2)Mean cycle threshold (Ct) reported for dilutions that show 100% positivity. Calculations only include positive results. NA = not applicable
Previously characterized clinical remainder specimens (15 positive and 15 negative) were extracted using the Promega Maxwell® RSC 48 extraction platform alongside the currently authorized QIAGEN EZ1®
Advanced XL extraction platform and evaluated using the 2019-nCoV Real-Time RT-PCR Diagnostic Panel and Thermo Fisher TaqPath™ 1-Step RT-qPCR Master Mix. Results from the Maxwell® RSC 48 were compared with the QIAGEN EZ1® Advanced XL extraction performed in parallel showing 100% (15/15) qualitative concurrence on positive samples and 93.3% (14/15) qualitative concurrence on negative samples. This evaluation showed that two originally negative (QIAGEN QIAamp® DSP Viral RNA Mini Kit) specimens (Specimens 16 and 24) yielded an inconclusive result after extraction using the QIAGEN EZ1®
Advanced XL. Repeat of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel resolved one of the two specimens (Specimen 24, negative result). The second specimen (Specimen 16) remained inconclusive. Both these specimens yielded a negative result on the Maxwell® RSC 48.
**Table 18. Clinical Comparison Results – Retrospective Study Results**
| Test Platform | | Promega Maxwell(® | | | Positive %Agreement (CI)(1 ) | Negative %Agreement (CI)(1 ) |
| ---------------------------------- | ------------ | --------------------- | -------- | ------------ | ------------------------------------- | ------------------------------------- |
| | Result | Positive | Negative | Inconclusive | | |
| QIAGEN EZ1(®) Advanced XL | Positive | 15 | 0 | 0 | 100.0 (79.6-100.0) | 93.3 (70.2-98.9) |
| | Negative | 0 | 14 | 0 | | |
| | Inconclusive | 0 | 1 | 0 | | |
||
(1) CI = 95% confidence interval
## Disposal
Dispose of hazardous or biologically contaminated materials according to the practices of your institution.
## References
1\. Ballew, H. C., *et al*. “Basic Laboratory Methods in Virology,” DHHS, Public Health Service 1975 (Revised 1981), Centers for Disease Control and Prevention, Atlanta, Georgia 30333.
2\. Clinical Laboratory Standards Institute (CLSI), “Collection, Transport, Preparation and Storage of Specimens for Molecular Methods: Proposed Guideline,” MM13-A 3\. Lieber, M., *et al*. "A Continuous Tumor Cell Line from a Human Lung Carcinoma with Properties of Type II Alveolar Epithelial Cells." *International Journal of Cancer* 1976, 17(1), 62-70.
## Revision History
| Revision # | Effective Date | Summary of Revisions |
| ---------- | ---------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| 1 | February 4, 2020 | Original Instructions for Use |
| 2 | March 15, 2020 | • Intended use update • Removal of N3 primer and probe set from Diagnostic Panel • Performance data update • Addition of alternative nucleic acid extraction platforms • Addition of acceptable alternatives to HSC and addition of QIAGEN RUO extraction reagents • Positive results no longer presumptive. No confirmation of positive results required |
| 3 | March 30, 2020 | • Addition of alternative enzyme master mix options |
| 4 | June 12, 2020 | • Addition of MagNA Pure 24 extraction method • Addition of performance data for the MagNA Pure 96 extraction method with SARS-CoV-2 • Addition of heat treatment alternative to specimen extraction • Addition of Roche and QIAGEN external lysis buffer alternatives • Acknowledgment of FDA policy permitting end users to qualify alternative components without seeking an EUA or EUA amendment |
| 5 | July 13, 2020 | • Addition of Promega Maxwell® RSC 48 extraction method • Update to*in silico |
| 6 | December 1, 2020 | • Addition of specimen pooling instructions and monitoring procedure (Appendices B and C) • Addition of Promega Maxwell CSC 48 extraction instrument • Addition of data for CDC testing of FDA reference panel |
||
## Contact Information, Ordering, and Product Support
For technical and product support, contact the CDC Division of Viral Diseases directly. Send email to: respvirus@cdc.gov
Note: If your laboratory is using reagents sourced from someone other than the CDC International Reagent Resource, please refer to the manufacturer’s instructions provided with the commercial materials.
## Appendix A: Heat Treatment Alternative to Extraction UltraPlex 1-Step ToughMix (4X)
**This procedure is only for use by public health laboratories.**
### Purpose:
In response to a global shortage of nucleic acid extraction reagents causing significant delays in testing, the CDC has investigated the use of a heat treatment method requiring minimal reagents as a specimen processing alternative to nucleic acid extraction for use with the 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
Where possible, laboratories should use qualified RNA or total nucleic acid extraction methods for processing of specimens for subsequent testing by the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel. Extraction removes inhibitory substances from specimens that could negatively impact PCR performance.
This procedure for use of heat treatment for specimen processing is only recommended when a shortage of qualified extraction reagents is a limiting factor in a laboratory’s ability to meet urgent
COVID-19 testing demand.
### Precautions/Warnings/Limitations:
• CDC has evaluated this heat treatment process and has determined that this process is effective for inactivation of SARS-CoV-2 in patient specimens.
• Performance was evaluated with only upper respiratory specimens. Heat treatment of lower respiratory specimens for subsequent testing by the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel has not been evaluated.
• This procedure for heat treatment of specimens is only for use with the Quantabio UltraPlex 1- Step ToughMix (4X).
• Heat treatment should only be conducted when a lab is ready to test the specimens by PCR. Testing of heat-treated specimens must be conducted the same day.
### Acceptable Specimens:
• Upper respiratory specimens
Note: Do not use heat treatment to process specimens that appear bloody or that contain particulate matter. Such specimens should be extracted using a qualified RNA or TNA extraction method prior to testing.
### Materials Required (not provided):
• 70% ethanol
• 10% bleach, freshly prepared
• 96-well PCR reaction plates (Applied Biosystems catalog \# 4346906, 4366932, 4346907, or equivalent)
• Optical strip caps (Applied Biosystems 4323032, or equivalent)
• 1.5 mL Sarstedt tubes or equivalent
• Aerosol resistant micropipette tips
• Micropipettes
• 96-well cold block
• Cold blocks for 1.5 mL - 2.0 mL tubes
• Vortex mixer
• 96-well plate centrifuge or equivalent
• Thermal cycler or equivalent
• Class II Biological Safety Cabinet (BSC)
### Procedure:
**Sample Preparation**
1\) Decontaminate BSC with 10% bleach followed by 70% ethanol.
2\) If samples are frozen, thaw on ice or at 4°C. Wipe the outside of the sample tube with 70% ethanol. Place thawed sample on cold rack or ice in BSC.
3\) Pulse vortex each sample and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
**Heat Treatment**
1\) Place a thermal cycler in the BSC, turn on, and program for 95°C for 1 min followed by 4°C hold.
2\) Place a 96-well PCR plate onto a cold rack or ice in the BSC.
3\) Transfer 100 µL of each sample to the 96-well PCR plate and securely cap each well using optical strip caps.
NOTE: Ensure that an HSC extraction control is included in each batch run as required under CLIA.
4\) Place this 96-well PCR plate on the pre-heated thermal cycler and start run. Leave plate on thermal cycler at 4°C, or place on ice or a cold block.
5\) Remove plate and centrifuge for 1 minute at 500 x *g* to pellet cellular debris.
6\) Place plate on a cold rack or ice and proceed to testing the supernatant by rRT-PCR. 7) Testing of heat-treated specimens must be conducted the same day heat treatment is performed. For long term storage, keep the original specimen at ≤-70°C.
### Special Testing Considerations for Heat Treated Specimens:
**Enzyme Master Mix**
• Testing of specimens that have been processed with heat treatment should be conducted with the **Quantabio UltraPlex 1-Step ToughMix (4X)**, which demonstrated the best performance with heat treated specimens. PCR testing of heat-treated specimens should follow the instructions in the main body of this Instructions for Use document.
**Resolution of Inconclusive and Invalid Results**
• Retesting of heat-treated specimens that generated an inconclusive or invalid result must include extraction of the original specimen with a qualified RNA or total nucleic acid (TNA) extraction method, if available. Do not re-test the heat-treated specimen material to resolve inconclusive or invalid test results.
### Verification:
CDC recommends performance of verification studies for the heat treatment method prior to diagnostic use that includes side-by-side preparation of a panel of positive and negative clinical specimens using a qualified extraction method and this heat treatment method with subsequent testing by the CDC 2019- nCoV Real-Time RT-PCR Diagnostic Panel.
### Performance Characteristics:
*Quantabio UltraPlex 1-Step ToughMix (4X)*
*Limit of Detection Comparison*
Serial dilutions of inactivated SARS-CoV-2 \[SARS-CoV-2 USA-WA1/2020\] were prepared in simulated specimen material (human A549 cells suspended in viral transport medium). Each concentration was prepared side-by-side five times by both EZ1 extraction and by heat treatment. Each extracted or heat treated sample was subsequently tested by the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel using the Quantabio UltraPlex 1-Step ToughMix (4X) on the Applied Biosystems 7500 Fast Dx instrument.
Observed detection was similar between the two specimen preparation methods.
**Table 1: UltraPlex Limit of Detection Comparison between QIAGEN EZ1 Advanced XL extraction and heat treatment (95°C for 1 min) method – Summary Results**
| Enzyme | Platform | Parameter | 2019-nCoV_N1 Assay | | | | | 2019-nCoV_N2 Assay | | | | | Observed LoD(1 ) |
| ------------------------------------------------------- | ------------------------ | ------------------- | ------------------ | ---------------- | ---------------- | ----------------- | ----------------- | ------------------ | ----------------- | ---------------- | ----------------- | ----------------- | ------------------------- |
| Quantabio UltraPlex 1-Step ToughMix (4X)
5 µL Template Addition | QIAGEN EZ1 Advanced XL | RNA copies/µL | 10(1.0) | 10(0.5) | 10(0.0) | 10(-0.5) | 10(-1.0) | 10(1.0) | 10(0.5) | 10(0.0) | 10(-0.5) | 10(-1.0) | 10(0.5) |
| | | # pos./total | 5/5 | 5/5 | 4/5 | 4/5 | 3/5 | 5/5 | 5/5 | 5/5 | 2/5 | 2/5 | |
| | | Mean Ct(2) | 34.11 | 34.59 | NA | NA | NA | | 32.97 33.76 34.70 | | NA | NA | |
| | | Std. Deviation | 0.75 | 0.99 | NA | NA | NA | 0.33 | 0.72 | 0.98 | NA | NA | |
| | Heat Treatment 95°C for 1 min | RNA copies/µL | 10(1.0) | 10(0.5) | 10(0.0) | 10(-0.5) | 10-(1.0) | 10(1.0) | 10(0.5) | 10(0.0) | 10(-0.5) | 10(-1.0) | 10(0.5) |
| | | # pos./total | 5/5 | 5/5 | 4/5 | 5/5 | 1/5 | 5/5 | 5/5 | 4/5 | 2/5 | 1/5 | |
| | | Mean Ct(2) | 33.41 | 34.32 | NA | 36.73 | NA | | 33.45 35.25 | NA | NA | NA | |
| | | Std. Deviation | 0.62 | 0.40 | NA | 0.82 | NA | 0.40 | 0.80 | NA | NA | NA | |
||
(1)Concentration is presented in RNA copies/µL. The observed LoD is the lowest concentration where both assays showed 100% positive detection.
(2)Mean Ct reported for dilutions that show 100% positivity. Calculations only include positive results.
NA = not applicable
*Clinical Comparison*
A panel of 39 upper respiratory specimens were tested side-by-side using extraction with the Qiagen EZ1 extraction instrument and heat treatment. Extracted and heat-treated specimens were subsequently tested with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel using the Quantabio UltraPlex 1-Step
ToughMix (4X). Qualitative results were compared to demonstrate agreement.
**Table 2: Clinical Comparison Results Summary – Heat Treatment versus QIAGEN EZ1 Advanced XL**
| | Test Result | Heat Treatment | | | Total | Positive % Agreement (CI)(1) | Negative % Agreement (CI)(1) |
| --------------------- | ------------ | -------------- | ------------ | -------- | ----- | ------------------------------------- | ------------------------------------- |
| | | Positive | Inconclusive | Negative | | | |
| QIAGEN EZ1Advanced XL | Positive | 18 | 1 | 0 | 19 | 94.7 (75.4-99.1) | 100 (83.9-100) |
| | Inconclusive | 0 | 0 | 0 | 0 | | |
| | Negative | 0 | 0 | 20 | 20 | | |
| | Total | 18 | 1 | 20 | 39 | | |
||
(1)CI = 95% confidence interval
### Questions and Comments:
If you have questions or comments about this procedure, please send by email to: respvirus@cdc.gov
## Appendix B: Pooled Specimen Preparation and Processing
### Purpose:
In response to strong demand for higher throughput testing approaches as well as a global shortage of nucleic acid extraction reagents causing significant delays in testing, the CDC has evaluated specimen pooling and determined that pooling of up to 4 specimens is suitable for use with the 2019-nCoV Real Time RT-PCR Diagnostic Panel.
Specimen pooling may cause a slight reduction in test sensitivity and therefore may be most appropriate for screening or diagnostic testing when laboratory staff, equipment or reagents are insufficient to accommodate testing demand. Specimen pooling only presents a throughput advantage when the disease prevalence is low. Therefore, laboratories should monitor specimen positivity rates over time to determine if pooling of specimens continues to provide a test throughput advantage over individual specimen testing. Please see Appendix C for more detail on implementation considerations.
While this procedure describes the process to prepare, process and test a pool size of up to 4 specimens, specimen pool sizes from 2-4 are authorized for use with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel. When using a pool size less than 4 specimens, please use the following instructions as a model. Pooled specimen input volume and the pooled specimen to lysis buffer volume ratios must remain as prescribed below (not a lower proportion of lysis buffer) to ensure inactivation of SARS-CoV-2 in patient specimens. An N-pool specimen approach should include equal volumes of each of the N specimens pooled together to create the total pooled specimen input volume required under the below pooled specimen extraction instructions.
### Precautions/Warnings/Limitations:
• Pooling of specimens has the potential to decrease sensitivity. The specimens in a pooled procedure are diluted, which could result in a low concentration of viral genetic material below the limit of detection of a given test.
• When pooling specimens, the laboratory cannot ensure the diagnostic integrity of an individual specimen because it is combined with other specimens before testing. Specimen integrity can be affected by the quality of swab specimen collection, which could result in some swabs having limited amounts of viral genetic material for detection. Inadequate individual specimens, including those with limited amounts of viral genetic material, might not be eliminated from the pooled specimen before testing and may be reported as negative through this process.
• Performance of this specimen pooling process was evaluated with nasopharyngeal (NP) swabs.
Pooling of other types of specimens for subsequent testing with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel has not been evaluated, however evidence suggests the Ct value distribution for other upper respiratory swab specimens is similar to that observed for NP swab specimens.
• Pooling should only be implemented in laboratories with a minimum of 10 days experience using the CDC 2019-nCoV Real-time RT-PCR Diagnostic Panel for diagnostic testing in the population of specimens being considered for pooling.
• This procedure for pooling of specimens has only been evaluated for use with the QIAGEN EZ1
Advanced XL, Roche MagNA Pure 96, and the Promega Maxwell RSC 48 instruments. Pooling using other extraction methods is not authorized under this EUA.
• Sufficient volume of specimens must be available to allow subsequent extraction and testing of individual specimens should the specimen pool test positive, inconclusive or invalid. • Appropriate interpretation, reporting and next steps may be different for surveillance testing and are not limited by the diagnostic interpretation instructions below.
• Laboratories are encouraged to revisit the question of whether pooling continues to make sense when testing demand no longer exceeds laboratory capacity and/or when testing reagents are no longer in short supply.
### Acceptable Specimen Types:
• Upper respiratory swabs (e.g., nasopharyngeal (NP) swabs, oropharyngeal (OP) swabs, NP/OP swabs combined, nasal swabs)
Note: Specimens must have adequate volume to support pooled specimen testing and any subsequent individual re-testing.
### Overview of Pooled Specimen Testing:
This flow chart provides an overview of the steps involved in pooled specimen testing and location of the instructions for each step within the document. For those steps that are identical for both individual specimen testing and for pooled specimen testing, instructions are found in the main body of the instructions for use. For steps in which pooled specimen testing differs from individual specimen testing, instructions specific to pooled specimen testing are presented in this Appendix.
```mermaid
flowchart TD
A["Sample Pool
Preparation"] --> B["Retain specimen
for individual
testing if needed"]
A --> C["Create Pool by adding
an equal volume of
each specimen (per
extraction platform)"]
C --> D["Follow pooling
extraction instructions
(Appx. B)"]
D --> E["Instructions for Use Assay
Setup (p. 16-19)"]
E --> F["Running a Test (p. 29-31)"]
F --> G["Data Analysis (p. 32-33)"]
G --> H["Interpret Extraction and
Run Controls (p. 34-36)"]
H --> I["Use Appx. B
instructions for
interpretation"]
I --> J{"Positive, Inconclusive,
or Invalid Result"}
I --> K["Negative Result"]
J -- "Positive" --> L["Do NOT report
pooled result,
test each specimen
individually"]
J -- "Inconclusive" --> L
J -- "Invalid" --> L
K --> M["Report pooled test result:
Not Detected"]
```
### Procedure:
**Specimen Pool Preparation**
1\) Decontaminate BSC with 10% bleach followed by 70% ethanol.
2\) If specimens are frozen, thaw on ice or at 4°C. Wipe the outside of the specimen tube with 70% ethanol. Place thawed specimen on cold rack or ice in BSC.
3\) Pulse vortex each specimen and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
4\) For each specimen pool, add an equal volume of each specimen (depending on total volume needed for extraction platform) to be included into the pool, into a sterile, nuclease-free tube.
5\) Pulse vortex each specimen pool and briefly centrifuge to collect the liquid at the bottom of the tube.
6\) Proceed to extraction using the modified extraction parameters below.
**Extraction Instructions**
**NOTE: These pooled specimen extraction instructions have been modified to optimize**
**recovery of nucleic acid when processing pooled specimens. When testing individual**
**specimens, please follow the individual specimen extraction instructions (p. 14-16).**
**QIAGEN EZ1 Advanced XL**
• Kit: Qiagen EZ1 DSP Virus Kit and Buffer AVL (supplied separately) for offboard lysis
• Card: EZ1 Advanced XL DSP Virus Card
• Instructions: Add 200 μL of pooled specimen to 200 μL of pre-aliquoted Buffer AVL (total input sample volume is 400 μL). Proceed with the extraction on the EZ1 Advanced XL. Elution volume is 60 μL.
**Roche MagNA Pure 96**
• Kit: Roche MagNA Pure 96 DNA and Viral NA Small Volume Kit
• Protocol: Viral NA Plasma Ext LysExt Lys SV 4.0 Protocol or Viral NA Plasma Ext Lys SV Protocol
• Instructions: Add 225 μL of pooled specimen to 225 μL of pre-aliquoted MagNA Pure 96 External Lysis Buffer (supplied separately) for total input sample volume of 450 μL. Proceed with the extraction on the MagNA Pure 96. (Internal Control = none).
• Elution volume is 50 μL.
**Promega Maxwell RSC 48 or Maxwell CSC 48**
• Kit: Promega Maxwell® Viral Total Nucleic Acid Purification Kit
• Protocol: Viral Total Nucleic Acid
• Instructions: Add 240 μL of pooled specimen to 660 μL of pre-aliquoted External Lysis Buffer
(600 μL Lysis Buffer plus 60 μL Proteinase K; supplied within the kit) (total input volume is 900 μL). Proceed with the extraction on the Maxwell® RSC 48 or Maxwell CSC 48.
• Elution volume is 50 μL.
**Testing, Interpretation, and Reporting Instructions**
1\) After extraction, continue PCR testing using the steps outlined in the following sections of the Instructions for Use: Assay Set Up (p. 16-20), Running a Test (p. 29-32) and Data Analysis
(p. 33-34).
2\) Interpret controls and PCR test results as outlined in the following sections of the Instructions for Use: Interpretation of Results and Reporting (p. 35-37), 2019-nCoV rRT-PCR Diagnostic Panel Results Interpretation Guide (p. 38). All extraction and PCR run controls must perform as expected.
A. If a specimen pool generates **negative** results, report “Not Detected” for each specimen included in the pool. The test result report should include a statement that the specimen was tested in a pooled format. No further testing is required.
B. If a specimen pool generates a **positive** result, do not report the result. Test each specimen included in the pool individually, according to the Instructions for Use. Report the individual result for each specimen.
C. If a specimen pool generates an **inconclusive** result, do not report the result. Test each specimen included in the pool individually, according to the Instructions for Use. Report the individual result for each specimen.
D. If a specimen pool generates an **invalid** result, do not report the result. Test each specimen within the pool individually, according to the Instructions for Use. Report the individual result for each specimen.
### Verification:
Verification should be conducted by all laboratories prior to implementing pooling for diagnostic testing.
In addition to method verification studies, verification must include a validation of the accuracy and function of the laboratory’s process of specimen and pool labeling, tracking and reporting through the laboratory information management system(s).
### Performance Characteristics:
*Pooling Validation*
A panel of 20 positive, previously characterized nasopharyngeal (NP) specimens, with 25% (5) representing the weak positive range (Ct 36.00-39.99), were used for evaluation of specimen pooling with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel; 80 negative NP specimens were also included. These specimens were used to create twenty positive 4-specimen pools, by combining one positive specimen with three negative specimens. Twenty negative pools were also created by combining equal volumes of four negative specimens. These pools were tested and qualitative results from pooled-testing were compared with the results from individual-testing to determine the positive and negative percent agreement of the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel for testing using 4-specimen pools. The performance of 4-specimen pooling was evaluated using the QIAGEN EZ1®
Advanced XL, the Promega Maxwell RSC 48, or the Roche MagNA Pure 96 platforms. Modifications were made to the input and output volume for each extraction platform, for pooling patient specimen, to compensate for the dilution effect due to pooling.
*QIAGEN EZ1® Advanced XL*
Individual positive panel members and positive and negative pools were extracted using the QIAGEN
EZ1® Advanced XL platform for subsequent testing on the Applied Biosystems 7500 Fast Dx with the Thermo Fisher TaqPath™ 1-Step RT-qPCR Master Mix, CG. Results obtained for twenty, 4- specimen pools were compared with the results from individual testing. Pools containing a positive specimen were considered to be in agreement with results from individual testing if the pool generated positive or inconclusive results (i.e., at least one of the SARS-CoV-2-specific primer and probe sets generated a Ct value less than 40). Negative specimen pools were considered to be in agreement with expected results if the pooled specimen result was negative (i.e., neither SARS-CoV-2-specific primer and probe set generated positive results).
A comparison of qualitative test results from individual testing of panel members with pooled specimen testing is summarized below in Table 1, along with testing agreement with results from individual testing for positive and negative specimen pools. Of the five positive specimen panel members in the weak positive category (determined by original diagnostic results): one returned an inconclusive result when tested individually, but returned a positive result when tested in a 4-specimen pool; one returned a negative result when tested individually, but returned a positive result when tested in a 4-specimen pool; and three were in agreement when tested individually and in 4-specimen pools.
**Table 1 -Summary of Pooled vs. Individual-testing - QIAGEN EZ1® Advanced XL**
| Test Platform | | Individual testing result | | | Positive PoolsPercent Agreement (CI)(1 ) | Negative PoolsPercent Agreement (CI)(1 ) |
| ------------------------ | ------------------------ | ------------------------- | ------------------------ | -------- | ------------------------------------------------- | ------------------------------------------------- |
| | Result | Positive | Inconclusive(†) | Negative | | |
| 4-specimenPooling Result | Positive | 17 | 1 | 1 | 100% (82.4-100) | 95.2% (77.3-99.2) |
| | Inconclusive(‡) | 1 | 0 | 0 | | |
| | Negative | 0 | 0 | 20 | | |
||
(1)CI = 95% confidence interval
(†)Inconclusive individually-tested results are not included in the final performance calculations.
(‡)Inconclusive pooled results are considered in agreement with the positive individually-tested results for the final performance calculations.
*Promega Maxwell RSC 48*
Individual positive panel members and positive and negative pools were extracted using the Promega
Maxwell RSC 48 platform for subsequent testing on the Applied Biosystems 7500 Fast Dx with the Thermo Fisher TaqPath™ 1-Step RT-qPCR Master Mix, CG. Results obtained for twenty, 4- specimen pools were compared with the results from individual testing. Pools containing a positive specimen were considered to be in agreement with the results from individual testing if the pooled specimen generated positive or inconclusive results (i.e., at least one of the SARS-CoV-2-specific primer and probe sets generated a Ct value less than 40). Twenty negative specimen pools (made from 4 known negative specimens) were considered to be in agreement with expected results if the pooled specimen result was negative (i.e., neither SARS-CoV-2-specific primer and probe set generated positive results).
A comparison of qualitative test results from individual testing of panel members with pooled specimen testing is summarized below in Table 2, along with testing agreement with results from individual testing for positive and negative specimen pools. Of the five positive specimen panel members in the weak positive category (determined by original diagnostic results): one returned a positive result when tested individually, but returned a negative result when tested in a 4-specimen pool; and four were in agreement when tested individually and in 4-specimen pools. Additionally, one moderate to high positive panel member returned an inconclusive result when tested individually but returned a positive result when tested in a 4-specimen pool.
**Table 2 -Summary of Pooled vs. Individual-testing Results – Promega Maxwell RSC 48**
| Test Platform | | Individual-testing result | | | Positive PoolsPercent Agreement (CI)(1 ) | Negative PoolsPercent Agreement (CI)(1 ) |
| ------------------------ | ------------------------ | ------------------------- | ------------------------ | -------- | ------------------------------------------------- | ------------------------------------------------- |
| | Result | Positive | Inconclusive(†) | Negative | | |
| 4-specimenPooling Result | Positive | 16 | 1 | 0 | 94.7% (75.4-99.1) | 100% (83.9-100) |
| | Inconclusive(‡) | 2 | 0 | 0 | | |
| | Negative | 1 | 0 | 20 | | |
||
(1)CI = 95% confidence interval
(†)Inconclusive individually-tested results are not included in the final performance calculations.
(‡)Inconclusive pooled results are considered in agreement with the positive individually-tested results for the final performance calculations.
*MagNA Pure 96*
Individual positive panel members and positive and negative pools were extracted on the MagNA Pure 96 platform for subsequent testing on the Applied Biosystems 7500 Fast Dx using the Thermo
Fisher TaqPath™ 1-Step RT-qPCR Master Mix, CG. Results obtained for twenty, 4-specimen pools were compared with the results from individual testing. Pools containing a positive specimen were considered to be in agreement with the results from individual testing if the pooled specimen generated positive or inconclusive results (i.e., at least one of the SARS-CoV-2-specific primer and probe sets generated a Ct value less than 40). Twenty negative specimen pools (made from 4 known negative specimens) were considered to be in agreement with expected results if the pooled specimen result was negative (i.e., neither SARS-CoV-2-specific primer and probe set generated positive results).
A comparison of qualitative test results from individual testing of panel members with pooled specimen testing is summarized below in Table 3, along with testing agreement with results from individual testing for positive and negative specimen pools. Of the five positive specimen panel members in the weak positive category (determined by original diagnostic results): one returned an inconclusive result when tested individually, but returned a positive result when tested in a 4-specimen pool; and four were in agreement when tested individually and in 4-specimen pools.
**Table 3 -Summary of Pooled vs. Individual-testing Results – Roche MagNA Pure 96**
| Test Platform | | Individual-testing result | | | Positive PoolsPercent Agreement (CI)(1 ) | Negative PoolsPercent Agreement (CI)(1 ) |
| ------------------------ | ------------------------ | ------------------------- | ------------------------ | -------- | ------------------------------------------------- | ------------------------------------------------- |
| | Result | Positive | Inconclusive(†) | Negative | | |
| 4-specimenPooling Result | Positive | 18 | 1 | 0 | 100% (83.2-100) | 100% (83.9-100) |
| | Inconclusive(‡) | 1 | 0 | 0 | | |
| | Negative | 0 | 0 | 20 | | |
||
(1)CI = 95% confidence interval
(†)Inconclusive individually-tested results are not included in the final performance calculations.
(‡)Inconclusive pooled results are considered in agreement with the positive individually-tested results for the final performance calculations.
In Silico *Sensitivity*
An *in silico* analysis was conducted to evaluate the effect of 4-sample pooling on the clinical sensitivity of the CDC 2019-Novel Coronavirus Real-Time RT-PCR Diagnostic Panel using the QIAGEN EZ1® Advanced
XL extraction platform. This analysis was conducted by performing a Passing-Bablok regression using the “Pooling Validation” data to calculate the Ct shifts resulting from the dilution effect of 4-specimen pools (1 positive specimen combined with 3 negative specimens) for each target. In the regression analysis, the X-axis displayed individual Ct values for positive specimens and the Y-axis displayed Ct values for the corresponding pools with one positive specimen and 3 negative specimens. The regression analysis was used to calculate an interval of Ct values \[X\*, 40\] where individual specimens with Ct values within this interval would have negative results in 4-specimen pools (1 positive and 3 negative).
The results from individually-tested NP swab specimens processed at the CDC using the QIAGEN EZ1® Advanced XL extraction platform (n= 381), were analyzed to determine an *in silico* PPA for 4-specimen pooling. The number of individual specimens with Ct values ranging from \[X\*, 40\] was determined. The X\* value for the N1 target was 37.2 and the X\* value for the N2 target was 37.5. The results, summarized
Table 4, show that 97.1% (370/381 95% CI 94.9-98.3%) of the specimens would not have negative results when combined into 4-specimen pools.
**Table 4. *in silico* Sensitivity for Pooled Specimens Extracted using the QIAGEN EZ1® Advanced XL**
| n | N1 Interval [X*, 40] | Number of samples with N1 Ct values in the interval | N2 Interval [X*, 40] | Number of samples with N2 Ct values in the interval | Number of Samples with both target Ct values in intervals | Neg | Inc | Pos | % Positive Percent Agreement* |
| --- | -------------------- | --------------------------------------------------- | -------------------- | --------------------------------------------------- | --------------------------------------------------------- | --- | --- | --- | ----------------------------- |
| 381 | [37.2, 40] | 16 | [37.5, 40] | 63 | 11 | 11 | 57 | 313 | 97.1 |
||
(\*)Since any pool that is not negative is re-tested as individual samples, the Positive Percent Agreement includes all pools that were not negative.
The specimens submitted to CDC for testing included many that had generated inconclusive results in the hands of public health laboratories and were forwarded to CDC for further testing. Thus, specimens received by CDC for testing overrepresent the weak positive category. The CDC also obtained the results of individually-tested NP swab specimens from three additional geographic locations: state lab 1 (n= 2217), state lab 2 (n= 6559), and state lab 3 (n= 2315). These data sets were analyzed with regard to the percent of weak positives (Ct 36.00-39.99) collected at each site. The results, summarized in Table 5, suggest that the percent of weak positive NP specimens received at State Health Department laboratories is smaller than that obtained at CDC. Therefore, the *in silico* analysis, summarized in Table 4, presents a PPA in a scenario where 4-specimen pooling is applied to testing populations with a greater than average number of weak positive specimens.
**Table 5. Percent of Weak Positive Specimens at CDC Compared with Three Geographic Locations**
| | n | Ct < 36.0 | | Ct 36.0 - 39.99 | |
|---------|------|---------------|---------------|-----------------|--------------|
| | | N1 | N2 | N1 | N2 |
| CDC | 381 | 314 (82.4 %) | 254 (66.7 %) | 67 (17.6 %) | 127 (33.3 %) |
| State 1 | 2217 | 2121 (95.7 %) | 2021 (91.2 %) | 150 (6.8 %) | 250 (11.3%) |
| State 2 | 6559 | 6343 (96.7 %) | 5883 (89.7 %) | 216 (3.3%) | 676 (10.3%) |
| State 3 | 2315 | 2073 (89.5 %) | 1884 (81.4 %) | 242 (10.5 %) | 431 (18.6 %) |
||
### References:
1\. Abdalhamid, B., *et al.* “Assessment of Specimen Pooling to Conserve SARS CoV-2 Testing
Resources.” *Am J Clin Path* 2020, 153, 715-718.
### Questions and Comments:
If you have questions or comments about this procedure, please send by email to: respvirus@cdc.gov
## Appendix C: Implementation and Monitoring of Pooled Specimen Testing
Purpose:
These instructions are intended to assist laboratories and jurisdictions to implement and monitor the efficiency and effectiveness of pooled specimen testing over time. A laboratory should have a minimum of 10 days experience performing the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel for diagnostic testing within the intended population prior to implementation of a pooling strategy. Laboratories should weigh the potential risks associated with pooling as described in Appendix B against the benefits of pooling for their laboratory and patient population. When pooling has been implemented to address overwhelming testing demands and/or scarcity of testing materials, laboratories should consider a return to individual specimen testing when laboratory capacity and resources permit.
Prior to Implementation of a Specimen Pooling Strategy:
• Determine the individual specimen positivity rate (PIndividual) for your testing population. Before implementation of specimen pooling, evaluate test data from the testing population for the previous 7-10 days to estimate the positivity rate (PIndividual) which is the number of positive results divided by the total number of specimens tested during these 7-10 days. PIndividual will be used to determine if pooling should be considered and will be used to monitor the performance of your pooling strategy.
**Note**: To calculate the efficiency of 4-sample pooling, using PIndividual, apply the formula F=1/(1+ 1/n-(1- PIndividual)(n)), where F is the efficiency and n is the pool size. For example, when PIndividual is 1%, the efficiency, F, is 3.46 for n = 4. This means that 1,000 tests can cover testing of 3,460 patients on average, which translates to a reduction in test volume of 71%. Using this formula, a pool size of n = 3 produces a greater efficiency than n = 4 at PIndividual ≥ 13%.
• Identify your positivity thresholds.
**Table 1: Association Between Individual Specimen Positivity Rates and Reduction in Test Volume with Pooling**
| Specimen Positivity Rate (P) | No. tests with 4 specimen pooling for 300 patients | Reduction in testing volume with 4 specimen pooling | No. tests with 3 specimen pooling for 300 patients | Reduction in testing volume with 3 specimen pooling | No. tests with 2 specimen pooling for 300 patients | Reduction in testing volume with 2 specimen pooling |
| ---------------------------- | -------------------------------------------------- | --------------------------------------------------- | -------------------------------------------------- | --------------------------------------------------- | -------------------------------------------------- | --------------------------------------------------- |
| 1% | 87 | 71% | 109 | 64% | 156 | 48% |
| 2% | 98 | 67% | 118 | 61% | 162 | 46% |
| 3% | 109 | 64% | 126 | 58% | 168 | 44% |
| 4% | 120 | 60% | 135 | 55% | 174 | 42% |
| 5% | 131 | 56% | 143 | 52% | 179 | 40% |
| 6% | 141 | 53% | 151 | 50% | 185 | 38% |
| 8% | 160 | 47% | 166 | 45% | 191 | 36% |
| 10% | 178 | 41% | 181 | 40% | 207 | 31% |
| 11% | 187 | 38% | 189 | 37% | 212 | 29% |
| 12% | 195 | 35% | 196 | 35% | 218 | 27% |
| 13% | 203 | 32% | 202 | 33% | 223 | 26% |
||
| Specimen Positivity Rate (P) | No. tests with 4 specimen pooling for 300 patients | Reduction in testing volume with 4 specimen pooling | No. tests with 3 specimen pooling for 300 patients | Reduction in testing volume with 3 specimen pooling | No. tests with 2 specimen pooling for 300 patients | Reduction in testing volume with 2 specimen pooling |
| ---------------------------- | -------------------------------------------------- | --------------------------------------------------- | -------------------------------------------------- | --------------------------------------------------- | -------------------------------------------------- | --------------------------------------------------- |
| 14% | 211 | 30% | 209 | 30% | 228 | 24% |
| 15% | 218 | 27% | 216 | 28% | 233 | 22% |
| 16% | 226 | 25% | 222 | 26% | 238 | 21% |
| 17% | 233 | 22% | 228 | 24% | 243 | 19% |
| 18% | 239 | 20% | 235 | 22% | 248 | 17% |
| 19% | 246 | 18% | 241 | 20% | 253 | 16% |
| 20% | 252 | 16% | 246 | 18% | 258 | 14% |
||
**Note**: Table 1 does not account for running the positive, negative, and extraction controls with each plate. **Note**: Unshaded cells indicate the optimal reduction in testing volume compared to other the pool sizes.
Table 1 presents the estimated increase in efficiency achieved through pooling at different rates of specimen positivity. Laboratories are encouraged to use this table and factor in additional testing necessary to monitor the effectiveness of pooling to determine the specimen positivity thresholds (PThreshold) at which (1) four-specimen pooling is appropriate, (2) smaller specimen pools are appropriate, and (3) the threshold at which specimen pooling offers no testing capacity/reagent consumption advantages. These thresholds should be documented for your laboratory’s pooling monitoring process.
Example: a laboratory might consider a 30% reduction in test volume as the minimum required reduction in test volume to be considered beneficial (this is subjective). Thus, the laboratory would set a positivity threshold (PThreshold) at 12%(2) for 4 specimen pooling, 14% for 3 specimen pooling, and 10% or less for 2 specimen pooling.
NOTE: It is recommended that PThreshold should not be greater than 20% for any pool size.
Moreover, laboratories may choose a threshold positivity rate lower than 20% for when to consider a pooling strategy.
• Define and document a specimen pooling strategy/process for your laboratory.
• Verify laboratory performance of pooled specimen testing (CLIA requirement).
• Establish and implement a pooling monitoring process appropriate to assure the quality of results generated through the laboratory’s pooling strategy. The pooling monitoring process should document the laboratory’s PThreshold for each pool size, PIndividual and the laboratory’s process to address the monitoring requirements below.
• Please note that information from the monitoring process described in this Appendix may not be the only information useful to monitor for pooling performance issues or to aid in decision-making for pooling strategy. Thus, laboratories are encouraged to monitor other sources of COVID-19 prevalence or test positivity rate information for their target population, comparing those trends to (2)At PIndividual ≥ 13%, n=3 offers a greater efficiency than n=4, therefore it is recommended that PThreshold should not be greater than 12% for n=4.
their pooling testing trends, as part of the laboratory’s pooling monitoring process in addition to the approach below.
Monitoring of the Pooling Strategy
At regular intervals (weekly at a minimum, continual analysis with a moving 7-10 day average preferred), laboratories must monitor the positivity rate of specimen pools as described below.
Figure 1: Overview of Pooling Monitoring Process to be Conducted at Defined Intervals
```mermaid
flowchart TD
A["Assess current testing demand and reagent availability.
Will laboratory continue pooled specimen testing?"]
A -- "Yes" --> B["Calculate PPool for the interval."]
A -- "No" --> C["Stop pooling."]
B --> D{"Is PPool lower than PThreshold for the number
of specimens being pooled?"}
D -- "No" --> E["Reduce pool size
or stop pooling."]
D -- "Yes" --> F{"Is PPool less than 0.85 x PIndividual?"}
F -- "No" --> K["Continue pooled
specimen testing."]
F -- "Yes" --> G{"Conduct re-assessment of pooling.
Did re-assessment indicate pooling is still
appropriate?"}
G -- "No" --> H["Stop pooling."]
G -- "Yes" --> I["Set new PIndividual based on re-assessment
data. Document for future monitoring
activities."]
I --> K
```
Data Monitoring Steps to Be Conducted at Each Interval
1\. Evaluate need for pooled specimen testing going forward.
Evaluate test demand and testing resource availability. When testing capacity and resource availability are sufficient to meet testing demand without the use of specimen pooling, consider whether the risks of reduced test sensitivity with pooling and extra effort of pooling outweigh the benefits of pooled specimen testing.
2\. Calculate Pooled Percent Positive (PPool) for the interval.
PPool = Specimens tested under pooling strategy generating positive results
Total specimens tested under pooling strategy 3\. Check Interval PPool Against Positivity Threshold (PThreshold) for the pool size in use. Compare the PPool for the current interval to the specimen positivity threshold established during pooling implementation.
• If PPool is greater than PThreshold for the pool size in use, consider a reduction in pool size or discontinuation of specimen pooling until specimen positivity rates decrease in your testing population.
• If PPool is less than PThreshold, proceed to step 4.
4\. Check Interval PPool Against Re-assessment Criteria
Compare PPool to PIndividual.
• If PPool is equal to or greater than 85% of PIndividual. (PPools ≥ 0.85 × PIndividual), then monitoring checks are complete for this interval. Proceed with the current pooling strategy.
• If PPool is less than 85% of PIndividual. (PPools < 0.85 × PIndividual), re-assessment is necessary to determine if pooled-specimen testing process is still acceptable. Please proceed to the Re-assessment of Pooling section below.
5\. Update PIndividual if Indicated by Re-assessment.
If re-assessment is conducted and indicates n-specimen pooling is still acceptable, re-establish PIndividual in your laboratory using the data generated during re-assessment.
If 10 positive specimens were tested during re-assessment: 10 positive specimens used for re-assessment(10) PIndividual = X (The\ total\ number\ of\ specimens\ tested\ to\ reach\ 10\ positive\ specimens\ 11) If 20 positive specimens were tested during re-assessment: 20 positive specimens used for re-assessment(20) PIndividual = X (The\ total\ number\ of\ specimens\ tested\ to\ reach\ 20\ positive\ specimens) 21 This updated new positivity rate should be used as PIndividual in the future monitoring.
Explanation: This calculation attempts to estimate the individual testing positivity rate in the population from which the 10 (or 20) individual positive samples were collected for re assessment. Since the total number of samples (N\*) that needed to be tested to obtain 10 (or
20\) consecutive positive samples for re-assessment is stopped at the 10(th) (or 20(th)) positive sample, then the positivity rate of 10/N\* (or 20/N\*) may be overestimated. PIndividual is corrected in the above calculations by including an appropriate multiplier: estimated positivity rate for 10 positive sample re-assessment data is (10/N\*)×(10/11) and for 20 samples is (20/N\*)×(20/21).
Re-assessment of Pooling:
Re-assessment of pooling should be conducted as indicated by monitoring activities. Two possible approaches are presented below.
*Option 1*
Incoming patient specimens should be tested individually until the collection contains 10 positive specimens.
• Using these specimens, 10 *n*-specimen pools should be created and tested, each with 1 positive and (*n*-1) negative specimens.
• Calculate the PPA between individual testing results and pooled testing results.
**Note:** For the calculation of the PPA, all pools that generate positive or inconclusive result are considered in agreement with the individually-tested positive result.
*Option 2*
Incoming patient specimens can continue to be tested in pools.
• Re-assessment study should start from time T0 and should consist of individual sample testing in parallel with the pooled testing. However, since all non-negative sample pools require individual testing of all individual samples included in the pool as a part of the n-sample pooling and deconvoluting workflow, the re-assessment study essentially consists of testing individual samples from the negative n-sample pools.
• Re-assessment study may pause at time T1 when a minimum of 10 consecutive positive individual results are obtained, including both positive individual results generated from individual testing of samples from the non-negative sample pools following the n-sample pooling and deconvoluting workflow, and positive individual results obtained from individual testing of samples from the negative sample pools for the time period from T0 to T1 \[T0, T1\].
• Considering that number of positive individual sample results among negative pools is K, PPA between testing n-sample pools and assaying single specimens using the candidate test should be calculated as PPA (EUA Test pool vs. EUA Test individual) = 100% x (10-K)/10. It is critical that all consecutive positive samples from time period \[T0, T1\] are included in the PPA calculations. With regard to calculating the PPA, all non-negative results testing pooled samples should be counted as in agreement with positive individually tested results.
*Re-assessment Acceptance Criteria for Option 1 and Option 2*
• If the PPA between pooled-testing results and individual-testing results is ≥ 90% (9 out of 10 or 10 out of 10), then continuation of testing using *n*-specimen pooling is acceptable. • If the PPA between pooled-testing results and individual-testing results is less than 85%: o If PPA ≤ 70% (7 out of 10), reduce the pool size (consider n = 3) and repeat the re assessment testing with the new pool size until PPA of pooled compared to individual testing is ≥ 90% OR consider cessation of pooling patient specimens. o If PPA is 80% (8 out of 10), collect an additional 10 consecutive individually positive samples. Then, calculate the PPA from the combined data of 20 samples, between pooled testing results and individual testing results. If the PPA is ≥ 85%, then implementation of testing using n-sample pooling is acceptable. Or, to compensate for lost sensitivity, reduce the pool size (consider n = 3) and repeat the re-assessment testing with the new pool size until PPA of pooled compared to individual testing is ≥ 85%.
• If PPA of at least 85% cannot be reached for any pool size, cease pooling patient specimens. • If n-sample pooling is acceptable, return to step 5 in “Data Monitoring” to re-establish PIndividual.
Additional Resources: 1\. Abdalhamid, et al., Assessment of Specimen Pooling to Conserve SARS CoV-2 Testing resources, Amer J Clin Pathol., Vol 153, June 2020, Pages 715–718. https://doi.org/10.1093/ajcp/aqaa064.
2\. Advisory on feasibility of using pooled samples for molecular testing of COVID-19. https://www.icmr.gov.in/pdf/covid/strategy/Advisory\_on\_feasibility\_of\_sample\_pooling.pdf 3\. CDC, Interim Guidance for Use of Pooling Procedures in SARS-CoV-2 Diagnostic, Screening and Surveillance Testing. https://www.cdc.gov/coronavirus/2019-ncov/lab/pooling-procedures.html
Questions and Comments:
If you have questions or comments about this procedure, please send by email to: respvirus@cdc.gov.
*Division of Viral Diseases / Respiratory Viruses Branch*
CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel – Verification Requirements
***\*\*\* DO NOT DISCARD: Important product-specific information \*\*\****
**CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel – Verification Requirements**
Please consult the following guidance from the Centers for Medicare & Medicaid Services (CMS) regarding diagnostic tests under Emergency Use Authorization (EUA): https://www.cms.gov/Medicare/Provider-Enrollment-and Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions
Items/QSO18-19-CLIA
**INTENDED USE**
The CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel is a real time RT-PCR test intended for the qualitative detection of nucleic acid from SARS-CoV-2 in upper and lower respiratory specimens (such as nasopharyngeal or oropharyngeal swabs, sputum, lower respiratory tract aspirates, bronchoalveolar lavage, and nasopharyngeal wash/aspirate or nasal aspirate) collected from individuals suspected of COVID-19 by their healthcare provider(1).
This test is also for the qualitative detection of nucleic acid from the SARS-CoV-2 in pooled samples containing up to four of the individual upper respiratory swab specimens
(nasopharyngeal (NP), oropharyngeal (OP), NP/OP combined, or nasal swabs) that were collected using individual vials containing transport media from individuals suspected of COVID-19 by their healthcare provider. Negative results from pooled testing should not be treated as definitive. If a patient’s clinical signs and symptoms are inconsistent with a negative result or results are necessary for patient management, then the patient should be considered for individual testing. Specimens included in pools with a positive, inconclusive, or invalid result must be tested individually prior to reporting a result. Specimens with low viral loads may not be detected in sample pools due to the decreased sensitivity of pooled testing.
Testing is limited to laboratories certified under the Clinical Laboratory Improvement
Amendments of 1988 (CLIA), 42 U.S.C. § 263a, that meet the requirements to perform high complexity tests.
Results are for the identification of SARS-CoV-2 RNA. SARS-CoV-2 RNA is generally detectable in upper and lower respiratory specimens during infection. Positive results are indicative of active infection with SARS-CoV-2 but do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for treatment or other patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
Testing with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel is intended for use by trained laboratory personnel who are proficient in performing real-time RT-PCR assays. The CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel is only for use under a Food and Drug Administration’s Emergency Use Authorization.
**REQUIRED MATERIALS**
The 2019 novel coronavirus positive control (nCoVPC) is provided with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel and should be prepared according to the Instructions for (1) For this EUA, a healthcare provider includes, but is not limited to, physicians, nurses, pharmacists, technologists, laboratory directors, epidemiologists, or any other practitioners or allied health professionals.
Use. The nCoVPC consists of an RNA transcript of the 2019-nCoV N gene as well as human
RNase P gene segment. nCoVPC will yield a positive result with the following primer and probe sets: 2019-nCoV\_N1, 2019-nCoV\_N2, and RP.
Approximately 2 mL of an upper respiratory specimen (e.g. nasopharyngeal swab (NPS) in transport media) are needed for testing. Specimens may be pooled if less than 2 mL of one specimen is available.
Refer to CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel package insert (manufacturer instructions) for additional reagents, materials, and instructions.
**PRECAUTIONS**
This reagent should be handled in an approved biosafety level 2 (BSL-2) handling area to avoid contamination of laboratory equipment and reagents that could cause false positive results. This product is an RNA transcript and is non-infectious. However, the nCoVPC should be handled in accordance with Good Laboratory Practices.
Store reagent at appropriate temperatures (see Instructions for Use) and hold on ice when thawed.
Please use standard precautions when handling respiratory specimens.
**INSTRUCTIONS FOR PREPARING SAMPLES BEFORE EXTRACTION WITH THE** **QIAamp(®) DSP VIRAL RNA MINI KIT OR THE QIAamp(®) VIRAL RNA MINI KIT**
• Refer to the 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use for reconstitution of the materials for use. RNA should be kept cold during preparation and use. • Make a 1/10 dilution of nCoVPC by adding 5 ∝L of nCoVPC into 45 ∝L of nuclease-free water or 10 mM Tris.
• Aliquot 560 ∝L of lysis buffer into each of nine tubes labeled 1-9.
• Add 140 ∝L of upper respiratory specimen (e.g. NPS in viral transport media) into each of the nine labeled tubes with lysis buffer.
• To prepare samples at a moderate concentration, spike 14 ∝L of undiluted nCoVPC
(rehydrated as described in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel
Instructions for Use) into each tube labeled 1-3 containing lysis buffer and specimen.
• To prepare samples at a low concentration, spike 14 ∝L of 1/10 dilution of nCoVPC into each tube labeled 4-6 containing lysis buffer and specimen.
• To prepare negative samples, spike 14 ∝L of nuclease-free water into each tube labeled 7-9 containing lysis buffer and specimen.
• Perform extractions of all nine samples according to the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use.
**INSTRUCTIONS FOR PREPARING SAMPLES BEFORE EXTRACTION WITH THE QIAGEN EZ1(®) ADVANCED XL**
• Refer to the 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use for reconstitution of the materials for use. RNA should be kept cold during preparation and use. • Make a 1/10 dilution of nCoVPC by adding 5 ∝L of nCoVPC into 45 ∝L of nuclease-free water or 10 mM Tris.
• Aliquot 280 ∝L of lysis buffer into each of nine tubes labeled 1-9.
• Add 120 ∝L of upper respiratory specimen (e.g. NPS in viral transport media) into each of the nine labeled tubes with lysis buffer.
• To prepare samples at a moderate concentration, spike 12 ∝L of undiluted nCoVPC
(rehydrated as described in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel
Instructions for Use) into each tube labeled 1-3 containing lysis buffer and specimen.
• To prepare samples at a low concentration, spike 12 ∝L of 1/10 dilution of nCoVPC into each tube labeled 4-6 containing lysis buffer and specimen.
• To prepare negative samples, spike 12 ∝L of nuclease-free water into each tube labeled 7-9 containing lysis buffer and specimen.
• Perform extractions of all nine samples according to the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use.
**INSTRUCTIONS FOR PREPARING SAMPLES BEFORE EXTRACTION WITH THE ROCHE MagNA PURE TOTAL NUCLEIC ACID KIT OR THE ROCHE MagNA PURE NUCLEIC ACID**
**ISOLATION KIT I**
• Refer to the 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use for reconstitution of the materials for use. RNA should be kept cold during preparation and use. • Make a 1/10 dilution of nCoVPC by adding 5 ∝L of nCoVPC into 45 ∝L of nuclease-free water or 10 mM Tris.
• Aliquot 300 ∝L of lysis buffer into each of nine tubes labeled 1-9.
• Add 100 ∝L of upper respiratory specimen (e.g. NPS in viral transport media) into each of the nine labeled tubes with lysis buffer.
• To prepare samples at a moderate concentration, spike 12 ∝L of undiluted nCoVPC
(rehydrated as described in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel
Instructions for Use) into each tube labeled 1-3 containing lysis buffer and specimen.
• To prepare samples at a low concentration, spike 12 ∝L of 1/10 dilution of nCoVPC into each tube labeled 4-6 containing lysis buffer and specimen.
• To prepare negative samples, spike 12 ∝L of nuclease-free water into each tube labeled 7-9 containing lysis buffer and specimen.
• Perform extractions of all nine samples according to the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use.
**INSTRUCTIONS FOR PREPARING SAMPLES BEFORE EXTRACTION WITH THE ROCHE**
**MagNA PURE 24 AND TOTAL NUCLEIC ACID ISOLATION KIT**
• Refer to the 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use for reconstitution of the materials for use. RNA should be kept cold during preparation and use. • Make a 1/10 dilution of nCoVPC by adding 5 ∝L of nCoVPC into 45 ∝L of nuclease-free water or 10 mM Tris.
• Aliquot 400 ∝L of lysis buffer into each of nine tubes labeled 1-9.
• Add 100 ∝L of upper respiratory specimen (e.g. NPS in viral transport media) into each of the nine labeled tubes with lysis buffer.
• To prepare samples at a moderate concentration, spike 12 ∝L of undiluted nCoVPC
(rehydrated as described in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel
Instructions for Use) into each tube labeled 1-3 containing lysis buffer and specimen.
• To prepare samples at a low concentration, spike 12 ∝L of 1/10 dilution of nCoVPC into each tube labeled 4-6 containing lysis buffer and specimen.
• To prepare negative samples, spike 12 ∝L of nuclease-free water into each tube labeled 7-9 containing lysis buffer and specimen.
• Perform extractions of all nine samples according to the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use.
**INSTRUCTIONS FOR PREPARING SAMPLES BEFORE EXTRACTION WITH THE ROCHE MagNA PURE 96 DNA AND VIRAL NA SMALL VOLUME KIT**
• Refer to the 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use for reconstitution of the materials for use. RNA should be kept cold during preparation and use. • Make a 1/10 dilution of nCoVPC by adding 5 ∝L of nCoVPC into 45 ∝L of nuclease-free water or 10 mM Tris.
• Aliquot 350 ∝L of lysis buffer into each of nine tubes labeled 1-9.
• Add 100 ∝L of upper respiratory specimen (e.g. NPS in viral transport media) into each of the nine labeled tubes with lysis buffer.
• To prepare samples at a moderate concentration, spike 12 ∝L of undiluted nCoVPC
(rehydrated as described in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel
Instructions for Use) into each tube labeled 1-3 containing lysis buffer and specimen.
• To prepare samples at a low concentration, spike 12 ∝L of 1/10 dilution of nCoVPC into each tube labeled 4-6 containing lysis buffer and specimen.
• To prepare negative samples, spike 12 ∝L of nuclease-free water into each tube labeled 7-9 containing lysis buffer and specimen.
• Perform extractions of all nine samples according to the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use.
**INSTRUCTIONS FOR PREPARING SAMPLES BEFORE EXTRACTION WITH THE** **PROMEGA MAXWELL(®) RSC 48**
• Refer to the 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use for reconstitution of the materials for use. RNA should be kept cold during preparation and use. • Make a 1/10 dilution of nCoVPC by adding 5 ∝L of nCoVPC into 45 ∝L of nuclease-free water or 10 mM Tris.
• Aliquot 330 ∝L of lysis buffer (300 µL of lysis buffer + 30 µL Proteinase K, included in the kit) into each of nine tubes labeled 1-9.
• Add 120 ∝L of upper respiratory specimen (e.g. NPS in viral transport media) into each of the nine labeled tubes with lysis buffer.
• To prepare samples at a moderate concentration, spike 12 ∝L of undiluted nCoVPC
(rehydrated as described in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel
Instructions for Use) into each tube labeled 1-3 containing lysis buffer and specimen.
• To prepare samples at a low concentration, spike 12 ∝L of 1/10 dilution of nCoVPC into each tube labeled 4-6 containing lysis buffer and specimen.
• To prepare negative samples, spike 12 ∝L of nuclease-free water into each tube labeled 7-9 containing lysis buffer and specimen.
• Perform extractions of all nine samples according to the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use.
**INSTRUCTIONS FOR PREPARING SAMPLES BEFORE EXTRACTION WITH THE** **BIOMÉRIEUX NucliSENS easyMAG OR THE BIOMÉRIEUX EMAG**
• Refer to the 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use for reconstitution of the materials for use. RNA should be kept cold during preparation and use. • Make a 1/10 dilution of nCoVPC by adding 5 ∝L of nCoVPC into 45 ∝L of nuclease-free water or 10 mM Tris.
• Aliquot 1000 μL or 2000 ∝L of pre-aliquoted easyMAG lysis buffer into each of nine tubes labeled 1-9 for the easyMAG or eMAG, respectively.
• Add 100 ∝L of upper respiratory specimen (e.g. NPS in viral transport media) into each of the nine labeled tubes with lysis buffer.
• To prepare samples at a moderate concentration, spike 12 ∝L of undiluted nCoVPC
(rehydrated as described in the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel
Instructions for Use) into each tube labeled 1-3 containing lysis buffer and specimen.
• To prepare samples at a low concentration, spike 12 ∝L of 1/10 dilution of nCoVPC into each tube labeled 4-6 containing lysis buffer and specimen.
• To prepare negative samples, spike 12 ∝L of nuclease-free water into each tube labeled 7-9 containing lysis buffer and specimen.
• Perform extractions of all nine samples according to the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use.
**PROCEDURE**
Follow the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel Instructions for Use for testing the nine extracted samples at least once.
**EXPECTED RESULTS**
Moderate nCoVPC samples should be positive for 2019-nCoV.
Low nCoVPC samples should be positive for 2019-nCoV.
Negative upper respiratory samples should be negative for 2019-nCoV.
≥90% of test results should be in agreement with the expected results. If test results are <90% in agreement with expected results, contact CDC at respvirus@cdc.gov.
**LIMITATIONS**
This test has not been FDA cleared or approved.
This test has been authorized by FDA under an EUA for use by authorized laboratories.
This test has been authorized only for the detection of nucleic acid from 2019-nCoV, not for any other viruses or pathogens.
This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of SARS-CoV-2 under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
**QUESTIONS**
Please send questions or comments by email to respvirus@cdc.gov.
**DISTRIBUTION**
Distributed to qualified laboratories by Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329 USA
**CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel**
**For use under EMERGENCY USE AUTHORIZATION (EUA) only. Rx only**
**CATALOG: 2019-nCoVEUA-01**
**KIT LOT:**
**EXPIRATION DATE:**
**INTENDED USE**
The CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel is a real-time RT-PCR test intended for the qualitative detection of nucleic acid from SARS-CoV-2 in upper and lower respiratory specimens (such as nasopharyngeal or oropharyngeal swabs, sputum, lower respiratory tract aspirates, bronchoalveolar lavage, and nasopharyngeal wash/aspirate or nasal aspirate) collected from individuals suspected of COVID-19 by their healthcare provider(1).
This test is also for the qualitative detection of nucleic acid from the SARS-CoV-2 in pooled samples containing up to four of the individual upper respiratory swab specimens (nasopharyngeal (NP), oropharyngeal (OP), NP/OP combined, or nasal swabs) that were collected using individual vials containing transport media from individuals suspected of COVID-19 by their healthcare provider. Negative results from pooled testing should not be treated as definitive. If a patient’s clinical signs and symptoms are inconsistent with a negative result or results are necessary for patient management, then the patient should be considered for individual testing. Specimens included in pools with a positive, inconclusive, or invalid result must be tested individually prior to reporting a result. Specimens with low viral loads may not be detected in sample pools due to the decreased sensitivity of pooled testing.
Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42
U.S.C. § 263a, that meet the requirements to perform high complexity tests.
Results are for the identification of SARS-CoV-2 RNA. SARS-CoV-2 RNA is generally detectable in upper and lower respiratory specimens during infection. Positive results are indicative of active infection with SARS-CoV-2 but do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for treatment or other patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
Testing with the CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel is intended for use by trained laboratory personnel who are proficient in performing real-time RT-PCR assays. The CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time
RT-PCR Diagnostic Panel is only for use under a Food and Drug Administration’s Emergency Use Authorization.
**PACKAGE CONTENTS**
| PACKAGING | COMPONENT | PARTNUMBER | COMPONENT LOT NUMBER | VIALSPER KIT | QUANTITY /VIAL | STATE |
| ------------------- | -------------------------------------------------- | ---------- | -------------------- | ------------ | ---------------------------- | ----- |
| Oligonucleotide Box | 2019-nCoV_N1 Combined Primer/Probe Mix | | | 1 | 22.5 nmol | Dried |
| | 2019-nCoV_N2 Combined Primer/Probe Mix | | | 1 | 22.5 nmol | Dried |
| | RP Combined Primer/Probe Mix | | | 1 | 22.5 nmol | Dried |
| Control Box | nCoVPC 2019-nCoV Positive Control (non-infectious) | | | 4 | 1 x 10(4) copies/µL | Dried |
||
**IVD**
(1) For this EUA, a healthcare provider includes, but is not limited to, physicians, nurses, pharmacists, technologists, laboratory directors, epidemiologists, or any other practitioners or allied health professionals.
**STORAGE INSTRUCTIONS**
Upon receipt, store at 2-8°C. Refer to the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic
Panel Instructions for Use before opening and preparing reagents for use.
**PROCEDURE/INTERPRETATION/LIMITATIONS**
Users should refer to the **CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel**
**Instructions for Use** posted on the FDA website for all IVD products used under Emergency Use Authorization, http://www.fda.gov/MedicalDevices/Safety/EmergencySituations/ucm161496.htm.
This test has not been FDA cleared or approved.
This test has been authorized by FDA under an EUA for use by authorized laboratories.
This test has been authorized only for the detection of nucleic acid from 2019-nCoV, not for any other viruses or pathogens.
This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of SARS-CoV-2 under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
**PRECAUTIONS**
This reagent should be handled in an approved BSL-2 handling area to avoid contamination of laboratory equipment and reagents that could cause false positive results. This product is non-infectious. However, this product should be handled in accordance with Good Laboratory Practices.
**REAGENT COMPLAINTS/QUESTIONS**
If you have a question/comment about this product, please contact the CDC Division of Viral Diseases/Respiratory
Viruses Branch by email at respvirus@cdc.gov.
**DISTRIBUTED BY** Manufactured by the Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, Georgia, 30329, USA
**IVD**
METADATA
last updated: 2026-03-10_105728
file_name: _archive-combined-files_fda-policy_308k.md
category: regulatory
subcategory: fda-policy
gfile_url: **FLAGGED - TBD user-facing Google-hosted public file URL**
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CONTENT
# _archive-combined-files_fda-policy_308k (48 files, 308,051 tokens)
# 1,795 _context-commentary_regulatory-fda-policy.md
METADATA
last updated: 2026-03-01 RT
file_name: _context-commentary_regulatory-fda-policy.md
category: regulatory
subcategory: fda-policy
words: 1160
tokens: 1795
CONTENT
## Context
This subcategory contains 47 documents spanning 2020–2023 that trace the evolution of FDA's regulatory policy for COVID-19 diagnostic testing. The collection includes seven versions of FDA's overarching COVID test policy guidance, EUA letters and amendment letters, review templates (molecular, antigen, home-use, pooling), fact sheet templates, FDA press announcements, and transition planning documents. Together they form a detailed record of how FDA managed the regulatory environment for COVID-19 tests from the earliest emergency through the end of the Public Health Emergency.
This collection is not complete and are mostly the documents that we downloaded and reviewed at FloodLAMP. There are almost certainly other important documents that are not included here.
#### AI Summary of FDA Policy
Below is an AI (ChatGPT 5.2 Pro and Claude Opus 4.6) generated summary, which may contain errors.
The FDA policy COVID-19 testing policy evolved through three broad phases:
- **Emergency expansion (early 2020):** FDA used enforcement discretion to allow CLIA high-complexity labs to develop, validate, and begin using molecular tests before EUA issuance, provided labs notified FDA and submitted an EUA within a set timeframe. Guidance versions 1–4 (Feb–May 2020) progressively broadened these pathways to include state authorization, commercial manufacturers, and serology.
- **Standardization and new use cases (mid-2020–2021):** FDA tightened quality oversight (notably revoking the serology umbrella EUA pathway), introduced standardized templates, and expanded authorized intended uses from "suspected COVID-19" into explicit asymptomatic screening and pooled testing. Serial testing emerged as a formal authorization strategy, and variant monitoring became a standard EUA condition.
- **Narrowing and wind-down (2022–2023):** FDA reduced the scope of new EUA reviews, encouraged developers toward traditional marketing pathways (510(k)/De Novo), standardized repeat-testing labeling for consumer antigen tests, and published transition plans for returning to normal device regulation. The COVID-19 PHE expired May 11, 2023, but FDA clarified that existing EUAs remain in effect as long as the underlying EUA declaration persists.
Key points of variation across the seven guidance versions:
| Version | Date | Key Change |
| --- | --- | --- |
| v1 | Feb 29, 2020 | Initial accelerated policy for CLIA high-complexity lab molecular LDTs |
| v2 | Mar 16, 2020 | Expanded pathways: state authorization, commercial distribution prior to EUA, serology policy |
| v3 | May 4, 2020 | Additional templates, clearer timelines, tightened oversight |
| v4 | May 11, 2020 | Further template and oversight refinements |
| v5 | Nov 15, 2021 | Major reset: umbrella EUAs for serial testing, reissued/narrowed molecular LDT umbrella EUA, FDA signals that newly offered tests should generally have EUA or traditional authorization before clinical use |
| v6 | Sep 27, 2022 | Narrowed EUA review priorities; encouraged traditional marketing pathways |
| v7 | Jan 12, 2023 | Final revision of the overarching COVID test policy guidance |
Three policy innovations are specifically documented in this subcategory:
##### Serial screening (Mar 2021 onward)
FDA authorized screening claims based on strong symptomatic performance combined with a repeat-testing regimen, rather than requiring standalone evidence in asymptomatic populations. This treated the testing algorithm and frequency as part of the risk-control package. By Nov 2022, serial testing instructions were standardized into enforceable antigen test labeling (two tests over three days if symptomatic; three tests over five days if asymptomatic, at least 48 hours apart). Key archive files include:
- `2021-03-16_FDA Website - FDA takes steps to streamline path for COVID-19 screening tools.md`
- `2021-03-16_FDA Template - Supplemental Template for Developers...for Screening with Serial Testing.md`
- `2021-03-13_FDA Fact Sheet - Screening for COVID-19 Deciding Which Test to Use When Establishing Testing Programs.md`
- `2021-10-25_FDA Template - Supplemental Template for Developers...for Screening with Serial Testing.md` (updated version)
- `2022-11-01_FDA Letter - Repeat Testing Revision Letter.md`
- `2022-11-01_FDA Website - Antigen EUA Revisions for Serial Repeat Testing.md`
- `2022-11-17_FDA Website - At Home COVID-19 Antigen Tests-Take Steps.md`
##### Asymptomatic/screening testing (Jul 2020 onward)
FDA distinguished between testing asymptomatic individuals under clinical "suspicion" (provider judgment) and broad population screening (no symptoms, no known exposure). The Jul 24, 2020 LabCorp reissuance was the first EUA explicitly authorizing screening of people without known or suspected infection, establishing screening as a distinct intended use with its own evidence and labeling requirements. Key archive files include:
- `2020-08-24_FDA Policy IVD - Pooled Sample Testing and Screening Testing for COVID-19.md`
- `2021-03-13_FDA Fact Sheet - Screening for COVID-19 Deciding Which Test to Use When Establishing Testing Programs.md`
- `2020-10-26_FDA Template - Antigen Template for Test Developers.md`
- `2021-10-06_FDA Template - For Developers of Molecular Diagnostic Tests.md`
##### Pooled testing (Jul 2020 onward)
FDA authorized sample pooling to conserve reagents and increase throughput, but constrained it through validation requirements (replicate detection thresholds, Ct shift limits, invalid-rate caps), restriction to CLIA high-complexity labs, and behavioral controls (reflex individual testing for positive/invalid pools, specific fact-sheet language). The Apr 20, 2021 amendment letter tied pooled screening specifically to serial testing programs operating at least weekly, treating serial frequency as a mitigation for the sensitivity loss inherent in pooling. FDA distinguished swab pooling from media pooling and provided different validation pathways for each. Key archive files include:
- `2020-08-24_FDA Policy IVD - Pooled Sample Testing and Screening Testing for COVID-19.md`
- `2021-04-20_FDA Letter - Amendment Letter.md`
- `2021-04-20_FDA Website - Pooling and Serial Testing Amendment.md`
- `2021-04-20_FDA Fact Sheet - Sample Updated Fact Sheet for Health Care Providers.md`
- `2021-04-20_FDA Fact Sheet - Sample Updated Fact Sheet for Patients.md`
An important distinction throughout the archive is between FDA's two regulatory levers: **EUA issuance** (test-specific, enforceable conditions, required fact sheets) and **enforcement discretion** (FDA choosing not to enforce certain requirements for a period, with conditions). The early guidances relied heavily on enforcement discretion to expand access; later guidances progressively moved back toward requiring EUA or traditional authorization before clinical use.
Related subcategories include `regulatory/open-euas` (the open EUA submissions FloodLAMP prepared), `regulatory/fda-townhalls` (a RAG demo over 100 FDA townhall transcripts for COVID-19 test developers), and `regulatory/ldts` (laboratory-developed test policy context).
## Commentary
For the primary commentary on FDA policy and the Open EUAs, see `regulatory/open-euas/_context-commentary_regulatory-open-euas.md`.
There remains a need for significant progress in FDA policy as it relates to pandemic preparedness and response. The complexity of the regulatory environment documented in this subcategory, with seven guidance versions, multiple overlapping enforcement mechanisms, and evolving intended-use distinctions, illustrates both the scale of the challenge and the difficulty of navigating it in real time as a small developer.
AI tools offer substantial potential for making this kind of dense regulatory material more accessible and navigable. As a related effort within this archive project, we built a demo RAG (Retrieval Augmented Generation) tool over a corpus of 100 FDA townhall meeting transcripts for COVID-19 diagnostic test developers (see `regulatory/fda-townhalls`). That tool takes natural language queries and returns the closest matching quoted FDA authority responses along with an AI-generated summary, demonstrating one approach to making regulatory guidance more searchable and usable. Feel free to try it at [FDA COVID-19 Diagnostics Townhalls - QRAG Demo](https://www.focusonfoundations.org/fda-town-halls-qrag-demo).
# 2,610 2020-02-29_FDA Guidance - COVID IVD Test Developers v1.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2020-02-29_FDA Guidance - COVID IVD Test Developers v1.md
file_date: 2020-02-29
title: FDA Guidance - COVID IVD Test Developers v1
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summary_short: The FDA Guidance for COVID-19 IVD Test Developers v1 establishes an accelerated policy allowing CLIA-certified high-complexity laboratories to develop, validate, and use SARS-CoV-2 molecular diagnostic tests prior to Emergency Use Authorization during the early public health emergency. It outlines minimum expectations for validation, FDA notification, result reporting, and EUA submission while permitting temporary clinical use to rapidly expand testing capacity. This guidance shaped early laboratory testing practices by balancing speed with basic analytical and clinical safeguards.
CONTENT
***INTERNAL TITLE:*** Policy for Diagnostics Testing in Laboratories Certified to Perform High Complexity Testing under CLIA prior to Emergency Use Authorization for Coronavirus Disease-2019 during the Public Health Emergency
Immediately in Effect Guidance for Clinical Laboratories and Food and Drug Administration Staff
**Document issued on the web on February 29, 2020.**
**Document announced in the Federal Register on March 6, 2020.**
For questions about this document, contact OHT7 at 301-796-7692 or OHT7/Division of Microbiology Devices at 301-348-1778 or CDRH-EUA-Templates@fda.hhs.gov.
U.S. Department of Health and Human Services
Food and Drug Administration
Center for Devices and Radiological Health
## Preface
### Public Comment
You may submit electronic comments and suggestions at any time for Agency consideration to https://www.regulations.gov. Submit written comments to the Dockets Management Staff, Food and Drug Administration, 5630 Fishers Lane, Room 1061, (HFA-305), Rockville, MD 20852. Identify all comments with the docket number FDA-2020-D-0987. Comments may not be acted upon by the Agency until the document is next revised or updated.
### Additional Copies
Additional copies are available from the Internet. You may also send an e-mail request to CDRH-Guidance@fda.hhs.gov to receive a copy of the guidance. Please include the document number 20010 and complete title of the guidance in the request.
## Table of Contents
| | | | |
|-|-|-|-|
| I. | Introduction | | 1 |
| II. | Background | | 2 |
| III. | Scope | | 3 |
| IV. | Policy | | 3 |
| A. | Validation | | 3 |
| (1) | Limit of Detection | | 3 |
| (2) | Clinical Evaluation | | 4 |
| (3) | Inclusivity | | 4 |
| (4) | Cross-reactivity | | 4 |
| B. | FDA Notification | | 4 |
| C. | Reporting of Results | | 4 |
| D. | EUA Request | | 5 |
| E. | Clinical Testing | | 5 |
||
## I. Introduction
The Food and Drug Administration (FDA or Agency) is issuing this guidance to provide a policy for novel coronavirus (COVID-19) molecular diagnostics tests developed and used in laboratories certified to perform high-complexity testing under the Clinical Laboratory Improvement Amendments (CLIA) prior to issuance of emergency use authorizations (EUA) for such tests.
On February 4, 2020, the Secretary of Health and Human Services determined that there is a public health emergency and that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the novel coronavirus (2019-nCoV). Rapid detection of COVID-19 cases in the United States requires wide availability of diagnostic testing to control the emergence of this rapidly spreading, severe illness. This guidance describes an accelerated policy enabling laboratories to use tests they develop faster in order to achieve more rapid testing capacity in the United States.
In light of this public health emergency, this guidance is being implemented without prior public comment because the FDA has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C)(i) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is immediately in effect, but it remains subject to comment in accordance with the Agency's good guidance practices.
FDA's guidance documents, including this guidance, do not establish legally enforceable responsibilities. Instead, guidances describe the Agency's current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word should in Agency guidance means that something is suggested or recommended, but not required.
## II. Background
There is currently an outbreak of respiratory disease caused by a novel coronavirus that was first detected in Wuhan City, Hubei Province, China and which has now been detected in 50 locations internationally, including cases in the United States. The virus has been named "SARS-CoV-2" and the disease it causes has been named "Coronavirus Disease 2019" (COVID-19). SARS-CoV-2 has demonstrated the capability to rapidly spread, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high, both globally and to the United States. To effectively respond to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical. FDA believes the policy set forth in this guidance will help address these urgent public health concerns by helping to expand available testing capabilities in healthcare settings, and reference and commercial laboratories.
The Centers for Disease Control and Prevention (CDC) laboratories have supported the COVID-19 response, including development of a diagnostic assay that was issued an EUA on February 4, 2020. Since authorizing CDC's EUA, FDA has been actively working with other SARS-CoV-2 diagnostic developers to help accelerate development programs and respond to requests for in vitro diagnostic EUAs. However, the severity and scope of the current COVID-19 situation around the globe necessitates greater testing capacity for the virus than is currently available.
The EUA authorities allow FDA to help strengthen the nation's public health protections against chemical, biological, radiological, and nuclear (CBRN) threats by facilitating the availability and use of medical countermeasures initiatives (MCMs) needed during certain public health emergencies. Under section 564 of the FD&C Act, the FDA Commissioner may allow unapproved medical products or unapproved uses of approved medical products to be used in certain emergency circumstances, after the HHS Secretary has made a declaration of emergency or threat justifying authorization of emergency use, to diagnose, treat, or prevent serious or life-threatening disease or conditions caused by CBRN threat agents when certain criteria are met.
FDA understands that some laboratories certified to perform high-complexity testing under CLIA are developing diagnostic tests to detect the SARS-CoV-2 virus and pursue EUA authorization for those tests. For a reasonable period of time after validation and while they are preparing their EUA requests, FDA does not intend to object to the use of these tests for specimen testing, as described below. FDA believes 15 days is a reasonable period of time to prepare an EUA submission for test that has already been validated.
This guidance is intended to help rapidly expand testing capacity by facilitating the development of molecular SARS-CoV-2 diagnostic assays. The accelerated approach discussed below should be considered for initial testing of patient specimens, with subsequent confirmatory testing performed as appropriate.
## III. Scope
The policy described in this guidance applies to laboratories certified to perform high-complexity testing under CLIA, that comply with CLIA requirements, that have developed and are using their own validated diagnostic test, and are pursuing an EUA.
## IV. Policy
FDA anticipates that clinical laboratories may need to design and manufacture the individual test kit components (e.g., primers, probes, etc.), or to purchase research use only (RUO) components from third party manufacturers for the development of their assays.
### A. Validation
All clinical tests should be validated prior to use; however, in the context of a public health emergency, it is especially important that tests are validated as false results can have broad public health impact beyond that to the individual patient. Below, FDA has provided recommendations regarding the minimum testing to be performed to ensure analytical and clinical validity of these tests, and FDA encourages laboratories to discuss any alternative testing with FDA that they would like to conduct.
#### (1) Limit of Detection
FDA recommends that laboratories document the limit of detection (LoD) of their SARS-CoV-2 assay. FDA generally does not have concerns with spiking RNA or inactivated virus into artificial or real clinical matrix (e.g., BAL fluid, sputum, etc.) for LoD determination.
FDA recommends that laboratories test a dilution series of three replicates per concentration, and then confirm the final concentration with 20 replicates. FDA defines LoD as the lowest concentration at which 19/20 replicates are positive. If multiple clinical matrices are intended for clinical testing, FDA recommends that laboratories submit in their EUA requests the results from the most challenging clinical matrix to FDA. For example, if testing respiratory specimens (e.g., sputum, BAL, nasophayngeal (NP) swabs, etc.), laboratories should include only results from sputum in their EUA request.
#### (2) Clinical Evaluation
In the absence of known positive samples for testing, FDA recommends that laboratories confirm performance of their assay with a series of contrived clinical specimens by testing a minimum of 30 contrived reactive specimens and 30 non-reactive specimens. Contrived reactive specimens can be created by spiking RNA or inactivated virus into leftover clinical specimens, of which the majority can be leftover upper respiratory specimens such as NP swabs, or lower respiratory tract specimens such as sputum, etc. Twenty of the contrived clinical specimens should be spiked at a concentration of 1x-2x LoD, with the remainder of specimens spanning the assay testing range. FDA defines the acceptance criteria for the performance as 95% agreement at 1x-2x LoD, and 100% agreement at all other concentrations and for negative specimens.
#### (3) Inclusivity
Laboratories should document the results of an in silico analysis indicating the percent identity matches against publicly available SARS-CoV-2 sequences that can be detected by the proposed molecular assay. FDA anticipates that 100% of published SARS-CoV-2 sequences will be detectable with the selected primers and probes.
#### (4) Cross-reactivity
At an minimum, FDA believes an in silico analysis of the assay primer and probes compared to common respiratory flora and other viral pathogens is sufficient for initial clinical use. FDA defines in silico cross-reactivity as greater than 80% homology between one of the primers/probes and any sequence present in the targeted microorganism. In addition, FDA recommends that laboratories should follow recognized laboratory procedures in the context of the sample types intended for testing for any additional cross-reactivity testing.
### B. FDA Notification
Following completion of assay validation, laboratories should notify FDA (e.g., e-mail to CDRH-EUA-Templates@fda.hhs.gov) that their assay has been validated. This notification should include the name of the laboratory, name of the lab director, address, and contact person in this email. FDA will acknowledge receipt of this notification via auto-reply. As noted above, FDA recommends that laboratories submit a completed EUA request within 15 business days of the initial communication to FDA that the assay has been successfully validated.
### C. Reporting of Results
In order to provide transparency, FDA recommends that test reports include a general statement that the test has been validated but FDA's independent review of this validation is pending.
Laboratories should immediately notify appropriate Federal, State, or local public health agencies of all positive results.
### D. EUA Request
The COVID-19 specific EUA template can be obtained by contacting FDA (CDRH-EUA-Templates@fda.hhs.gov), or downloading the template available on the FDA website. FDA will communicate any questions or concerns regarding the completed EUA request or EUA template to the clinical laboratory. FDA will also work collaboratively to address any potential concerns or safety considerations raised in the request and will contact the laboratory regarding a final determination on the EUA request.
If FDA is not able to authorize an EUA, FDA will notify the laboratory. FDA believes it would be important for the laboratory to terminate testing patient specimens and issue a corrected test report that indicates the prior test result may not be valid.
### E. Clinical Testing
While awaiting FDA determination on the EUA request, FDA recommends that clinical laboratories obtain confirmation of the first five positive and the first five negative clinical specimens using an EUA-authorized assay, which may involve sending these ten specimens to another laboratory for confirmation. If any of these results cannot be confirmed, the laboratory should notify FDA at CDRH-EUA-Templates@fda.hhs.gov, and take other appropriate actions such as terminating testing patient specimens, and issuing a corrected test report that indicates the prior test result may not be valid.
# 5,900 2020-03-16_FDA Guidance - COVID IVD Test Developers v2.md
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summary_short: The FDA Guidance for COVID IVD Test Developers v2 expands the February 29, 2020 policy by covering not only CLIA high-complexity laboratory-developed molecular tests but also state-authorized testing pathways, commercial manufacturer test distribution prior to EUA, and serology testing policies during the public health emergency. It provides validation study recommendations by test type (molecular, antigen, serology) and sets expectations for notification, transparency in reporting, and EUA submission timelines while allowing limited use during review. The guidance helped scale U.S. testing capacity by defining flexible, risk-managed routes for labs and manufacturers to deploy validated tests quickly.
CONTENT
***INTERNAL TITLE:*** Policy for Diagnostic Tests for Coronavirus Disease-2019 during the Public Health Emergency
Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff
**Document issued on the web on March 16, 2020.**
**This document supersedes "Policy for Diagnostics Testing in Laboratories Certified to Perform High-Complexity Testing under Clinical Laboratory Improvement Amendments (CLIA) prior to Emergency Use Authorization for Coronavirus Disease-2019 during the Public Health Emergency" issued February 29, 2020.**
For questions about this document, contact CDRH-EUA-Templates@fda.hhs.gov.
U.S. Department of Health and Human Services
Food and Drug Administration
Center for Devices and Radiological Health
## Preface
### Public Comment
You may submit electronic comments and suggestions at any time for Agency consideration to https://www.regulations.gov. Submit written comments to the Dockets Management Staff, Food and Drug Administration, 5630 Fishers Lane, Room 1061, (HFA-305), Rockville, MD 20852. Identify all comments with the docket number FDA-2020-D-0987. Comments may not be acted upon by the Agency until the document is next revised or updated.
### Additional Copies
Additional copies are available from the Internet. You may also send an e-mail request to CDRH-Guidance@fda.hhs.gov to receive a copy of the guidance. Please include the document number 20010 and complete title of the guidance in the request.
### Table of Contents
| | | |
|---------|-------|------|
| I. | Introduction | 1 |
| II. | Background | 2 |
| III. | Scope | 3 |
| IV. | Policy | 3 |
| A. | Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High-Complexity Testing Using Their Validated Tests Prior to EUA Submission | 3 |
| 1. | Validation | 4 |
| 2. | FDA Notification | 4 |
| 4. | EUA Request | 5 |
| 5. | Clinical Testing | 5 |
| B. | State Authorization of Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High-Complexity Testing | 6 |
| C. | Commercial Manufacturer Development and Distribution of Tests Prior to EUA Submission | 7 |
| 1. | Validation | 7 |
| 2. | FDA Notification | 7 |
| 4. | EUA Request | 8 |
| 5. | Clinical Testing | 8 |
| D. | Commercial Manufacturer Development and Distribution and Laboratory Development and Use of Serology Tests Without an EUA | 9 |
| V. | Validation Study Recommendations Based on the Technological Principles of Diagnostic Tests | 9 |
| A. | Molecular Diagnostics | 9 |
| (1) | Limit of Detection | 9 |
| (2) | Clinical Evaluation | 10 |
| (3) | Inclusivity | 10 |
| (4) | Cross-reactivity | 10 |
| B. | Antigen Detection Diagnostics | 10 |
| C. | Serological Diagnostics | 11 |
||
## I. Introduction
The Food and Drug Administration (FDA or Agency) is issuing this guidance to provide a policy to help accelerate the availability of novel coronavirus (COVID-19) diagnostic tests developed by laboratories and commercial manufacturers during the public health emergency.
On February 4, 2020, the Secretary of Health and Human Services (HHS) determined that there is a public health emergency and that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the novel coronavirus (2019-nCoV). Rapid detection of COVID-19 cases in the United States requires wide availability of diagnostic testing to control the emergence of this rapidly spreading, severe illness. This guidance describes a policy for laboratories and commercial manufacturers to help accelerate the use of tests they develop in order to achieve more rapid and widespread testing capacity in the United States.
In light of this public health emergency, this guidance is being implemented without prior public comment because the FDA has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C)(i) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is immediately in effect, but it remains subject to comment in accordance with the Agency's good guidance practices.
FDA's guidance documents, including this guidance, do not establish legally enforceable responsibilities. Instead, guidances describe the Agency's current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word should in Agency guidance means that something is suggested or recommended, but not required.
## II. Background
There is currently an outbreak of respiratory disease caused by a novel coronavirus that was first detected in Wuhan City, Hubei Province, China, which has now been designated a pandemic by the World Health Organization (WHO) and which has been detected internationally, including cases in the United States. The virus has been named "SARS-CoV-2" and the disease it causes has been named "Coronavirus Disease 2019" (COVID-19). SARS-CoV-2 has demonstrated the capability to spread rapidly, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high, both globally and to the United States. To respond effectively to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical. FDA believes the policy set forth in this guidance will help address these urgent public health concerns by helping to expand the number and variety of diagnostic tests, as well as available testing capabilities in reference and commercial laboratories and healthcare settings.
The Centers for Disease Control and Prevention (CDC) laboratories have supported the COVID-19 response, including development of a diagnostic assay that was issued an Emergency Use Authorization (EUA) on February 4, 2020. Since authorizing CDC's EUA, FDA has been actively working with other SARS-CoV-2 diagnostic test developers to help accelerate development programs and respond to requests for in vitro diagnostic EUAs. However, the severity and scope of the current COVID-19 situation around the globe necessitates greater testing capacity for the virus than is currently available.
The EUA authorities allow FDA to help strengthen the nation's public health protections against chemical, biological, radiological, and nuclear (CBRN) threats by facilitating the availability and use of medical countermeasures initiatives (MCMs) needed during certain public health emergencies. Under section 564 of the FD&C Act, the FDA Commissioner may authorize the use of unapproved medical products, or unapproved uses of approved medical products, in certain emergency circumstances, after the HHS Secretary has made a declaration of emergency or threat justifying authorization of emergency use, to diagnose, treat, or prevent serious or life-threatening disease or conditions caused by CBRN threat agents when certain criteria are met.
## III. Scope
The policies described in this guidance for accelerated availability of testing for COVID-19 applies to certain laboratories and commercial manufacturers developing SARS-CoV-2 diagnostic tests during the public health emergency, as described below.
## IV. Policy
This guidance describes policies intended to help rapidly expand testing capacity by facilitating the development and use of SARS-CoV-2 diagnostic tests during the public health emergency.
This guidance describes two policies for accelerating the development of certain laboratory tests for COVID-19 – one leading to an EUA submission to FDA, and the other not leading to an EUA submission when the test is developed under the authorities of the State in which the lab resides and the State takes responsibility for COVID-19 testing by laboratories in its State. The policy leading to an EUA remains unchanged from the initial publication of this guidance on February 29, 2020.
In addition, this guidance describes a policy for commercial manufacturers to more rapidly distribute their SARS-CoV-2 diagnostics to laboratories for specimen testing after validation while an EUA is being prepared for submission to FDA.
This guidance also describes a policy regarding the use of serological testing without an EUA.
In the context of a public health emergency involving pandemic infectious disease, it is critically important that tests are validated as false results can have broad public health impact beyond that to the individual patient. In this guidance, FDA provides recommendations regarding validation of COVID-19 tests. FDA encourages test developers to discuss any alternative approaches to validation with FDA.
### A. Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High Complexity Testing Using Their Validated Tests Prior to EUA Submission
The policy described in this subsection applies to laboratories certified under Clinical Laboratory Improvement Amendments (CLIA) that meet the CLIA regulatory requirements to perform high-complexity testing and that seek to develop and perform diagnostic tests to detect the SARS-CoV-2 virus and pursue EUA authorization from FDA for those tests.
FDA anticipates that clinical laboratories may need to design and manufacture the individual test kit components (e.g., primers, probes, etc.), or to purchase research use only (RUO) components from third party manufacturers, for the development of their assays.
In light of the increasing numbers of COVID-19 cases throughout the country and the urgent need to expand the nation's capacity for COVID-19 testing during the public health emergency, for a reasonable period of time after validation and while they are preparing their EUA requests, FDA does not intend to object to the use of these SARS-CoV-2 tests for specimen testing, as described below. FDA believes that 15 business days is a reasonable period of time to prepare an EUA submission for a test that has already been validated.
#### 1. Validation
All clinical tests should be validated prior to use. In the context of a public health emergency, it is especially important that tests are validated as false results can have broad public health impact beyond that to the individual patient. FDA has provided recommendations regarding the minimum testing that should be performed to ensure analytical and clinical validity in section V below. FDA encourages laboratories to discuss any alternative testing with FDA that they would like to conduct.
#### 2. FDA Notification
Following completion of assay validation, laboratories should notify FDA (e.g., e-mail to CDRH-EUA-Templates@FDA.HHS.GOV) that their assay has been validated. This notification should include the name of the laboratory, name of the lab director, address, and contact person in this email. FDA will acknowledge receipt of this notification via auto-reply. As noted above, FDA recommends that laboratories submit a completed EUA request within 15 business days of the initial communication to FDA that the assay has been successfully validated.
It would be helpful to FDA if laboratories provide information on testing capacity. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
#### 3. Reporting of Results
In order to provide transparency, FDA recommends that test reports include a general statement that the test has been validated but FDA's independent review of this validation is pending.
Additionally, reporting of results from serological testing under this policy should include the limitations outlined in section D below unless and until data is submitted and an EUA is authorized for any claims outside those described in section D below.
Laboratories should immediately notify appropriate Federal, State, and local public health agencies of all positive results.
#### 4. EUA Request
FDA has made available, through download from our website, a template that laboratories may choose to use to facilitate the preparation, submission, and authorization of an EUA. Laboratories that intend to use alternative approaches should consider seeking FDA's feedback or advice to help them through the pre-EUA and EUA process. FDA encourages laboratories to discuss any alternative technological approaches with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
Soon after receiving the EUA request, FDA intends to perform a preliminary review to identify if there are any problems with the performance data. If a problem is identified, FDA intends to work with the laboratory to address the problem (e.g., through labeling or bench testing). If any problems are significant and cannot be addressed in a timely manner, FDA would expect the laboratory to stop testing and issue corrected test reports indicating prior results may not be accurate.
If FDA is not able to authorize an EUA, FDA will notify the laboratory. FDA would expect the laboratory to stop testing and issue corrected test reports indicating prior test results may not be accurate. FDA does not intend to object to the use of a test, without a new or amended EUA, where the test is validated using a bridging study to an EUA-authorized test. One way to bridge to a new component is to establish equivalent performance between parallel testing of the same specimens with the new and original components. We recommend testing 3-fold serial dilutions of SARS-CoV-2 viral materials (e.g., whole genomic viral RNA or inactivated virus, etc.) in pooled respiratory sample matrix in triplicate.
FDA would like to see your validation data informally through an email to CDRH-EUA-Templates@FDA.HHS.GOV. If FDA's review of validation data indicates that it could be applicable to modifications of other tests with an authorized EUA, and the laboratory agrees to FDA sharing that information on our website for use by other laboratories, FDA intends to update our FAQs so other laboratories can refer to the validation for their testing, without conducting their own bridging study for the same modification.
#### 5. Clinical Testing
While awaiting FDA determination on the EUA request, FDA recommends that clinical laboratories obtain confirmation of the first five positive and the first five negative clinical specimens using an EUA-authorized assay, which may involve sending these ten specimens to another laboratory for confirmation. If any of these results cannot be confirmed, the laboratory should notify FDA at CDRH-EUA-Templates@FDA.HHS.GOV, and take other appropriate actions such as terminating testing patient specimens, and issuing a corrected test report that indicates the prior test result may not be valid.
### B. State Authorization of Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High Complexity Testing
On March 12, 2020, FDA issued enforcement discretion and stated that it was not objecting to the Wadsworth Center authorizing certain laboratories in the State of New York to begin patient testing under certain circumstances to increase availability of COVID-19 testing in response to a request from the Wadsworth Center of the New York State Department of Health (Wadsworth). Wadsworth had informed FDA that it would be willing to have clinical laboratories that currently hold a New York State Department of Health clinical laboratory permit to notify Wadsworth that they have validated a test for COVID-19, and to submit validation studies to Wadsworth. Wadsworth likewise said it would notify the laboratory if it identified any concerns, and request that the laboratory terminate testing patient specimens and issue a corrected test report that indicates the prior test result might not be valid.
On March 13, 2020, the President issued a "Memorandum on Expanding State-Approved Diagnostic Tests" (Memorandum), which refers to the flexibility that FDA allowed New York State and states as follows:
"Should additional States request flexibility to authorize laboratories within the State to develop and perform tests used to detect COVID-19, the Secretary shall take appropriate action, consistent with law, to facilitate the request."
In accordance with the Memorandum, FDA describes below its policy regarding States and territories that authorize laboratories within their State or territory to develop their own COVID-19 tests and perform specimen testing, where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA.
A State or territory choosing to authorize laboratories within that State or territory to develop and perform a test for COVID-19 would do so under authority of its own State law, and under a process that it establishes. FDA does not intend to object to the use of such tests for specimen testing where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA, and where instead the State or territory takes responsibility for COVID-19 testing by laboratories in its State during the COVID-19 outbreak.
FDA requests that the State or territory notify us if they choose to use this flexibility to expedite COVID-19 testing. FDA will not be reviewing the process adopted by the State or territory, which we understand may be different than the process adopted by New York State. FDA expects that such states as part of their oversight process will require laboratories developing SARS-CoV-2 tests to validate those tests prior to use. FDA encourages laboratories that develop and perform a test for COVID-19 under this policy to notify FDA that they have started clinical testing by sending an email to that effect to CDRH-EUA-Templates@FDA.HHS.GOV. It would be helpful to FDA if laboratories provide information on testing capacity. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
### C. Commercial Manufacturer Development and Distribution of Tests Prior to EUA Submission
The policy described in this subsection applies to commercial manufacturers that seek to develop and distribute diagnostic test kits to detect the SARS-CoV-2 virus to clinical laboratories or to healthcare workers for point-of-care testing. This policy does not apply to at home testing.
In light of the increasing numbers of COVID-19 cases throughout the country and the urgent need to expand the nation's capacity for COVID-19 testing during the public health emergency, FDA does not intend to object to a commercial manufacturer's development and distribution of SARS-CoV-2 test kits for specimen testing for a reasonable period of time after the manufacturer's validation of the test and while the manufacturer is preparing its EUA request where the manufacturer provides instructions for use of the test and posts data about the test's performance characteristics on the manufacturer's website. Transparency can help mitigate potential adverse impacts from a poorly designed test by facilitating better informed decisions by potential purchasers and users.
FDA believes that 15 business days is a reasonable period of time to prepare an EUA submission for a test whose performance characteristics have already been validated. Soon after receiving the EUA request, FDA will perform a preliminary review to identify if there are any problems with the performance data. If a problem is identified, FDA intends to work with the manufacturer to address the problem (e.g., through labeling or bench testing). If the problem is significant and cannot be addressed in a timely manner, and the manufacturer has already distributed the device, FDA would expect the manufacturer to suspend distribution and conduct a recall of the test.
#### 1. Validation
All clinical tests should be validated prior to use. In the context of a public health emergency, it is especially important that tests are validated as false results can have broad public health impact beyond that to the individual patient. FDA has provided recommendations regarding the minimum testing that should be performed to ensure analytical and clinical validity in section V below. FDA encourages laboratories to discuss any alternative testing with FDA that they would like to conduct.
#### 2. FDA Notification
Following completion of assay validation, manufacturers should notify FDA (e.g., e-mail to CDRH-EUA-Templates@FDA.HHS.GOV) that their assay has been validated and they intend to begin distribution. This notification should include the name of the manufacturer, address, contact person, and a copy of the instructions for use including summary of assay performance. FDA will acknowledge receipt of this notification via auto-reply. As noted above, FDA recommends that manufacturers submit a completed EUA request within 15 business days of the initial communication to FDA that the assay has been successfully validated.
It would be helpful to FDA if manufacturers provide information on testing capacity, as well as the number of laboratories in the U.S. with the required platforms installed. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
#### 3. Reporting of Results
In order to provide transparency, FDA recommends that test reports include a general statement that the test has been validated but FDA's independent review of this validation is pending.
#### 4. EUA Request
FDA has made available, through download from our website, a template for test kit manufacturers that is intended to facilitate the preparation, submission and authorization of an EUA. Manufacturers can use alternative approaches. Manufacturers who intend to use alternative approaches should consider seeking FDA's feedback or advice to help them through the pre-EUA and EUA process. FDA encourages manufacturers to discuss any alternative technological approaches with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
FDA will communicate any questions or concerns regarding the completed EUA request or EUA template to the manufacturer. FDA will also work collaboratively to address any potential concerns or safety considerations raised in the request and will contact the manufacturer regarding a final determination on the EUA request.
If FDA is not able to authorize an EUA, FDA intends to notify the manufacturer. FDA would expect the manufacturer to suspend distribution and conduct a recall of the test.
Modifications to a manufacturer's EUA-authorized test are submitted as an amendment to the EUA. Where validation data supporting the modification has been submitted in the amendment, FDA does not intend to object to implementation of the modification while FDA conducts its review.
#### 5. Clinical Testing
While awaiting FDA determination on the EUA request, FDA recommends that manufacturers make publicly available on their website the instructions for use, including a summary of assay performance.
### D. Commercial Manufacturer Development and Distribution and Laboratory Development and Use of Serology Tests Without an EUA
The policy described in this subsection applies to developers of serology tests that identify antibodies (e.g., IgM, IgG) to SARS-CoV-2 from clinical specimens. This policy is limited to such testing in laboratories or by healthcare workers at the point-of-care. This policy does not apply to at home testing.
Considering that serology tests are less complex than molecular tests and are solely used to identify antibodies to the virus, FDA does not intend to object to the development and distribution by commercial manufacturers or development and use by laboratories of serology tests to identify antibodies to SARS-CoV-2, where the test has been validated, notification is provided to FDA, and information along the lines of the following is included in the test reports:
- This test has not been reviewed by the FDA.
- Negative results do not rule out SARS-CoV-2 infection, particularly in those who have been in contact with the virus. Follow-up testing with a molecular diagnostic should be considered to rule out infection in these individuals.
- Results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection or to inform infection status.
- Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.
FDA recommends that developers planning to submit an EUA for serological testing as the sole basis to diagnose or inform infection status, include information along the lines of the statements above in their test reports until data is submitted and an EUA is authorized for additional uses.
## V. Validation Study Recommendations Based on the Technological Principles of Diagnostic Tests
In this section, FDA provides recommendations for developers regarding the minimum testing that should be performed for SARS-CoV-2 diagnostics based upon the underlying technological principles of the test. Depending on the characteristics of your test, additional validation studies may be recommended. FDA encourages test developers to discuss any alternative technological approaches with FDA through CDRH-EUA-templates@FDA.HHS.GOV.
### A. Molecular Diagnostics
FDA defines SARS-CoV-2 molecular diagnostic tests as tests that detect SARS-CoV-2 nucleic acids from human specimens. FDA recommends that the following validation studies be conducted for a molecular SARS-CoV-2 diagnostic:
#### (1) Limit of Detection
FDA recommends that laboratories document the limit of detection (LoD) of their SARS-CoV-2 assay. FDA generally does not have concerns with spiking RNA or inactivated virus into artificial or real clinical matrix (e.g., Bronchoalveolar lavage [BAL] fluid, sputum, etc.) for LoD determination.
FDA recommends that laboratories test a dilution series of three replicates per concentration, and then confirm the final concentration with 20 replicates. For this guidance, FDA defines LoD as the lowest concentration at which 19/20 replicates are positive. If multiple clinical matrices are intended for clinical testing, FDA recommends that laboratories submit in their EUA requests the results from the most challenging clinical matrix to FDA. For example, if testing respiratory specimens (e.g., sputum, BAL, nasopharyngeal (NP) swabs, etc.), laboratories should include only results from sputum in their EUA request.
#### (2) Clinical Evaluation
In the absence of known positive samples for testing, FDA recommends that laboratories confirm performance of their assay with a series of contrived clinical specimens by testing a minimum of 30 contrived reactive specimens and 30 non-reactive specimens. Contrived reactive specimens can be created by spiking RNA or inactivated virus into leftover clinical specimens, of which the majority can be leftover upper respiratory specimens such as NP swabs, or lower respiratory tract specimens such as sputum, etc. We recommend that twenty of the contrived clinical specimens be spiked at a concentration of 1x-2x LoD, with the remainder of specimens spanning the assay testing range. For this guidance, FDA defines the acceptance criteria for the performance as 95% agreement at 1x-2x LoD, and 100% agreement at all other concentrations and for negative specimens.
#### (3) Inclusivity
Laboratories should document the results of an in silico analysis indicating the percent identity matches against publicly available SARS-CoV-2 sequences that can be detected by the proposed molecular assay. FDA anticipates that 100% of published SARS-CoV-2 sequences will be detectable with the selected primers and probes.
#### (4) Cross-reactivity
At a minimum, FDA believes an in silico analysis of the assay primer and probes compared to common respiratory flora and other viral pathogens is sufficient for initial clinical use. For this guidance, FDA defines in silico cross-reactivity as greater than 80% homology between one of the primers/probes and any sequence present in the targeted microorganism. In addition, FDA recommends that laboratories follow recognized laboratory procedures in the context of the sample types intended for testing for any additional cross-reactivity testing.
Additional information for the validation of molecular diagnostics is included in the manufacturer and laboratory EUA templates available for download on our website.
### B. Antigen Detection Diagnostics
FDA defines SARS-CoV-2 antigen diagnostic tests as those that detect SARS-CoV-2 antigens directly from clinical specimens. FDA recommends that the following validation studies be conducted for a SARS-CoV-2 antigen test:
- Limit of Detection/Analytical Sensitivity
- Cross-reactivity/Analytical Specificity
- Microbial Interference
- Clinical Agreement Study
The clinical agreement study is intended to establish the performance characteristics (e.g., sensitivity/PPA, specificity/NPA) of the test. FDA believes that clinical agreement should be established on human specimens, preferably leftover specimens from patients with or without SARS-CoV-2 infection. If SARS-CoV-2 positive clinical specimens cannot be obtained, it is acceptable to spike leftover specimens with SARS-CoV-2 materials. For devices claiming multiple clinical matrices, the most challenging matrix should be used in your validation studies.
### C. Serological Diagnostics
FDA defines SARS-CoV-2 serological diagnostic tests as tests that identify antibodies (e.g., IgM, IgG) to SARS-CoV-2 from clinical specimens. FDA recommends that the following validation studies be conducted for a SARS-CoV-2 serological assay:
- Cross-reactivity/Analytical Specificity
- Class Specificity
- Clinical Agreement Study
The clinical agreement study is intended to establish the performance characteristics (e.g., sensitivity/PPA, specificity/NPA) of the test. FDA recommends that clinical accuracy should be established on human specimens from patients with microbiologically confirmed COVID-19 infection.
# 285 2020-03-31_FDA Website - EUA for Molecular Diagnostic Tests.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2020-03-31_FDA Website - EUA for Molecular Diagnostic Tests.md
file_date: 2020-03-31
title: FDA Website - EUA for Molecular Diagnostic Tests
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subcategory: fda-policy
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web_url: https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2#umbrella-molecular
summary_short: The FDA umbrella EUA for molecular laboratory-developed tests (LDTs) for SARS-CoV-2 outlines eligibility criteria, including CLIA high-complexity certification and use limited to the single developing laboratory, with authorized tests listed in Appendix A. It also notes the November 15, 2021 reissuance that limited authorization to tests already in Appendix A and provides links to the authorization letter and provider/patient fact sheets.
CONTENT
On March 31, 2020, the FDA issued an umbrella EUA for molecular laboratory developed tests (LDTs) for detection of SARS-CoV-2 that meet certain criteria for eligibility described in the EUA. Under this EUA, authorized tests are authorized for use in the single laboratory that developed the authorized test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, that meet requirements to perform high complexity tests. Tests authorized under this umbrella EUA were added to Appendix A in the table below.
On November 15, 2021, the FDA reissued this EUA such that only tests that are listed in Appendix A are authorized for use as described in the EUA, and no additional tests will be authorized by this EUA. The reissued EUA also includes updated Conditions of Authorization and Fact Sheets to reflect the most up-to-date information.
EUA Letter of Authorization - [Laboratories Who Have Developed a Molecular-Based Test (LDTs) for Coronavirus Disease 2019 (COVID-19)](https://www.fda.gov/media/136598/download?attachment)
Fact Sheet for [Healthcare Providers](https://www.fda.gov/media/136599/download?attachment)
Fact Sheet for [Patients](https://www.fda.gov/media/136600/download?attachment)
# 271 2020-04-28_FDA Website - Umbrella EUA for Independently Validated Serology Tests.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2020-04-28_FDA Website - Umbrella EUA for Independently Validated Serology Tests.md
file_date: 2020-04-28
title: FDA Website - Umbrella EUA for Independently Validated Serology Tests
category: regulatory
subcategory: fda-policy
tags:
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conversion_input_file_type: docx
conversion: manual cut and paste
license: Public Domain
tokens: 271
words: 181
notes: date converted 2024-04-05
web_url: https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-emergency-use-authorizations-euas-serology-and-other-adaptive-immune-response#umbrella-serological
summary_short: The Umbrella EUA for Independently Validated SARS-CoV-2 Serology Tests describes FDA’s April 28, 2020 authorization pathway for antibody tests validated through designated government studies such as NIH/NCI. It explains that no tests were ultimately authorized under this umbrella and that FDA revoked the EUA on July 21, 2020 in favor of issuing individual EUAs with test-specific conditions and broader, more flexible scopes of authorization.
CONTENT
On April 28, 2020, FDA issued an umbrella EUA for SARS-CoV-2 Antibody Tests (Lateral flow or Enzyme-linked immunosorbent assay (ELISA) tests) that have been evaluated in an independent validation study performed at the National Institutes of Health's (NIH) National Cancer Institute (NCI), or by another government agency designated by the FDA, and are confirmed by the FDA to meet the criteria set forth in the Scope of Authorization of the EUA. To date, however, no device has been added to the list of authorized devices in Appendix A of the letter of authorization.
On July 21, 2020, FDA determined, based on information and experience since issuing this EUA, that circumstances support revocation of this umbrella EUA so that FDA may issue individual EUAs. Individual EUAs will allow for broader indications and scopes of authorization, individualized conditions of authorization to address any issue unique to a specific test, and more streamlined EUA amendments, such as additional uses that would not fall under this umbrella EUA.
Accordingly, [the EUA was revoked](https://www.fda.gov/media/140351/download?attachment) under Section 564(g)(2)(C) of the Federal Food, Drug, and Cosmetic (FD&C) Act.
# 18,972 2020-05-04_FDA Guidance - COVID IVD Test Developers v3.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2020-05-04_FDA Guidance - COVID IVD Test Developers v3.md
file_date: 2020-05-04
title: FDA Guidance - COVID IVD Test Developers v3
category: regulatory
subcategory: fda-policy
tags:
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xfile_type: docx
gfile_url: https://docs.google.com/document/d/1znZ6frcoKUCeafYZdDkTZ1S2r9uklCrH
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pdf_gdrive_url: https://drive.google.com/file/d/1gH7xdIi7L0hRx97Eob9oEUcMSend_7f7
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2020-05-04_FDA%20Guidance%20-%20COVID%20IVD%20Test%20Developers%20v3.pdf
conversion_input_file_type: pdf
conversion: claude
license: Public Domain
tokens: 18972
words: 14273
notes:
summary_short: The FDA Guidance for COVID IVD Test Developers v3 revises the March 16, 2020 policy to further scale pandemic testing while tightening oversight, especially for commercial serology tests, and adding streamlined EUA templates and pathways (including NIH/NCI-evaluated serology under an umbrella EUA). It keeps the core CLIA lab and commercial manufacturer “validate + notify + submit EUA within a set window” approach but adds clearer enforcement levers like FDA website listing/removal if submissions aren’t timely and more explicit rules for modifications and bridging studies. The guidance provides updated validation recommendations by test type and reflects the shift from early flexibility toward stronger performance and labeling controls as more data and market experience accumulated.
CONTENT
***INTERNAL TITLE:*** Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)
Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff
**Document issued on the web on May 4, 2020.**
**This document supersedes "Policy for Diagnostic Tests for Coronavirus Disease-2019 during the Public Health Emergency: Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff" issued March 16, 2020.**
U.S. Department of Health and Human Services
Food and Drug Administration
Center for Devices and Radiological Health
## Preface
### Public Comment
This guidance is being issued to address the Coronavirus Disease 2019 (COVID-19) public health emergency. This guidance is being implemented without prior public comment because the Food and Drug Administration (FDA or Agency) has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is being implemented immediately, but it remains subject to comment in accordance with the Agency's good guidance practices.
Comments may be submitted at any time for Agency consideration. Submit written comments to the Dockets Management Staff (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. Submit electronic comments to https://www.regulations.gov. All comments should be identified with the docket number FDA-2020-D-0987 and complete title of the guidance in the request.
### Additional Copies
Additional copies are available from the FDA webpage titled "COVID-19-Related Guidance Documents for Industry, FDA Staff, and Other Stakeholders," available at https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders, and the FDA webpage titled "Search for FDA Guidance Documents," available at https://www.fda.gov/regulatory-information/search-fda-guidance-documents. You may also send an e-mail request to CDRH-Guidance@fda.hhs.gov to receive an additional copy of the guidance. Please include the document number 20010-R2 and complete title of the guidance in the request.
### Questions
For questions about this document, contact CDRH-EUA-Templates@fda.hhs.gov.
## Table of Contents
Here's the content from the screenshot converted to a Markdown pipe table:
| | | |
|---------|-------|------|
| I. | Introduction | 4 |
| II. | Background | 5 |
| III. | Scope | 6 |
| IV. | Policy | 6 |
| A. | Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High-Complexity Testing Using Their Validated Diagnostic Tests Prior to EUA Submission | 8 |
| 1. | Validation | 8 |
| 2. | FDA Notification | 8 |
| 4. | EUA Request | 9 |
| 5. | Clinical Testing | 10 |
| B. | State Authorization of Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High-Complexity Testing | 10 |
| C. | Commercial Manufacturer Development and Distribution of Diagnostic Tests Prior to EUA Submission | 11 |
| 1. | Validation | 12 |
| 2. | FDA Notification | 12 |
| 4. | EUA Request | 13 |
| 5. | Clinical Testing | 14 |
| D. | Commercial Manufacturer Development and Distribution and Laboratory Development and Use of Serology Tests Without or Prior to an EUA | 14 |
| 1. | Validation | 15 |
| 2. | FDA Notification | 15 |
| 4. | EUA Request | 17 |
| V. | Validation Study Recommendations Based on the Technological Principles of Tests | 17 |
| A. | Molecular Diagnostics | 17 |
| (1) | Limit of Detection | 18 |
| (2) | Clinical Evaluation | 18 |
| (3) | Inclusivity | 18 |
| (4) | Cross-reactivity | 18 |
| B. | Antigen Detection Diagnostics | 19 |
| C. | Serological Tests | 19 |
||
## I. Introduction
FDA plays a critical role in protecting the United States from threats such as emerging infectious diseases, including the Coronavirus Disease 2019 (COVID-19) pandemic. FDA is committed to providing timely guidance to support response efforts to this pandemic.
FDA is issuing this guidance to provide a policy to help accelerate the availability of novel coronavirus (COVID-19) tests developed by laboratories and commercial manufacturers for the duration of the public health emergency. Rapid detection of COVID-19 cases in the United States requires wide availability of testing to control the emergence of this rapidly spreading, severe illness. This guidance describes a policy for laboratories and commercial manufacturers to help accelerate the use of tests they develop in order to achieve more rapid and widespread testing capacity in the United States.
This policy is intended to remain in effect only for the duration of the public health emergency related to COVID-19 declared by the Secretary of Health and Human Services (HHS) on January 31, 2020, effective January 27, 2020, including any renewals made by the HHS Secretary in accordance with section 319(a)(2) of the Public Health Service Act (PHS Act).
Given this public health emergency, and as discussed in the Notice in the Federal Register of March 25, 2020, titled "Process for Making Available Guidance Documents Related to Coronavirus Disease 2019," available at https://www.govinfo.gov/content/pkg/FR-2020-03-25/pdf/2020-06222.pdf, this guidance is being implemented without prior public comment because FDA has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is being implemented immediately, but it remains subject to comment in accordance with the Agency's good guidance practices.
In general, FDA's guidance documents, including this guidance, do not establish legally enforceable responsibilities. Instead, guidances describe the Agency's current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word should in Agency guidance means that something is suggested or recommended, but not required.
## II. Background
There is currently a pandemic of respiratory disease caused by a novel coronavirus. The virus has been named "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2) and the disease it causes has been named "Coronavirus Disease 2019" (COVID-19). On January 31, 2020, HHS issued a declaration of a public health emergency related to COVID-19 and mobilized the Operating Divisions of HHS. In addition, on March 13, 2020, the President declared a national emergency in response to COVID-19.
SARS-CoV-2 has demonstrated the capability to spread rapidly, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high, both globally and to the United States. To respond effectively to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical. FDA believes the policies set forth in this guidance will help address these urgent public health concerns by helping to expand the number and variety of tests, as well as available testing capabilities in reference and commercial laboratories and healthcare settings, while helping ensure these tests are accurate and reliable.
The Centers for Disease Control and Prevention (CDC) laboratories have supported the COVID-19 response, including development of a diagnostic assay that was issued an Emergency Use Authorization (EUA) on February 4, 2020. Since authorizing CDC's EUA, FDA has been actively working with other SARS-CoV-2 diagnostic test developers to help accelerate development programs and respond to requests for in vitro diagnostic EUAs. However, the severity and scope of the current COVID-19 situation around the globe necessitates greater testing capacity for the virus than is currently available.
The EUA authorities allow FDA to help strengthen the nation's public health protections against chemical, biological, radiological, and nuclear (CBRN) threats by facilitating the availability and use of medical countermeasures initiatives (MCMs) needed during certain public health emergencies. Under section 564 of the FD&C Act, the FDA Commissioner may authorize the use of unapproved medical products, or unapproved uses of approved medical products, in certain emergency circumstances, after the HHS Secretary has made a declaration of emergency or threat justifying authorization of emergency use, to diagnose, treat, or prevent serious or life-threatening disease or conditions caused by CBRN threat agents when certain criteria are met.
## III. Scope
The policies described in this guidance for accelerating availability of testing for COVID-19 apply to certain laboratories and commercial manufacturers developing SARS-CoV-2 tests during the public health emergency, as described below.
## IV. Policy
This guidance describes policies intended to help rapidly expand testing capacity by facilitating the development and use of SARS-CoV-2 tests during the public health emergency.
This guidance describes two policies for accelerating the development of certain laboratory-developed diagnostic tests for COVID-19 – one leading to an EUA submission to FDA, and the other not leading to an EUA submission when the test is developed under the authorities of the State in which the laboratory resides and the State takes responsibility for COVID-19 testing by laboratories in its State. The policy leading to an EUA remains unchanged from the initial publication of this guidance on February 29, 2020, though some process updates and clarifications have been made as discussed further below. The policy for State oversight remains unchanged from the second publication of this guidance on March 16, 2020.
In addition, this guidance describes a policy for commercial manufacturers to more rapidly distribute their SARS-CoV-2 diagnostic tests to laboratories for specimen testing after validation, while an EUA is being prepared for submission to FDA. This policy remains unchanged from the second publication of this guidance on March 16, 2020, though some process updates and clarification have been made as discussed further below.
This guidance also describes a policy regarding SARS-CoV-2 serological testing, which is modified from the policy included in the March 16, 2020 guidance as it pertains to commercial manufacturers but not laboratories. At the time of previous issuance, FDA provided flexibility for serology tests to be marketed with notification to FDA and certain labeling information, but without submission of an EUA. FDA's policy was based on the considerations that serology tests are not meant to diagnose active SARS-CoV-2 infection and that early availability and use of these tests could help answer critical questions about the prevalence of COVID-19 infections in different communities, whether the presence of antibodies conveys immunity, and, if so, for how long. That policy succeeded in encouraging development of serology tests.
Since that policy was issued, FDA has authorized several serology tests under individual EUAs and has issued an umbrella EUA providing a streamlined approach for EUA authorization of serology tests that are evaluated by the National Institutes of Health's National Cancer Institute (NIH/NCI). The umbrella EUA for NIH-evaluated tests has provided a streamlined pathway for EUA authorization of commercial serology tests. Also since that time, FDA has become aware that a concerning number of commercial serology tests are being promoted inappropriately, including for diagnostic use, or are performing poorly based on an independent evaluation by the NIH, indicating that greater FDA oversight of commercial serology tests is important to protect the public health.
Under the modified policy, FDA does not intend to object as described below where commercial manufacturers develop and distribute their serology tests after validation, for a limited period of time, while an EUA is being prepared for submission to FDA. Appendices with templates for such submissions have been added to facilitate and streamline the EUA process.
The policy for serological tests developed and used by laboratories that are certified under the Clinical Laboratory Improvement Amendments (CLIA) to perform high-complexity testing has not changed from the March 16, 2020 guidance, though FDA continues to encourage such laboratories to submit EUAs for their laboratory developed tests.
In the context of a public health emergency involving pandemic infectious disease, it is critically important that tests are validated because false results not only can negatively impact the individual patient but also can have broad public health impact. In this guidance, FDA provides recommendations regarding validation of COVID-19 tests based on the available information. FDA encourages test developers to discuss any alternative technological approaches to validating their test with FDA.
### A. Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High-Complexity Testing Using Their Validated Diagnostic Tests Prior to EUA Submission
The policy described in this subsection applies to laboratories certified under CLIA that meet the CLIA regulatory requirements to perform high-complexity testing and that seek to develop and perform diagnostic tests to detect the SARS-CoV-2 virus and pursue an EUA from FDA for those tests. This policy does not apply to home collection of specimens to be sent for testing at a laboratory certified under CLIA for high-complexity testing.
FDA anticipates that clinical laboratories may need to design and manufacture the individual test kit components (e.g., primers, probes, etc.), or to purchase research use only (RUO) components from third party manufacturers, for the development of their assays.
In light of the increasing numbers of COVID-19 cases throughout the country and the urgent need to expand the nation's capacity for COVID-19 testing during the public health emergency, FDA does not intend to object to the use of these SARS-CoV-2 tests for specimen testing for a reasonable period of time, where the test has been validated and while the laboratory is preparing their EUA request, and where the laboratory gives notification of validation to FDA, as described below. FDA believes that 15 business days is a reasonable period of time to prepare an EUA submission for a test that has already been validated.
#### 1. Validation
All clinical tests should be validated prior to use. In the context of a public health emergency, it is critically important that tests are validated because false results can negatively impact not only the individual patient but also can have broad public health impact. FDA has provided recommendations regarding testing that should be performed to ensure analytical and clinical validity in section V below. FDA encourages laboratories to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
#### 2. FDA Notification
Following completion of assay validation, laboratories should notify FDA (e.g., email to CDRH-EUA-Templates@FDA.HHS.GOV) that their assay has been validated. This notification should include the name of the laboratory, name of the laboratory director, laboratory address, and contact person in this email. FDA will acknowledge receipt of this notification via auto-reply, and generally will add the laboratory name to FDA's website listing. As noted above, FDA recommends that laboratories submit a completed EUA request within 15 business days of the notification to FDA that the assay has been successfully validated. If an EUA request is not submitted within this timeframe, FDA intends to remove the laboratory from its website listing of laboratories that have notified FDA and may take additional actions as appropriate.
It would be helpful to FDA if laboratories provide information on testing capacity. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
#### 3. Reporting of Results
In order to provide transparency, FDA recommends that test reports include a general statement that the test has been validated but FDA's independent review of this validation is pending.
Laboratories should immediately notify appropriate Federal, State, and local public health agencies of all positive results.
#### 4. EUA Request
FDA has made available, through download from our website, a template that laboratories may choose to use to facilitate the preparation, submission, and authorization of an EUA for a molecular diagnostic test. Laboratories that intend to use alternative approaches should consider seeking FDA's feedback or recommendation to help them through the pre-EUA and EUA process. FDA encourages laboratories to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
Soon after receiving the EUA request, FDA intends to perform a preliminary review to identify if there are any problems with the performance data. If a problem is identified, FDA intends to work with the laboratory to address the problem (e.g., through labeling or bench testing). If any problems are significant and cannot be addressed in a timely manner, FDA would expect the laboratory to stop testing and issue corrected test reports indicating prior results may not be accurate. In such circumstances, FDA intends to remove the laboratory from the website listing of notifications.
Issued EUAs are posted on FDA's website.
When a laboratory makes a modification to an EUA authorized test for use of a new specimen type, FDA does not intend to object to the use of such a modified test without notification to FDA or a new or amended EUA where the new specimen type has been previously authorized for another test of the same technology and where the EUA authorized test is validated for the new specimen type. Modifications to an EUA authorized test for use of a new specimen type that has not been previously authorized for another test of the same technology must be authorized under a new or amended EUA prior to clinical use.
For all other types of modifications, FDA does not intend to object to the use of a test, without notification to FDA or a new or amended EUA, where the test is a modification of an EUA-authorized test and the modified test is validated using a bridging study to the EUA-authorized test. One way to bridge to a new component is to establish equivalent performance between parallel testing of the same specimens with the new and original components. We recommend testing 3-fold serial dilutions of SARS-CoV-2 viral materials (e.g., whole genomic viral RNA or inactivated virus, etc.) in a pooled respiratory sample matrix in triplicate until you achieve a hit rate of <100%. If the resultant Limit of Detection (LoD) is the same as the LoD for the unmodified authorized test (i.e., ≤3xLOD), then FDA believes the two tests can be considered to have equivalent performance.
When validating through a bridging study and not pursuing an EUA amendment for the modification, FDA would like to see the laboratory's validation data informally through an email to CDRH-EUA-Templates@FDA.HHS.GOV. If FDA's review of the bridged validation data indicates that it could be applicable to modifications of other tests with an EUA, or to other laboratories modifying the same authorized test, and the laboratory agrees to FDA sharing that information on our website for use by other laboratories, FDA intends to update our FAQs so other laboratories can refer to the validation for their testing, without conducting their own bridging study for the same modification. This informal sharing of data would not be considered to be a notification, as discussed above, or an EUA request.
#### 5. Clinical Testing
While awaiting an FDA determination on the EUA request, FDA recommends that clinical laboratories obtain confirmation of the first five positive and the first five negative clinical specimens using an EUA-authorized assay. This testing may be performed within the same laboratory using an EUA-authorized assay or may involve sending these ten specimens to another laboratory for confirmation. If any of these results cannot be confirmed, the laboratory should notify FDA at CDRH-EUA-Templates@FDA.HHS.GOV, and take other appropriate actions such as terminating testing patient specimens, and issuing corrected test reports indicating prior test results may not be accurate.
### B. State Authorization of Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High-Complexity Testing
On March 12, 2020, FDA issued enforcement discretion and stated that it was not objecting to the Wadsworth Center authorizing certain laboratories in the State of New York to begin patient testing under certain circumstances to increase availability of COVID-19 testing in response to a request from the Wadsworth Center of the New York State Department of Health (Wadsworth). Wadsworth had informed FDA that it would be willing to have clinical laboratories that currently hold a New York State Department of Health clinical laboratory permit to notify Wadsworth that they have validated a test for COVID-19, and to submit validation studies to Wadsworth. Wadsworth likewise said it would notify the laboratory if it identified any concerns, and request that the laboratory terminate testing patient specimens and issue corrected test reports indicating prior test results might not be accurate.
On March 13, 2020, the President issued a "Memorandum on Expanding State-Approved Diagnostic Tests" (Memorandum), which refers to the flexibility that FDA allowed New York State and states as follows:
"Should additional States request flexibility to authorize laboratories within the State to develop and perform tests used to detect COVID-19, the Secretary shall take appropriate action, consistent with law, to facilitate the request."
In accordance with the Memorandum, FDA describes below its policy regarding States and territories that authorize laboratories within their State or territory to develop their own COVID-19 tests and perform specimen testing, where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA.
A State or territory choosing to authorize laboratories within that State or territory to develop and perform a test for COVID-19 would do so under authority of its own State law, and under a process that it establishes. FDA does not intend to object to the use of such tests for specimen testing where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA, and where instead the State or territory takes responsibility for COVID-19 testing by laboratories in its State during the COVID-19 outbreak.
FDA requests that the State or territory notify us if they choose to use this flexibility to expedite COVID-19 testing. FDA will not be reviewing the process adopted by the State or territory, which we understand may be different than the process adopted by New York State. FDA expects that such states as part of their oversight process will require laboratories developing SARS-CoV-2 tests to validate those tests prior to use. FDA encourages laboratories that develop and perform a test for COVID-19 under this policy to notify FDA that they have started clinical testing by sending an email to that effect to CDRH-EUA-Templates@FDA.HHS.GOV. It would be helpful to FDA if laboratories provide information on testing capacity. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
### C. Commercial Manufacturer Development and Distribution of Diagnostic Tests Prior to EUA Submission
The policy described in this subsection applies to commercial manufacturers that seek to develop and distribute diagnostic test kits to detect the SARS-CoV-2 virus to clinical laboratories or to healthcare workers for point-of-care testing. Unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to laboratories certified to perform high complexity testing, including testing at the point-of-care when the site is covered by the laboratory's CLIA certificate for high-complexity testing.
This policy does not apply to at-home testing, including at-home specimen collection.
In light of the increasing numbers of COVID-19 cases throughout the country and the urgent need to expand the nation's capacity for COVID-19 testing during the public health emergency, FDA does not intend to object to a commercial manufacturer's development and distribution of SARS-CoV-2 test kits for specimen testing for a reasonable period of time, where the test has been validated and while the manufacturer is preparing its EUA request, where the manufacturer gives notification of validation to FDA as described below, and where the manufacturer provides instructions for use of the test and posts data about the test's performance characteristics on the manufacturer's website. Transparency can help mitigate potential adverse impacts from a poorly designed test by facilitating better informed decisions by potential purchasers and users.
FDA believes that 15 business days is a reasonable period of time to prepare an EUA submission for a test that has already been validated. Soon after receiving the EUA request, FDA will perform a preliminary review to identify if there are any problems with the performance data. If a problem is identified, FDA intends to work with the manufacturer to address the problem (e.g., through labeling or bench testing). If the problem is significant and cannot be addressed in a timely manner, and the manufacturer has already distributed the device, FDA would expect the manufacturer to suspend distribution and conduct a recall of the test.
#### 1. Validation
All clinical tests should be validated prior to use. In the context of a public health emergency, it is critically important that tests are validated because false results can negatively impact not only the individual patient but also can have broad public health impact. FDA has provided recommendations regarding testing that should be performed to ensure analytical and clinical validity in section V below. FDA encourages manufacturers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
#### 2. FDA Notification
Following completion of assay validation, manufacturers should notify FDA (e.g., e-mail to CDRH-EUA-Templates@FDA.HHS.GOV) that their assay has been validated and they intend to begin distribution. This notification should include the name of the manufacturer, address, contact person, a website link, and a copy of the instructions for use including a summary of assay performance. FDA will acknowledge receipt of this notification via auto-reply, and generally will add the name of the manufacturer and test to FDA's website listing.
In circumstances where manufacturers use distributor(s) for their product, the manufacturers should identify the names of all distributors in their notification. Distributors and laboratories using these tests should not provide separate notification. As noted above, FDA recommends that manufacturers submit a completed EUA request within 15 business days of the notification to FDA that the assay has been successfully validated. If an EUA request is not submitted within this timeframe, FDA intends to remove the manufacturer/test from its website listing of notified tests and may take additional actions as appropriate.
It would be helpful to FDA if manufacturers provide information on testing capacity, as well as the number of laboratories in the U.S. with the required platforms installed. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
#### 3. Reporting of Results
In order to provide transparency, FDA recommends that instructions for use and test reports include a general statement that the test has been validated but FDA's independent review of this validation is pending.
#### 4. EUA Request
FDA has made available, through download from our website, a template that test kit manufacturers may choose to use to facilitate the preparation, submission, and authorization of an EUA for a molecular diagnostic. Manufacturers can use alternative approaches. Manufacturers who intend to use alternative approaches should consider seeking FDA's feedback or recommendations to help them through the pre-EUA and EUA process. FDA encourages manufacturers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
Soon after receiving the EUA request, FDA intends to perform a preliminary review to identify if there are any problems with the performance data. If a problem is identified, FDA intends to work with the manufacturer to address the problem (e.g., through labeling or bench testing). If any problems are significant and cannot be addressed in a timely manner, FDA would expect the manufacturer to suspend distribution and conduct a recall of the test, which should include a notification concerning corrected test reports indicating prior test results may not be accurate. In such circumstances, FDA intends to remove the manufacturer/test from the website listing of notifications.
Issued EUAs are posted on FDA's website.
A manufacturer may request certain modifications to its EUA-authorized test as an amendment to the EUA as specified in the EUA's Conditions of Authorization. Where validation data supporting the modification have been submitted in the amendment, FDA does not intend to object to implementation of the modification while FDA conducts its review, except for modifications to add specimen types that have not been previously authorized with another test of the same technology.
#### 5. Clinical Testing
While awaiting FDA determination on the EUA request, FDA recommends that manufacturers make publicly available on their website the instructions for use, including a summary of assay performance.
### D. Commercial Manufacturer Development and Distribution and Laboratory Development and Use of Serology Tests Prior to or Without an EUA
The policy described in this subsection applies to developers of serology tests that identify antibodies (e.g., IgG, IgM) to SARS-CoV-2 from clinical specimens. Unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to laboratories certified to perform high complexity testing, and at the point-of-care when covered by the laboratory's CLIA certificate for high-complexity testing. This policy does not apply to at-home testing, including at-home specimen collection, due to additional considerations that require FDA review.
FDA does not intend to object to a commercial manufacturer's development and distribution of serology tests to identify antibodies to SARS-CoV-2 for a reasonable period of time, where the test has been validated and while the manufacturer is preparing its EUA request, where the manufacturer gives notification of validation to FDA as described in subsection D.2 below, and where the manufacturer includes information in the instructions for use as described in subsection D.3 below. FDA provided early market access through its March 16, 2020, updated guidance, but that access was premised on the understanding that tests should be validated before being marketed to fall under the enforcement discretion policy. Given that any test on the market under the March 16 enforcement discretion policy or this policy should already be validated by the manufacturer before being marketed, FDA believes that 10 business days (from the date of notification or the date of publication of this guidance, whichever is later) is a reasonable period of time to prepare an EUA submission for a test whose performance characteristics have already been validated.
If FDA becomes aware of questions or concerns about a test after notification, such as poor performance or misleading statements about the test, FDA will communicate those concerns to the manufacturer and provide the manufacturer an opportunity to address the questions or concerns. If the concerns cannot be or have not been addressed in a timely manner, and the manufacturer has already distributed the test, FDA would expect the manufacturer to suspend distribution of the test. FDA also intends to remove the test from the website listing of notifications and may take additional actions as appropriate.
While laboratories are encouraged to submit EUA requests for serology tests, FDA does not intend to object to the development and use of serology tests to identify antibodies to SARS-CoV-2 by laboratories that are certified under CLIA to perform high-complexity testing, where the test has been validated, notification is provided to FDA, and information is included in the test reports as described in subsection D.3 below. At this time, we believe it is most beneficial to focus our EUA review and authorization efforts on tests from commercial manufacturers, which have the potential to be distributed more broadly, rather than laboratory-developed serology tests that are not for diagnostic purposes, are being performed at one laboratory that is CLIA-certified to perform high-complexity testing, and that are validated in-house. However, if FDA becomes aware of questions or concerns about a laboratory-developed serology test, such as poor performance or misleading statements about the test, FDA will communicate those concerns to the laboratory and provide the laboratory an opportunity to address the questions or concerns. If the concerns cannot be or have not been addressed in a timely manner, FDA intends to remove the laboratory from the website listing of notifications and may take additional actions as appropriate.
#### 1. Validation
All clinical tests should be validated prior to use. In the context of a public health emergency, it is critically important that tests are validated because false results can negatively impact not only the individual patient but also can have broad public health impact. FDA has provided recommendations regarding testing that should be performed to ensure analytical and clinical validity in section V below. FDA encourages developers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV and additionally encourages developers to refer to the templates provided as examples in the Appendices to this guidance for serology test manufacturers and laboratories.
#### 2. FDA Notification
Following completion of assay validation, developers should notify FDA by email to CDRH-EUA-Templates@FDA.HHS.GOV that their assay has been validated and they intend to begin distribution or testing.
a. For tests developed and used by laboratories certified under CLIA that meet the CLIA regulatory requirements to perform high-complexity testing, this notification should include the name of the laboratory, name of the laboratory director, laboratory address, and contact person in this email. FDA will acknowledge receipt of this notification via auto-reply, and generally will add the laboratory name to FDA's website listing.
It would be helpful to FDA if laboratories provide information on testing capacity. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
b. For tests developed and distributed by commercial manufacturers, this notification should include the name of the manufacturer, address, contact person, and a copy of the instructions for use that includes a summary of assay performance. FDA will acknowledge receipt of this notification via auto-reply, and generally will add the name of the manufacturer and test to FDA's website listing. As noted above, FDA recommends that manufacturers submit a completed EUA request within 10 business days of the notification to FDA that the assay has been successfully validated, or the date of publication of this guidance, whichever is later. If an EUA request is not submitted within this timeframe, FDA intends to remove the manufacturer/test from its website listing of notified tests and may take additional actions as appropriate.
In circumstances where manufacturers use distributor(s) for their test, the manufacturer should identify the names of all distributors in their notification. Distributors should not provide separate notification.
It would be helpful to FDA if manufacturers provide information on test production capacity, the number of laboratories in the U.S. with the required platforms installed. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
#### 3. Labeling and Reporting of Results
In order to provide important information about the intended use of the test and its limitations, FDA recommends that instructions for use and patient test reports include information that helps users and patients understand the test results, such as the following:
- This test has not been reviewed by the FDA.
- Negative results do not preclude acute SARS-CoV-2 infection. If acute infection is suspected, direct testing for SARS-CoV-2 is necessary.
- Results from antibody testing should not be used to diagnose or exclude acute SARS-CoV-2 infection.
- Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.
#### 4. EUA Request
Templates for commercial manufacturers and laboratories are provided in Appendices A and B to facilitate the preparation, submission, and authorization of an EUA. Developers can use alternative approaches. Developers who intend to use alternative approaches should consider seeking FDA's feedback or recommendations to help them through the EUA process. FDA encourages developers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
FDA may leverage data from testing at the National Institutes of Health's National Cancer Institute (NIH/NCI), or at another federal government laboratory designated by FDA, to inform decisions on EUA requests and other actions. FDA has issued an EUA for certain serology tests evaluated in the NIH/NCI independent validation study, or by another government agency designated by FDA, that are confirmed by FDA to meet certain specific performance and other criteria, and added to the EUA.
FDA will communicate any questions or concerns regarding a pre-EUA or EUA submission to the developer. FDA will also work collaboratively to address any potential concerns or safety considerations raised in the pre-EUA submission or EUA request and will contact the developer regarding a final determination on the EUA request.
Issued EUAs are posted on FDA's website.
If FDA is not able to issue an EUA, FDA intends to notify the manufacturer. Where the manufacturer has distributed tests, FDA also would expect the manufacturer to suspend distribution of the test, which should include a notification indicating that prior test results may not be accurate. FDA intends to remove the manufacturer/test from the website listing of notifications. FDA may also take other action as may be appropriate in the circumstances.
## V. Validation Study Recommendations Based on the Technological Principles of Tests
In this section, FDA provides recommendations for developers regarding testing that should be performed to demonstrate that a SARS-CoV-2 test is validated based upon the underlying technological principles of the test. Depending on the characteristics of your test, additional validation studies may be recommended. FDA encourages test developers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-templates@FDA.HHS.GOV.
### A. Molecular Diagnostic Tests
FDA defines SARS-CoV-2 molecular diagnostic tests as tests that detect SARS-CoV-2 nucleic acids from human specimens. FDA recommends that the following validation studies be conducted for molecular SARS-CoV-2 diagnostic tests:
#### (1) Limit of Detection
FDA recommends that developers document the limit of detection (LoD) of their SARS-CoV-2 assay. FDA generally does not have concerns with spiking RNA or inactivated virus into artificial or real clinical matrix (e.g., Bronchoalveolar lavage [BAL] fluid, sputum, etc.) for LoD determination.
FDA recommends that developers test a dilution series of three replicates per concentration with inactivated virus on actual patient specimen, and then confirm the final concentration with 20 replicates. For this guidance, FDA defines LoD as the lowest concentration at which 19/20 replicates are positive. If multiple clinical matrices are intended for clinical testing, FDA recommends that developers submit in their EUA requests the results from the most challenging clinical matrix to FDA. For example, if testing respiratory specimens (e.g., sputum, BAL, nasopharyngeal (NP) swabs, etc.), laboratories should include only results from sputum in their EUA request.
#### (2) Clinical Evaluation
The availability of positive samples has increased as the pandemic has progressed. As such, FDA now recommends that developers use positive clinical samples for clinical validation. Moreover, due to the increased availability of clinical samples, FDA recommends that developers confirm performance of their assay by testing a minimum of 30 positive specimens and 30 negative specimens as determined by an authorized assay. If you do not have access to clinical samples as determined by an authorized assay, contrived clinical specimens may be considered. Contrived reactive specimens can be created by spiking RNA or inactivated virus into leftover clinical specimens, of which the majority can be leftover upper respiratory specimens such as NP swabs, or lower respiratory tract specimens such as sputum, etc. If contrived samples are used, FDA recommends that twenty of the contrived clinical specimens be spiked at a concentration of 1x-2x LoD, with the remainder of specimens spanning the assay testing range. For this guidance, FDA defines the acceptance criteria for the performance as 95% agreement at 1x-2x LoD, and 100% agreement at all other concentrations and for negative specimens.
#### (3) Inclusivity
Developers should document the results of an in silico analysis indicating the percent identity matches against publicly available SARS-CoV-2 sequences that can be detected by the proposed molecular assay. FDA anticipates that 100% of published SARS-CoV-2 sequences will be detectable with the selected primers and probes.
#### (4) Cross-reactivity
FDA recommends cross-reactivity wet testing on common respiratory flora and other viral pathogens at concentrations of 10^6 CFU/ml or higher for bacteria and 10^5 pfu/ml or higher for viruses, except for SARS-Coronavirus and MERS-Coronavirus, which can be accomplished by in silico analysis. As an alternative, FDA believes an in silico analysis of the assay primer and probes compared to common respiratory flora and other viral pathogens can be performed. For this guidance, FDA defines in silico cross-reactivity as greater than 80% homology between one of the primers/probes and any sequence present in the targeted microorganism. In addition, FDA recommends that developers follow recognized laboratory procedures in the context of the sample types intended for testing for any additional cross-reactivity testing.
Additional information for the validation of molecular diagnostics is included in the manufacturer and developers EUA templates available for download on our website.
### B. Antigen Detection Tests
FDA defines SARS-CoV-2 antigen tests as those that detect proteins that are part of the SARS-CoV-2 virus directly from clinical specimens. FDA recommends that the following validation studies be conducted for a SARS-CoV-2 antigen test:
- Limit of Detection/Analytical Sensitivity
- Cross-reactivity/Analytical Specificity
- Microbial Interference
- Clinical Agreement Study
The clinical agreement study is intended to establish the performance characteristics (e.g., sensitivity/PPA, specificity/NPA) of the test. FDA believes that clinical agreement should be established on human specimens, preferably leftover specimens from patients with or without SARS-CoV-2 infection.
### C. Serological Tests
FDA defines SARS-CoV-2 serological tests as tests that identify antibodies (e.g., IgG, IgM) to SARS-CoV-2 from clinical specimens. FDA recommends that the following validation studies be conducted for a SARS-CoV-2 serological assay:
- Cross-reactivity/Analytical Specificity
- Class Specificity
- Clinical Agreement Study
The clinical agreement study is intended to establish the performance characteristics (e.g., sensitivity/PPA, specificity/NPA) of the test. FDA recommends that clinical accuracy should be established on human specimens from patients with microbiologically confirmed COVID-19 infection.
EUA templates for serology tests for manufacturers and laboratories are provided in Appendices A and B, respectively, to facilitate pre-EUA/EUA submissions. These templates include further recommendations concerning the above validation studies and make additional recommendations about other information that should be provided to FDA as part of the pre-EUA/EUA submission process. Developers can use alternative approaches. FDA encourages developers to discuss any alternative approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
## Appendix A: Serology Template for Manufacturers
This template (the "template") provides FDA's current recommendations concerning what data and information should be submitted to FDA in support of a pre-EUA/EUA submission for a SARS-CoV-2 antibody test. As outlined in Section V.C. of this guidance, FDA recommends that the following validation studies be conducted for a SARS-CoV-2 serological assay: Cross-reactivity/Analytical Specificity, Class Specificity, and Clinical Agreement Study. This template is intended to help manufacturers provide these validation data and other recommended information to FDA, but alternative approaches can be used. For more information about EUAs in general, please see the FDA Guidance document: [Emergency Use Authorization of Medical Products and Related Authorities](https://www.fda.gov/media/97321/download).
### GENERAL INFORMATION ABOUT THIS TEMPLATE
- Text highlighted in yellow [Text] should be completed by the test manufacturer (sponsor) as applicable to their specific test. Text in bold outlines the Food and Drug Administration's (FDA) additional recommendations for the sponsors' consideration when completing the suggested information in each section.
- Please be reminded that tests for the detection of antibodies against SARS-CoV-2 must not be distributed and/or used for clinical diagnoses.
- This is an EUA interactive review template for Pre-EUA/EUA submissions. The template is subject to change as we learn more about the COVID-19 disease and its risk-benefit profile.
- A test authorized under an EUA is only authorized for emergency use while the EUA is in effect.
- The EUA is not a pathway to permanent marketing of your device. Therefore, we strongly recommend that you consider, in addition to an EUA, a traditional premarket submission for your IVD so that your device can still be legally marketed after termination of the public health emergency declaration. We recommend that you identify as soon as possible in the Pre-EUA review process any consideration of moving your product forward towards De Novo/510(k) clearance.
### EXAMPLE TEMPLATE:
#### A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution of the [test name] in [indicate labs e.g., U.S. laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform moderate complexity and high complexity tests, and U.S. laboratories certified under CLIA to perform high complexity tests, and as applicable, for near patient testing, or point of care use], for the detection of [specify types of antibodies e.g., IgM, IgG, total] antibodies to SARS-CoV-2 in [specify matrices] from individuals with current or prior COVID-19 infection.
#### B. MEASURAND
[Specify what the test detects and whether it can differentiate between IgM and IgG or if it detects total antibody without differentiation.]
#### C. APPLICANT
[Official name, address and contact information of applicant]
#### D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name: [test name]
Established Name - [test name]
#### E. REGULATORY INFORMATION
Approval/Clearance Status:
The [test name] is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
Product Code:
QKO
#### F. PROPOSED INTENDED USE
1\) Intended Use:
The proposed IU will be finalized based on the data provided at the time of authorization.
The [test name] is a [specify technology e.g., Enzyme-Linked Immunosorbent Assay (ELISA)] intended for qualitative [or semi-quantitative or quantitative tests, if appropriate validation data is provided. Performance evaluations beyond what is currently described in the template may be necessary] detection of [specify the antibody class or classes that are being detected, or indicate whether the test only detects total antibodies] antibodies to SARS-CoV-2 in human [specify matrices including anticoagulants]. The [test name] is intended for use as an aid in identifying individuals with an adaptive immune response to SARS-CoV-2, indicating recent or prior infection. At this time, it is unknown for how long antibodies persist following infection and if the presence of antibodies confers protective immunity. Testing is limited to [laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C 263a, to perform moderate or high complexity tests and as applicable, Point of Care (POC) testing].
Results are for the detection of SARS CoV-2 antibodies. [Specify antibodies detected] antibodies to SARS-CoV-2 are generally detectable in blood several days after initial infection, although the duration of time antibodies are present post-infection is not well characterized. Individuals may have detectable virus present for several weeks following seroconversion.
Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities.
[As applicable, the sensitivity of [test name] early after infection is unknown.] Negative results do not preclude acute SARS-CoV-2 infection. If acute infection is suspected, direct testing for SARS-CoV-2 is necessary.
False positive results for [test name] may occur due to cross-reactivity from pre-existing antibodies or other possible causes. [For lateral flow devices: Due to the risk of false positive results, confirmation of positive results should be considered using second, different [as appropriate, IgG or IgM] assay].
The [test name] is only for use under the Food and Drug Administration's Emergency Use Authorization.
2\) Special Conditions for Use Statements:
For prescription use only
For in vitro diagnostic use only
For Emergency Use Authorization only
3\) Special Instrument Requirements:
The [test name] test is to be used with the [list all instruments, software requirements, other applicable instrumentation, etc.].
#### G. DEVICE DESCRIPTION AND TEST PRINCIPLE
1\) Product Overview/Test Principle:
[Describe the technology of the test and how this technology works to identify measurand (i.e., the test principle), the instruments/reader employed/required to perform the test from sample collection to result, and the specimen types for which you claim to have performance characteristics as described below]
The [test name] uses the following:
[List the antigen(s) and antibodies used in the assay to detect the antibodies in human specimens]
2\) Description of Test Steps: [Describe in order the steps of the test from specimen collection to result output.]
3\) Control Material
[List all control materials (provided with the test kit and/or required but not provided with the test kit) and describe what they are, how they are expected to work, where in the testing process they are used, and the frequency of use. If a control is commercially available, provide supplier's name and catalog number or other identifier; if your device relies on external controls that are manufactured by a third party please note that these controls should also be validated within your analytical and clinical studies described below in Section J.]
Controls that will be provided with the test kit include:
a) An external positive control for each antibody class claimed (e.g., IgG, IgM) is needed to [describe need] and is used [describe use – please specify the concentration of the positive control relative to the cut-off of your test (note that ideally the positive control concentration should be such that it is close to the cut-off of your test) and specify frequency of use.]
b) An external negative control is needed to [describe need] and is used [describe use – please specify the composition of the negative control and specify frequency of use.]
c) A [other (e.g., sample adequacy, internal, etc.)] control is needed to [describe need] and is used [describe use – please specify the composition of the control and specify frequency of use.]
Controls that are required but not provided with the test kit include [describe control – provide recommended sources of the control materials – either a separate control kit for purchase that you develop and market or a control material that can be purchased from a third party]. This/these control(s) is/are needed to [describe need] and is/are used [describe use – please also specify frequency of use].
#### H. INTERPRETATION OF RESULTS
Assessment of [test name] results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
[Clearly describe how results are to be interpreted. If applicable, clearly indicate how to interpret numeric test values as positive or negative for the presence of antibodies against SARS-CoV-2. Indicate how to identify indeterminate/equivocal results (if applicable) and how the user should resolve them. Also describe if and when repeat testing may be required.
If your test is a lateral flow, please describe the results interpretation for each of the test lines. You could consider reporting the results in the form of a table as shown below for a test that detects and differentiates between IgG and IgM:
**Table 1. Interpretation of Results**
| C Line | M Line | G Line | Test Result Interpretation |
|--------|--------|--------|---------------------------|
| not present | Any | Any | Invalid Test. The specimen must be retested with another device |
| + | - | - | Valid Test, Negative for antibodies for SARS-CoV-2 |
| + | + | - | Valid Test, IgM positive for antibodies for SARS-CoV-2 |
| + | + | + | Valid Test, IgM and IgG positive for antibodies for SARS-CoV-2 |
| + | - | + | Valid Test, IgG positive for antibodies for SARS-CoV-2 |
||
If you have a lateral flow device, please include a schematic/picture showing the location of the sample well, buffer well, and control and test lines]
#### I. PRODUCT MANUFACTURING
1\) Overview of Manufacturing and Distribution
The product will be manufactured at [manufacturer's name and FDA registration number (if applicable)] by [manufacturer name] personnel consistent with practices for the production of [types of devices] based on [type of quality system*]. Material manufactured by [manufacturer's name] may be bottled and kitted by [packager name] manufacturing facility.
The current manufacturing capabilities include the ability to manufacture approximately [insert the approximate number of units/products that can currently be manufactured per week at the manufacturing facility] products per week, however in the event of a surge in demand this could be increased to [please insert the approximate maximum number of units/products that could potentially be manufactured per week at the manufacturing facility if there was a surge in demand] product per week within a [please specify in weeks/months the expected timeframe required to increase product production if required] timeframe.
2\) Component Included with the Test: Components manufactured by [manufacturer's name and FDA registration number (if applicable)] and supplied with the test include:
[List all components and reagents provided for your test, including volumes, concentrations, quantities, etc.]
**Example: Table Kit Components**
| Kit components (example) | Manufacturer |
|--------------------------|--------------|
| Test Cassette with test strip | |
| Negative control | |
| Positive control | |
| Sample buffer (bottle) | |
| Transfer pipette | |
| Lancet (for fingerstick only) | |
| Instructions for Use leaflet | |
| Packing materials | |
||
3\) Components required but not included with the test:
[List all components (e.g., timer, analyzer/reader) and reagents not included with the test that must be supplied by the user to perform the test, with specific supplier names and catalog numbers or other identifiers for obtaining these components and reagents. Please include here all specific consumables that were validated for use with your device, that are not interchangeable with other products and that are needed to guarantee device performance as established in the EUA validation studies listed in section J below].
4\) The [test name] has been validated using only the components referenced above. The [test name] was developed using [briefly describe the capture antigens and antibodies used in the test, how they were designed and purified (e.g., are monoclonal antibodies used, are they manufactured in house or purchased commercially, what species they derive from, what epitope is targeted by the antibodies used in the assay, and if commercial products is there a certificate of analysis, etc.).
5\) Testing Capabilities: [Briefly describe current sample throughput capacity, total time required to perform the test (from clinical specimen collection to result), and number of tests that can be performed. Please provide the number of kits you can manufacture per day/week.]
6\) Distribution Plan
[Describe if you will partner with other companies for the distribution of the device]
7\) Reagent Stability
[Describe the information that supports the stability claims for your device. Please indicate if the test is already in use in other parts of the world.]
#### J. PERFORMANCE EVALUATION
1\) Analytical Sensitivity and Specificity
a) Reactivity/lnclusivity:
Although mutations in the SARS-CoV-2 genome have been identified as the virus has spread, no serologically unique strains have been described relative to the originally isolated virus (this research is exceptionally limited at present).
b) Cross-Reactivity:
If a large number of known negative samples (e.g., ≥75 samples collected in the US prior to December 2019) are tested from a population with a high prevalence of vaccination against, and/or infection with, the following viruses, and specificity >98% is observed, cross-reactivity testing for the following viruses would not be expected at this time:
- anti-influenza A (IgG and IgM)
- anti-influenza B (IgG and IgM)
- anti-HCV (IgG and IgM)
- anti-HBV (IgG and IgM)
- anti-Haemophilus influenzae (IgG and IgM)
- anti-229E (alpha coronavirus)
- anti-NL63 (alpha coronavirus)
- anti-OC43 (beta coronavirus)
- anti-HKU1 (beta coronavirus)
- ANA
- anti-respiratory syncytial virus (IgG and IgM)
- anti-HIV
[If a large number of known negative samples are not evaluated, or lower than 95% specificity is observed, describe the cross-reactivity testing performed to evaluate the cross-reactants in the table above. Please include in your description the number of samples tested and how samples were prepared.]
If testing of the cross-reactants is needed to demonstrate cross-reactivity of the test, FDA believes testing a minimum of 5 individual samples for each disease/infectious agent/antibody class listed above may be acceptable.
If natural specimens are used, it is important to assess cross reactivity using sera from patients with the underlying diseases in the acute or convalescent stages of infection in order to obtain high levels of IgM or IgG for the underlying condition. If spiked samples with the IgM or IgG antibodies for the underlying conditions are prepared for this study, it is important to confirm that "negative samples" are SARS-CoV-2 IgM and IgG seronegative with the candidate assay prior to spiking. Additionally, commercially available IgM or IgG antibodies for the underlying conditions panels may be acceptable if collected prior to the COVID-19 pandemic to ensure the panels are SARS-CoV-2 antibody negative.
We recommend you present your results in the following suggested table and calculate agreement between the candidate test result and the expected result.
**Table Cross-Reactivity: [test name] example table for wet tested organisms below:**
| Virus/Bacteria/Parasite | Antibody positive | Source/ Sample type | Results* |
|-------------------------|--------------------|--------------------|----------|
| | | | |
||
*If applicable, please include the signal output for your test's technology.
[If your test exhibits significant cross-reactivity that would produce false positive results for any virus evaluated, please describe a plan to address this risk.]
2\) Class Specificity:
If your test is intended for the detection of total antibody with no differentiation between different immunoglobulins, then this study does not apply. [In this case, please indicate that this study is not applicable.]
[If your test is intended for the detection of total antibody with no differentiation between different immunoglobulins, then this study does not apply. Please indicate not applicable.
If your test is intended to differentiate between different immunoglobulins, describe the approach used to evaluate class specificity.]
[If class specificity testing is needed for your test, please describe the study, or studies, performed to demonstrate that the assay accurately detects each antibody class (e.g., IgG and IgM). This should include a description of the studies performed to evaluate the potential for human IgM to cross react and therefore produce false positive results for IgG, and the reverse, and the potential for IgM to compete with IgG and produce false negative results. Please indicate the number of samples, and the number of replicates per sample, tested. FDA believes that evaluating at least 5 samples positive for both antibody classes (IgM positive while also IgG positive), in duplicate, may be acceptable.]
Approaches to evaluate class specificity depend on the assay format. If you have well-characterized the anti-IgG and anti-IgM reagents, used in your test class specificity testing may not be needed. In this case, please describe how the reagents were characterized and such characterization supports class specificity. One recommended approach includes treating the specimen with dithiothreitol (DTT) where the final IgG result will remain unaffected and the final IgM signal will decrease or be negative. A positive control should also be included that confirms DTT activity.
[Please provide the protocol and results, including line data, from any class specificity testing.]
FDA believes that 100% agreement with expected result would establish antibody class specificity.
**If a DTT Treatment approach is followed, below is an example table for IgM and IgG:**
| Sample ID | Replicates | Result NO DTT Treatment (IgM/IgG) | Result DTT Treatment (IgM/IgG) | Expected result with DTT treatment (IgM/IgG) | Result Agreement |
|-----------|------------|-----------------------------------|--------------------------------|----------------------------------------------|-------------------|
| 1 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
| 2 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
| 3 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
| 4 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
| 5 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
||
3\) Clinical Agreement Study:
[Please describe the clinical study used to evaluate the clinical performance of the test. Please note that the exact requirements for the clinical evaluation depend on access to COVID-19 disease clinical specimens at the time of the studies and the nature of the emergency.]
Initial clinical agreement trials typically evaluate all matrices that the sponsor intends to claim in their EUA submission.
The comparator method used to establish clinical truth for the patient at this time is a PCR based assay. Results from the comparator PCR method are obtained using specimens that have been validated for use with the comparator method. Consider collecting nasal swab samples from a patient for PCR and then follow with a fingerstick or blood draw from the same patient. [Please identify the PCR comparator that was used. If the PCR comparator is not an EUA-authorized test, please provide Limit of Detection (LoD) and cross-reactivity validation data. If it is an EUA-authorized test, then no validation is needed.]
Ideally, performance characteristics are established in a clinical study with prospective samples. If a prospective study is not feasible, an acceptable alternative would be to test retrospectively collected SARS-CoV-2 antibody positive specimens from patients that have been previously confirmed infected by SARS-CoV-2 RT PCR, accompanied by basic information such as the population from which the sample was drawn and the comparator method, specimen collection date, date of onset of symptoms (if present/known), and comparator method to confirm patients as SARS-CoV-2 infected or not infected (see above).
Clinical agreement data should be provided using at least 30 antibody positive samples for each immunoglobulin claimed and 75 antibody negative samples from patients tested for SARS-CoV-2 and confirmed as negative and the data should demonstrate a minimum overall 90.0% positive percent agreement and overall 95.0% negative percent agreement, and for tests that report specifically IgM and IgG results, a minimum positive percent agreement for IgM of 70% and a minimum positive percent agreement for IgG of 90%. Point estimates not lower than 93% for combined NPA, not lower than 90% for combined PPA, and for tests that specifically report IgG or IgG and IgM, PPA for IgG not lower than 87%, and PPA for IgM not lower than 67% may be acceptable if a larger number of samples are evaluated and the lower bounds of the 95% confidence intervals are higher than would be demonstrated in a clinical agreement study with 30 antibody positive and 75 antibody negative samples.
For visually read tests, blinding and randomization should be included in the experimental design
If a claim for fingerstick is desired, we believe evaluating a minimum of 30 positive and 30 negative fingerstick whole blood samples may be acceptable to demonstrate clinical performance in fingerstick samples. If a claim for near patient testing, or point-of-care (POC) is desired, please see the section specific to POC below.
[Please specify how the samples were generated, collected, and sourced. Please also specify if the samples were fully prospective, mix of prospective, retrospective and/or contrived. Please specify inclusion/exclusion criteria, collection and testing sites, number of samples collected and tested, and number of operators performing the testing, as available.]
[Please clearly describe the data analysis methods used and provide the results from the study, including line data. We suggest calculating positive and negative percent agreement between the candidate device and the comparator method results separately for each claimed matrix, using 2 x 2 tables as follows:
| | | Comparator method/Clinical truth ||
|:-:|:-----------:|:--------------------------------:|:----------:|
| | | Positive | Negative |
| Your Device | Positive | A | B |
| | Negative | C | D |
||
Percent Positive Agreement = A/(A + C) or
True Positives/(True Positives + False Negatives)
Negative Percent Agreement = D/(B + D) or
True Negatives/(True Negatives + False positives)
If you claim that your test can differentiate between IgG and IgM, PPA and NPA for IgG and IgM separately should be calculated separately.]
4\) Matrix Equivalency
[Please describe the protocol and provide the results from any matrix equivalency studies performed to support the performance of the assay in claimed sample matrices (serum, EDTA plasma, venipuncture whole blood, different anticoagulants, etc.) that were not evaluated in the initial clinical agreement study.] Please note: Fingerstick whole blood is not considered to be the same sample type as venipuncture whole blood and clinical agreement against PCR should be evaluated (please see Section J.3 above).
Matrix equivalency studies are performed to evaluate specimen matrices for which clinical agreement isn't initially assessed. In these studies, the matrix in which the clinical study(ies) are conducted is the comparator matrix/specimen type and each matrix set (whole blood, plasma, serum) comes from the same donor (i.e., paired samples).
Typically, negative, low positive (e.g., for lateral flow tests, faint test line), and moderate positive (e.g., for lateral flow tests, strong test line) are evaluated. We believe five samples, run in duplicate for each concentration, for a total of 30 results per matrix (assuming 3 concentrations were evaluated) may be acceptable. To allow for comparison, negative samples for each claimed specimen type/matrix are spiked with the same amount of analyte (SARS-CoV-2 IgG and IgM). We believe confirming samples are antibody seronegative with the candidate assay before spiking with SARS-CoV-2 IgG and IgM antibodies is important. For visually read tests, blinding and randomization are important considerations for the experimental design.
For these types of studies, typically, each sample is assayed with the candidate device, and the results obtained for the comparator matrix are compared to the results obtained for each additional matrix under evaluation for each subject. Positive percent agreement and negative percent agreement for each matrix with respect to the comparator matrix are calculated. We believe that at least 95% agreement across all matrices/subject may be acceptable to demonstrate that performance between the matrices can be considered equivalent.
5\) Studies to support Point of Care claim, as applicable.
[If the device is intended for near patient testing or Point of Care (POC), please provide data to demonstrate that non-laboratory personnel can perform the test accurately in the intended use environment (i.e. a non-laboratorian healthcare provider accuracy study). Please also provide data to demonstrate robust use of your device for near patient testing (e.g., as applicable, studies to demonstrate the impact of adding different volumes of sample, different volumes of reagents, incorrect order of sample or reagent application).]
#### K. UNMET NEED ADDRESSED BY THE PRODUCT
This section will be completed by FDA.
#### L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the qualitative detection of SARS-CoV-2 IgM or IgG antibodies have been approved or cleared by FDA.
#### M. RISKS AND BENEFITS:
This section will be completed by FDA.
#### N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
[Include proposed Fact Sheets for Patients and Healthcare Providers] - see examples for authorized EUA tests on our website. During review, FDA will make available Fact Sheet templates.
#### O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
[Include Instructions for Use, Box Labels, Vial Labels and any other proposed labeling.]
#### P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
[Manufacturer Name] will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report on adverse events, and this website is referenced in the Fact Sheet for Health Care providers as well as through the [Manufacturer Name] Product Support website: [link to Manufacturer's website]. Each report of an adverse event will be processed according to [Manufacturer Name]'s Non-Conformance Reporting Requirements, and Medical Device Reports will be filed with the FDA as required. Through a process of inventory control, [Manufacturer Name] will also maintain records of device usage/purchase. [Manufacturer Name] will collect information on the performance of the test, and report to FDA any suspected occurrence of false positive or false negative results of which [Manufacturer Name] becomes aware. [Manufacturer Name] will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
## Appendix B: Serology Template for Laboratories
This template (the "template") includes FDA's current recommendations for laboratories concerning what data and information they should submit to support an EUA request for a SARS-CoV-2 antibody test developed for use in a single CLIA certified high-complexity laboratory. As outlined in Section V.C. of this guidance, FDA recommends that the following validation studies be conducted for a SARS-CoV-2 serological assay: Cross-reactivity/Analytical Specificity, Class Specificity, and Clinical Agreement Study. This template provides one example of how a laboratory can submit these validation data and other recommended information to FDA, but alternative approaches can be used. For more information about EUAs in general, please see the FDA Guidance document: [Emergency Use Authorization of Medical Products and Related Authorities](https://www.fda.gov/media/97321/download).
### GENERAL INFORMATION ABOUT THIS TEMPLATE
- This EUA review template (EUA template) is only intended for use by CLIA certified high-complexity laboratories who intend to submit a pre-EUA or EUA to FDA for a SARS-CoV-2 antibody test.
- Text highlighted in yellow [Text] should be completed by the laboratory (sponsor) as applicable to their specific test. Text in bold outlines the Food and Drug Administration's (FDA) recommendations for the sponsors' consideration when providing the suggested information in a specific section. Text in regular font is recommended language provided by FDA as an example. As explained throughout, this template is intended to be a helpful aid that provides FDA's recommendations to help facilitate the pre-EUA/EUA submission process.
- This is an EUA interactive review template for Pre-EUA/EUA submissions. The template is subject to change as we learn more about the COVID-19 disease and its risk-benefit profile.
- Please be reminded that tests for the detection of antibodies against SARS-CoV-2 must not be distributed and/or used for clinical diagnoses.
### EXAMPLE TEMPLATE
#### A. PURPOSE OF SUBMISSION
Emergency Use Authorization (EUA) request for [test name] to be performed for the detection of [specify types of antibodies e.g., IgG, IgG/IgM or total] antibodies to SARS-CoV-2 in [specify matrices] from individuals with current or prior COVID-19 infection. The test will be performed in CLIA certified high-complexity laboratories. Additional testing and confirmation procedures should be performed in consultation with public health and/or other authorities to whom reporting is required. Positive results should also be reported in accordance with local, state, and federal regulations.
#### B. MEASURAND
[Specify what the test detects and whether it can differentiate between IgM and IgG or if the test detects total antibody without differentiation]
#### C. LABORATORY/SPONSOR
[Include the following information: Official name, address and contact information of applicant and all locations where specimen testing will be performed]
#### D. REGULATORY INFORMATION
D. Approval/Clearance Status:
The [test name] is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
#### E. PROPOSED INTENDED USE
1\) Intended Use (IU):
The proposed IU will be finalized based on the data provided at the time of authorization. An example IU is provided below.
The [test name] is a [specify technology e.g., Enzyme-Linked Immunosorbent Assay (ELISA)] intended for qualitative [or semi-quantitative or quantitative tests, if appropriate validation data is provided. Performance evaluations beyond what is currently described in the template may be necessary] detection of [specify the antibody class or classes that are being detected, or indicate whether the test only detects total antibodies] antibodies to SARS-CoV-2 in human [specify matrices including anticoagulants]. The [test name] is intended for use as an aid in identifying individuals with an adaptive immune response to SARS-CoV-2, indicating recent or prior infection. At this time, it is unknown for how long antibodies persist following infection and if the presence of antibodies confers protective immunity. The [test name] should not be used to diagnose acute SARS-CoV-2 infection. Testing is limited to [Name of Clinical Laboratory(s)] that are Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a certified high-complexity laboratories.
Results are for the detection of SARS CoV-2 antibodies. [Specify antibodies detected] antibodies to SARS-CoV-2 are generally detectable in blood several days after initial infection, although the duration of time antibodies are present post-infection is not well characterized. Individuals may have detectable virus present for several weeks following seroconversion.
Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities.
[As applicable, the sensitivity of [test name] early after infection is unknown.] Negative results do not preclude acute SARS-CoV-2 infection. If acute infection is suspected, direct testing for SARS-CoV-2 is necessary.
False positive results for [test name] may occur due to cross-reactivity from pre-existing antibodies or other possible causes.
The [test name] is only for use under the Food and Drug Administration's Emergency Use Authorization.
2\) Special Conditions for Use Statements:
For prescription use only
For in vitro diagnostic use only
For Emergency Use Authorization only
3\) Instruments Used:
The [test name] test is to be used with the [list all instruments, software requirements, other applicable instrumentation, etc.].
#### F. DEVICE DESCRIPTION AND TEST PRINCIPLE
1\) Product Overview/Test Principle:
[Briefly describe the technology of the test and how this technology identifies the measurand (i.e., the test principle), and the instruments/reader employed/required to perform the test from sample collection to result and the specimen types for which you claim to have performance characteristics as described below.]
The [test name] uses the following: [List the antigen(s) and antibodies used in the assay to detect the antibodies in human specimens]
2\) Description of Test Steps: [Describe in order the steps of the test from specimen collection to result output.]
3\) Control Material
[Please describe the assay controls to be performed in the laboratory, including the positive control for each antibody class the test is intended to detect, the negative control, and any other necessary controls. Please also describe the frequency with which controls will be performed.]
#### G. INTERPRETATION OF RESULTS
Assessment of [test name] results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
[Clearly indicate how to interpret numeric test values as positive or negative for the presence of antibodies against SARS-CoV-2. If applicable, indicate how to identify indeterminate/equivocal results and how the user should resolve them. Also describe if and when repeat testing may be required.]
#### H. PERFORMANCE EVALUATION
1\) Analytical Sensitivity and Specificity
a) Reactivity/lnclusivity:
Although mutations in the SARS-CoV-2 genome have been identified as the virus has spread, no serologically unique strains have been described relative to the originally isolated virus (this research is exceptionally limited at present).
b) Cross-Reactivity:
If a large number of known negative samples (e.g., ≥75 samples collected in the US prior to December 2019) are tested from a population with a high prevalence of vaccination against, and/or infection with, the following viruses, and specificity >98% is observed, cross-reactivity testing for the following viruses would not be expected at this time:
- anti-influenza A (IgG and IgM)
- anti-influenza B (IgG and IgM)
- anti-HCV (IgG and IgM)
- anti-HBV (IgG and IgM)
- anti-Haemophilus influenzae (IgG and IgM)
- anti-229E (alpha coronavirus)
- anti-NL63 (alpha coronavirus)
- anti-OC43 (beta coronavirus)
- anti-HKU1 (beta coronavirus)
- ANA
- anti-respiratory syncytial virus (IgG and IgM)
- anti-HIV
[If a large number of known negative samples are not evaluated, or lower than 95% specificity is observed, describe the cross-reactivity testing performed to evaluate the cross-reactants in the table above.]
If testing of the cross-reactants on above is needed to demonstrate cross-reactivity for the test, FDA believes testing a minimum of 5 individual samples for each disease/infectious agent/antibody class listed above may be acceptable.
If natural specimens are used, it is important to assess cross reactivity using sera from patients with the underlying diseases in the acute or convalescent stages of infection in order to obtain high levels of IgM or IgG for the underlying condition. If spiked samples with the IgM or IgG antibodies for the underlying conditions are prepared for this study, it is important to confirm that "negative samples" are SARS-CoV-2 IgM and IgG seronegative with the candidate assay prior to spiking. Additionally, commercially available IgM or IgG antibodies for the underlying conditions panels may be acceptable if collected prior to the COVID-19 pandemic to ensure the panels are SARS-CoV-2 antibody negative.
We recommend you present your results in the following suggested table and calculate agreement between the candidate test result and the expected result.
**Cross-Reactivity: [test name] example table for wet tested organisms below:**
| Virus/Bacteria/Parasite Antibody positive | Source/ Sample type | Results* |
|-------------------------|--------------------|--------------------|
| | | |
||
*If applicable, please include the signal output for your test's technology.
[If your test exhibits significant cross-reactivity that would produce false positive results for any virus evaluated, please describe a plan to address this risk.]
2\) Class Specificity:
If your test is intended for the detection of total antibody with no differentiation between different immunoglobulins, then this study does not apply. [In this case, please indicate that this study is not applicable.]
[If your test is intended for the detection of total antibody with no differentiation between different immunoglobulins, then this study does not apply. Please indicate not applicable.
If your test is intended to differentiate between different immunoglobulins, describe the approach used to evaluate class specificity.]
[If class specificity testing is needed for your test, please describe the study, or studies, performed to demonstrate that the assay accurately detects each antibody class (e.g., IgG and IgM). This should include a description of the studies performed to evaluate the potential for human IgM to cross react and therefore produce false positive results for IgG, and the reverse, and the potential for IgM to compete with IgG and produce false negative results. Please indicate the number of samples, and the number of replicates per sample, tested. FDA believes that evaluating at least 5 samples positive for both antibody classes (IgM positive while also IgG positive), in duplicate, may be acceptable.]
Approaches to evaluate class specificity depend on the assay format. If you have well-characterized the anti-IgG and anti-IgM reagents, used in your test class specificity testing may not be needed. In this case, please describe how the reagents were characterized and such characterization supports class specificity. One recommended approach includes treating the specimen with dithiothreitol (DTT) where the final IgG result will remain unaffected and the final IgM signal will decrease or be negative. A positive control should also be included that confirms DTT activity.
[Please provide the protocol and results, including line data, from any class specificity testing.]
FDA believes that 100% agreement with expected result would establish antibody class specificity.
If a DTT Treatment approach is followed, below is an example table for IgM and IgG:
| Sample ID | Replicates | Result NO DTT Treatment (IgM/IgG) | Result DTT Treatment (IgM/IgG) | Expected result with DTT treatment (IgM/IgG) | Result Agreement |
|-----------|------------|-----------------------------------|--------------------------------|----------------------------------------------|-------------------|
| 1 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
| 2 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
| 3 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
| 4 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
| 5 | 1 | +/+ | -/+ | -/+ | yes |
| | 2 | +/+ | -/+ | -/+ | yes |
||
3\) Clinical Agreement Study:
[Please describe the clinical study used to evaluate the clinical performance of the test. Please note that the exact requirements for the clinical evaluation depend on access to COVID-19 disease clinical specimens at the time of the studies and the nature of the emergency.]
Initial clinical agreement trials typically evaluate all matrices that the sponsor intends to claim in their EUA submission.
The comparator method used to establish clinical truth for the patient at this time is a PCR based assay. Results from the comparator PCR method are obtained using specimens that have been validated for use with the comparator method. Consider collecting nasal swab samples from a patient for PCR and then follow with a fingerstick or blood draw from the same patient. [Please identify the PCR comparator that was used. If the PCR comparator is not an EUA-authorized test, please provide Limit of Detection (LoD) and cross-reactivity validation data. If it is an EUA-authorized test, then no validation is needed.]
Ideally, performance characteristics are established in a clinical study with prospective samples. If a prospective study is not feasible, an acceptable alternative would be to test retrospectively collected SARS-CoV-2 antibody positive specimens from patients that have been previously confirmed infected by SARS-CoV-2 RT PCR, accompanied by basic information such as the population from which the sample was drawn and the comparator method, specimen collection date, date of onset of symptoms (if present/known), and comparator method to confirm patients as SARS-CoV-2 infected or not infected (see above).
Clinical agreement data should be provided using at least 30 antibody positive samples for each immunoglobulin claimed and 75 antibody negative samples from patients tested for SARS-CoV-2 and confirmed as negative and the data should demonstrate a minimum overall 90.0% positive percent agreement and overall 95.0% negative percent agreement, and for tests that report specifically IgM and IgG results, a minimum positive percent agreement for IgM of 70% and a minimum positive percent agreement for IgG of 90%. Point estimates not lower than 93% for combined NPA, not lower than 90% for combined PPA, and for tests that specifically report IgG or IgG and IgM, PPA for IgG not lower than 87%, and PPA for IgM not lower than 67% may be acceptable if a larger number of samples are evaluated and the lower bounds of the 95% confidence intervals are higher than would be demonstrated in a clinical agreement study with 30 antibody positive and 75 antibody negative samples.
If a claim for fingerstick is desired, we believe evaluating a minimum of 30 positive and 30 negative fingerstick whole blood samples may be acceptable to demonstrate clinical performance in fingerstick samples.
[Please specify how the samples were generated, collected, and sourced. Please also specify if the samples were fully prospective, mix of prospective, retrospective and/or contrived. Please specify inclusion/exclusion criteria, collection and testing sites, number of samples collected and tested, and number of operators performing the testing, as available.]
[Please clearly describe the data analysis methods used and provide the results from the study, including line data. We suggest calculating positive and negative percent agreement between the candidate device and the comparator method results separately for each claimed matrix, using 2 x 2 tables as follows:
| | | Comparator method/Clinical truth ||
|:-:|:-----------:|:--------------------------------:|:----------:|
| | | Positive | Negative |
| Your Device| Positive | A | B |
| | Negative | C | D |
||
Percent Positive Agreement = A/(A + C) or
True Positives/(True Positives + False Negatives)
Negative Percent Agreement = D/(B + D) or
True Negatives/(True Negatives + False positives)
If you claim that your test can differentiate between IgG and IgM, PPA and NPA for IgG and IgM separately would be calculated separately.]
4\) Matrix Equivalency
[Please describe the protocol and results from any matrix equivalency studies performed to support the performance of the assay in claimed sample matrices (serum, EDTA plasma, venipuncture whole blood, different anticoagulants, etc.) that were not evaluated in the initial clinical agreement study.]
Matrix equivalency studies are performed to evaluate specimen matrices for which clinical agreement isn't initially assessed. In these studies, the matrix in which the clinical study(ies) are conducted is the comparator matrix/specimen type and each matrix set (whole blood, plasma, serum) comes from the same donor (i.e., paired samples).
Typically, negative, low positive, and moderate positive samples are evaluated. We believe five samples, run in duplicate for each concentration for a total of 30 results per matrix (assuming 3 concentrations were evaluated) may be acceptable. To allow for comparison, negative samples for each claimed specimen type/matrix are spiked with the same amount of analyte (SARS-CoV-2 IgG and IgM). We believe confirming samples are antibody seronegative with the candidate assay before spiking with SARS-CoV-2 IgG and IgM antibodies is important.
For these types of studies, typically, each sample is assayed with the candidate device, and the results obtained for the comparator matrix are compared to the results obtained for each additional matrix under evaluation for each subject. Positive percent agreement and negative percent agreement for each matrix with respect to the comparator matrix are calculated. We believe that at least 95% agreement across all matrices/subject may be acceptable to demonstrate that performance between the matrices can be considered equivalent.
#### I. UNMET NEED ADDRESSED BY THE PRODUCT
This section will be completed by FDA.
#### J. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the qualitative detection of SARS-CoV-2 IgM or IgG antibodies have been approved or cleared by FDA.
#### K. RISKS AND BENEFITS:
This section will be completed by FDA.
#### L. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
[Include proposed Fact Sheets for Patients and Healthcare Providers] - see examples for authorized EUA tests on our website. During review, FDA will make available Fact Sheet templates.
#### M. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
[In lieu of a package insert or labeling, please include your Laboratory SOP/protocol.]
#### N. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
The laboratory will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report on adverse events, and this website is referenced in the Fact Sheet for Health Care providers. The laboratory will maintain will information on the performance of the test, and report to FDA any suspected change in performance of which they become aware. The laboratory will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
# 9,407 2020-05-11_FDA Guidance - COVID IVD Test Developers v4.md
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last updated: 2026-03-04 by BA
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summary_short: The FDA Guidance for COVID IVD Test Developers v4 updates the May 4, 2020 policy by emphasizing the expanded availability of downloadable EUA templates for different COVID-19 test types and clarifying expectations for labs, states, and commercial manufacturers operating under enforcement discretion during the public health emergency. It maintains the core “validate + notify + submit EUA within a defined window” framework (including listing/removal on FDA’s notification pages) while continuing tighter controls and labeling expectations for serology tests and broader validation guidance for molecular, antigen, and serological assays. The guidance helps developers navigate a more standardized EUA process by pairing policy flexibilities with clearer submission tools and oversight triggers.
CONTENT
***INTERNAL TITLE:*** Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)
Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff
**Document issued on the web on May 11, 2020.**
**This document supersedes "Policy for Diagnostic Tests for Coronavirus Disease-2019 during the Public Health Emergency: Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff" issued May 4, 2020.**
U.S. Department of Health and Human Services
Food and Drug Administration
Center for Devices and Radiological Health
## Preface
### Public Comment
This guidance is being issued to address the Coronavirus Disease 2019 (COVID-19) public health emergency. This guidance is being implemented without prior public comment because the Food and Drug Administration (FDA or Agency) has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is being implemented immediately, but it remains subject to comment in accordance with the Agency's good guidance practices.
Comments may be submitted at any time for Agency consideration. Submit written comments to the Dockets Management Staff (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. Submit electronic comments to https://www.regulations.gov. All comments should be identified with the docket number FDA-2020-D-0987 and complete title of the guidance in the request.
### Additional Copies
Additional copies are available from the FDA webpage titled "COVID-19-Related Guidance Documents for Industry, FDA Staff, and Other Stakeholders," available at https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders, and the FDA webpage titled "Search for FDA Guidance Documents," available at https://www.fda.gov/regulatory-information/search-fda-guidance-documents. You may also send an e-mail request to CDRH-Guidance@fda.hhs.gov to receive an additional copy of the guidance. Please include the document number 20010-R3 and complete title of the guidance in the request.
### Questions
For questions about this document, contact CDRH-EUA-Templates@fda.hhs.gov.
## Table of Contents
| | | |
|---------|-------|------|
| I. | Introduction | 4 |
| II. | Background | 5 |
| III. | Scope | 6 |
| IV. | Policy | 6 |
| A. | Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High-Complexity Testing Using Their Validated Diagnostic Tests Prior to EUA Submission | 8 |
| 1. | Validation | 8 |
| 2. | FDA Notification | 9 |
| 4. | EUA Request | 9 |
| 5. | Clinical Testing | 10 |
| B. | State Authorization of Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High-Complexity Testing | 11 |
| C. | Commercial Manufacturer Development and Distribution of Diagnostic Tests Prior to EUA Submission | 12 |
| 1. | Validation | 12 |
| 2. | FDA Notification | 12 |
| 4. | EUA Request | 13 |
| 5. | Clinical Testing | 14 |
| D. | Commercial Manufacturer Development and Distribution and Laboratory Development and Use of Serology Tests Prior to or Without an EUA | 14 |
| 1. | Validation | 15 |
| 2. | FDA Notification | 16 |
| 4. | EUA Request | 17 |
| V. | Validation Study Recommendations Based on the Technological Principles of Tests | 17 |
| A. | Molecular Diagnostic Tests | 18 |
| (1) | Limit of Detection | 18 |
| (2) | Clinical Evaluation | 18 |
| (3) | Inclusivity | 19 |
| (4) | Cross-reactivity | 19 |
| B. | Antigen Detection Tests | 19 |
| C. | Serological Tests | 20 |
| VI. | Availability of EUA Templates | 20 |
||
## I. Introduction
FDA plays a critical role in protecting the United States from threats such as emerging infectious diseases, including the Coronavirus Disease 2019 (COVID-19) pandemic. FDA is committed to providing timely guidance to support response efforts to this pandemic.
FDA is issuing this guidance to provide a policy to help accelerate the availability of novel coronavirus (COVID-19) tests developed by laboratories and commercial manufacturers for the duration of the public health emergency. Rapid detection of COVID-19 cases in the United States requires wide availability of testing to control the emergence of this rapidly spreading, severe illness. This guidance describes a policy for laboratories and commercial manufacturers to help accelerate the use of tests they develop in order to achieve more rapid and widespread testing capacity in the United States.
This policy is intended to remain in effect only for the duration of the public health emergency related to COVID-19 declared by the Secretary of Health and Human Services (HHS) on January 31, 2020, effective January 27, 2020, including any renewals made by the HHS Secretary in accordance with section 319(a)(2) of the Public Health Service Act (PHS Act).
Given this public health emergency, and as discussed in the Notice in the Federal Register of March 25, 2020, titled "Process for Making Available Guidance Documents Related to Coronavirus Disease 2019," available at https://www.govinfo.gov/content/pkg/FR-2020-03-25/pdf/2020-06222.pdf, this guidance is being implemented without prior public comment because FDA has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is being implemented immediately, but it remains subject to comment in accordance with the Agency's good guidance practices.
In general, FDA's guidance documents, including this guidance, do not establish legally enforceable responsibilities. Instead, guidances describe the Agency's current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word should in Agency guidance means that something is suggested or recommended, but not required.
## II. Background
There is currently a pandemic of respiratory disease caused by a novel coronavirus. The virus has been named "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2) and the disease it causes has been named "Coronavirus Disease 2019" (COVID-19). On January 31, 2020, HHS issued a declaration of a public health emergency related to COVID-19 and mobilized the Operating Divisions of HHS. In addition, on March 13, 2020, the President declared a national emergency in response to COVID-19.
SARS-CoV-2 has demonstrated the capability to spread rapidly, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high, both globally and to the United States. To respond effectively to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical. FDA believes the policies set forth in this guidance will help address these urgent public health concerns by helping to expand the number and variety of tests, as well as available testing capabilities in reference and commercial laboratories and healthcare settings, while helping ensure these tests are accurate and reliable.
The Centers for Disease Control and Prevention (CDC) laboratories have supported the COVID-19 response, including development of a diagnostic assay that was issued an Emergency Use Authorization (EUA) on February 4, 2020. Since authorizing CDC's EUA, FDA has been actively working with other SARS-CoV-2 diagnostic test developers to help accelerate development programs and respond to requests for in vitro diagnostic EUAs. However, the severity and scope of the current COVID-19 situation around the globe necessitates greater testing capacity for the virus than is currently available.
The EUA authorities allow FDA to help strengthen the nation's public health protections against chemical, biological, radiological, and nuclear (CBRN) threats by facilitating the availability and use of medical countermeasures initiatives (MCMs) needed during certain public health emergencies. Under section 564 of the FD&C Act, the FDA Commissioner may authorize the use of unapproved medical products, or unapproved uses of approved medical products, in certain emergency circumstances, after the HHS Secretary has made a declaration of emergency or threat justifying authorization of emergency use, to diagnose, treat, or prevent serious or life-threatening disease or conditions caused by CBRN threat agents when certain criteria are met.
## III. Scope
The policies described in this guidance for accelerating availability of testing for COVID-19 apply to certain laboratories and commercial manufacturers developing SARS-CoV-2 tests during the public health emergency, as described below.
## IV. Policy
This guidance describes policies intended to help rapidly expand testing capacity by facilitating the development and use of SARS-CoV-2 tests during the public health emergency.
This guidance describes two policies for accelerating the development of certain laboratory-developed diagnostic tests for COVID-19 – one leading to an EUA submission to FDA, and the other not leading to an EUA submission when the test is developed under the authorities of the State in which the laboratory resides and the State takes responsibility for COVID-19 testing by laboratories in its State. The policy leading to an EUA remains unchanged from the initial publication of this guidance on February 29, 2020, though some process updates and clarifications have been made as discussed further below. The policy for State oversight remains unchanged from the second publication of this guidance on March 16, 2020.
In addition, this guidance describes a policy for commercial manufacturers to more rapidly distribute their SARS-CoV-2 diagnostic tests to laboratories for specimen testing after validation, while an EUA is being prepared for submission to FDA. This policy remains unchanged from the second publication of this guidance on March 16, 2020, though some process updates and clarification have been made as discussed further below.
This guidance also describes a policy regarding SARS-CoV-2 serological testing, which was modified in the May 4, 2020 publication of this guidance as it pertains to commercial manufacturers but not laboratories. At the time of prior issuance on March 16, 2020, FDA provided flexibility for serology tests to be marketed with notification to FDA and certain labeling information, but without submission of an EUA. FDA's policy was based on the considerations that serology tests are not meant to diagnose active SARS-CoV-2 infection and that early availability and use of these tests could help answer critical questions about the prevalence of COVID-19 infections in different communities, whether the presence of antibodies conveys immunity, and, if so, for how long. That policy succeeded in encouraging development of serology tests.
In addition to this policy, FDA has authorized several serology tests under individual EUAs and has issued an umbrella EUA providing a streamlined approach for EUA authorization of commercial serology tests that are evaluated by the National Institutes of Health's National Cancer Institute (NIH/NCI). Also since the March 16, 2020 publication of this guidance, FDA has become aware that a concerning number of commercial serology tests are being promoted inappropriately, including for diagnostic use, or are performing poorly based on an independent evaluation by the NIH, indicating that greater FDA oversight of commercial serology tests is important to protect the public health.
As outlined in the May 4, 2020 update, FDA does not intend to object as described below where commercial manufacturers develop and distribute their serology tests after validation, for a limited period of time, while an EUA is being prepared for submission to FDA. Appendices with templates for such submissions have been added to facilitate and streamline the EUA process.
The policy for serological tests developed and used by laboratories that are certified under the Clinical Laboratory Improvement Amendments (CLIA) to perform high-complexity testing has not changed from the March 16, 2020 guidance, though FDA continues to encourage such laboratories to submit EUAs for their laboratory developed tests.
In the context of a public health emergency involving pandemic infectious disease, it is critically important that tests are validated because false results not only can negatively impact the individual patient but also can have broad public health impact. In this guidance, FDA provides recommendations regarding validation of COVID-19 tests based on the available information. FDA encourages test developers to discuss any alternative technological approaches to validating their test with FDA.
The latest update addresses availability, through download from our website, of a series of templates that developers may choose to use to facilitate the preparation, submission, and authorization of an EUA for various types of COVID-19 tests.
### A. Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High Complexity Testing Using Their Validated Diagnostic Tests Prior to EUA Submission
The policy described in this subsection applies to laboratories certified under CLIA that meet the CLIA regulatory requirements to perform high-complexity testing and that seek to develop and perform diagnostic tests to detect the SARS-CoV-2 virus and pursue an EUA from FDA for those tests. This policy does not apply to home collection of specimens to be sent for testing at a laboratory certified under CLIA for high-complexity testing.
FDA anticipates that clinical laboratories may need to design and manufacture the individual test kit components (e.g., primers, probes, etc.), or to purchase research use only (RUO) components from third party manufacturers, for the development of their assays.
In light of the increasing numbers of COVID-19 cases throughout the country and the urgent need to expand the nation's capacity for COVID-19 testing during the public health emergency, FDA does not intend to object to the use of these SARS-CoV-2 tests for specimen testing for a reasonable period of time, where the test has been validated and while the laboratory is preparing their EUA request, and where the laboratory gives notification of validation to FDA, as described below. FDA believes that 15 business days is a reasonable period of time to prepare an EUA submission for a test that has already been validated.
#### 1. Validation
All clinical tests should be validated prior to use. In the context of a public health emergency, it is critically important that tests are validated because false results can negatively impact not only the individual patient but also can have broad public health impact. FDA has provided recommendations regarding testing that should be performed to ensure analytical and clinical validity in section V below. FDA encourages laboratories to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
#### 2. FDA Notification
Following completion of assay validation, laboratories should notify FDA (e.g., email to CDRH-EUA-Templates@FDA.HHS.GOV) that their assay has been validated. This notification should include the name of the laboratory, name of the laboratory director, laboratory address, and contact person in this email. FDA will acknowledge receipt of this notification via auto-reply, and generally will add the laboratory name to FDA's website listing. As noted above, FDA recommends that laboratories submit a completed EUA request within 15 business days of the notification to FDA that the assay has been successfully validated. If an EUA request is not submitted within this timeframe, FDA intends to remove the laboratory from its website listing of laboratories that have notified FDA and may take additional actions as appropriate.
It would be helpful to FDA if laboratories provide information on testing capacity. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
#### 3. Reporting of Results
In order to provide transparency, FDA recommends that test reports include a general statement that the test has been validated but FDA's independent review of this validation is pending.
Laboratories should immediately notify appropriate Federal, State, and local public health agencies of all positive results.
#### 4. EUA Request
FDA has made available, through download from our website, a template that laboratories may choose to use to facilitate the preparation, submission, and authorization of an EUA for a molecular diagnostic test. Laboratories that intend to use alternative approaches should consider seeking FDA's feedback or recommendation to help them through the pre-EUA and EUA process. FDA encourages laboratories to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
Soon after receiving the EUA request, FDA intends to perform a preliminary review to identify if there are any problems with the performance data. If a problem is identified, FDA intends to work with the laboratory to address the problem (e.g., through labeling or bench testing). If any problems are significant and cannot be addressed in a timely manner, FDA would expect the laboratory to stop testing and issue corrected test reports indicating prior results may not be accurate. In such circumstances, FDA intends to remove the laboratory from the website listing of notifications.
Issued EUAs are posted on FDA's website.
When a laboratory makes a modification to an EUA authorized test for use of a new specimen type, FDA does not intend to object to the use of such a modified test without notification to FDA or a new or amended EUA where the new specimen type has been previously authorized for another test of the same technology and where the EUA authorized test is validated for the new specimen type. Modifications to an EUA authorized test for use of a new specimen type that has not been previously authorized for another test of the same technology must be authorized under a new or amended EUA prior to clinical use.
For all other types of modifications, FDA does not intend to object to the use of a test, without notification to FDA or a new or amended EUA, where the test is a modification of an EUA-authorized test and the modified test is validated using a bridging study to the EUA-authorized test. One way to bridge to a new component is to establish equivalent performance between parallel testing of the same specimens with the new and original components. We recommend testing 3-fold serial dilutions of SARS-CoV-2 viral materials (e.g., whole genomic viral RNA or inactivated virus, etc.) in a pooled respiratory sample matrix in triplicate until you achieve a hit rate of <100%. If the resultant Limit of Detection (LoD) is the same as the LoD for the unmodified authorized test (i.e., ≤3xLOD), then FDA believes the two tests can be considered to have equivalent performance.
When validating through a bridging study and not pursuing an EUA amendment for the modification, FDA would like to see the laboratory's validation data informally through an email to CDRH-EUA-Templates@FDA.HHS.GOV. If FDA's review of the bridged validation data indicates that it could be applicable to modifications of other tests with an EUA, or to other laboratories modifying the same authorized test, and the laboratory agrees to FDA sharing that information on our website for use by other laboratories, FDA intends to update our FAQs so other laboratories can refer to the validation for their testing, without conducting their own bridging study for the same modification. This informal sharing of data would not be considered to be a notification, as discussed above, or an EUA request.
#### 5. Clinical Testing
While awaiting an FDA determination on the EUA request, FDA recommends that clinical laboratories obtain confirmation of the first five positive and the first five negative clinical specimens using an EUA-authorized assay. This testing may be performed within the same laboratory using an EUA-authorized assay or may involve sending these ten specimens to another laboratory for confirmation. If any of these results cannot be confirmed, the laboratory should notify FDA at CDRH-EUA-Templates@FDA.HHS.GOV, and take other appropriate actions such as terminating testing patient specimens, and issuing corrected test reports indicating prior test results may not be accurate.
### B. State Authorization of Laboratories Certified under CLIA that Meet the CLIA Regulatory Requirements to Perform High Complexity Testing
On March 12, 2020, FDA issued enforcement discretion and stated that it was not objecting to the Wadsworth Center authorizing certain laboratories in the State of New York to begin patient testing under certain circumstances to increase availability of COVID-19 testing in response to a request from the Wadsworth Center of the New York State Department of Health (Wadsworth). Wadsworth had informed FDA that it would be willing to have clinical laboratories that currently hold a New York State Department of Health clinical laboratory permit to notify Wadsworth that they have validated a test for COVID-19, and to submit validation studies to Wadsworth. Wadsworth likewise said it would notify the laboratory if it identified any concerns, and request that the laboratory terminate testing patient specimens and issue corrected test reports indicating prior test results might not be accurate.
On March 13, 2020, the President issued a "Memorandum on Expanding State-Approved Diagnostic Tests" (Memorandum), which refers to the flexibility that FDA allowed New York State and states as follows:
"Should additional States request flexibility to authorize laboratories within the State to develop and perform tests used to detect COVID-19, the Secretary shall take appropriate action, consistent with law, to facilitate the request."
In accordance with the Memorandum, FDA describes below its policy regarding States and territories that authorize laboratories within their State or territory to develop their own COVID-19 tests and perform specimen testing, where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA.
A State or territory choosing to authorize laboratories within that State or territory to develop and perform a test for COVID-19 would do so under authority of its own State law, and under a process that it establishes. FDA does not intend to object to the use of such tests for specimen testing where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA, and where instead the State or territory takes responsibility for COVID-19 testing by laboratories in its State during the COVID-19 outbreak.
FDA requests that the State or territory notify us if they choose to use this flexibility to expedite COVID-19 testing. FDA will not be reviewing the process adopted by the State or territory, which we understand may be different than the process adopted by New York State. FDA expects that such states as part of their oversight process will require laboratories developing SARS-CoV-2 tests to validate those tests prior to use. FDA encourages laboratories that develop and perform a test for COVID-19 under this policy to notify FDA that they have started clinical testing by sending an email to that effect to CDRH-EUA-Templates@FDA.HHS.GOV. It would be helpful to FDA if laboratories provide information on testing capacity. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
### C. Commercial Manufacturer Development and Distribution of Diagnostic Tests Prior to EUA Submission
The policy described in this subsection applies to commercial manufacturers that seek to develop and distribute diagnostic test kits to detect the SARS-CoV-2 virus to clinical laboratories or to healthcare workers for point-of-care testing. Unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to laboratories certified to perform high complexity testing, including testing at the point-of-care when the site is covered by the laboratory's CLIA certificate for high-complexity testing.
This policy does not apply to at-home testing, including at-home specimen collection.
In light of the increasing numbers of COVID-19 cases throughout the country and the urgent need to expand the nation's capacity for COVID-19 testing during the public health emergency, FDA does not intend to object to a commercial manufacturer's development and distribution of SARS-CoV-2 test kits for specimen testing for a reasonable period of time, where the test has been validated and while the manufacturer is preparing its EUA request, where the manufacturer gives notification of validation to FDA as described below, and where the manufacturer provides instructions for use of the test and posts data about the test's performance characteristics on the manufacturer's website. Transparency can help mitigate potential adverse impacts from a poorly designed test by facilitating better informed decisions by potential purchasers and users.
FDA believes that 15 business days is a reasonable period of time to prepare an EUA submission for a test that has already been validated. Soon after receiving the EUA request, FDA will perform a preliminary review to identify if there are any problems with the performance data. If a problem is identified, FDA intends to work with the manufacturer to address the problem (e.g., through labeling or bench testing). If the problem is significant and cannot be addressed in a timely manner, and the manufacturer has already distributed the device, FDA would expect the manufacturer to suspend distribution and conduct a recall of the test.
#### 1. Validation
All clinical tests should be validated prior to use. In the context of a public health emergency, it is critically important that tests are validated because false results can negatively impact not only the individual patient but also can have broad public health impact. FDA has provided recommendations regarding testing that should be performed to ensure analytical and clinical validity in section V below. FDA encourages manufacturers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
#### 2. FDA Notification
Following completion of assay validation, manufacturers should notify FDA (e.g., e-mail to CDRH-EUA-Templates@FDA.HHS.GOV) that their assay has been validated and they intend to begin distribution. This notification should include the name of the manufacturer, address, contact person, a website link, and a copy of the instructions for use including a summary of assay performance. FDA will acknowledge receipt of this notification via auto-reply, and generally will add the name of the manufacturer and test to FDA's website listing.
In circumstances where manufacturers use distributor(s) for their product, the manufacturers should identify the names of all distributors in their notification. Distributors and laboratories using these tests should not provide separate notification. As noted above, FDA recommends that manufacturers submit a completed EUA request within 15 business days of the notification to FDA that the assay has been successfully validated. If an EUA request is not submitted within this timeframe, FDA intends to remove the manufacturer/test from its website listing of notified tests and may take additional actions as appropriate.
It would be helpful to FDA if manufacturers provide information on testing capacity, as well as the number of laboratories in the U.S. with the required platforms installed. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
#### 3. Reporting of Results
In order to provide transparency, FDA recommends that instructions for use and test reports include a general statement that the test has been validated but FDA's independent review of this validation is pending.
#### 4. EUA Request
FDA has made available, through download from our website, templates that test kit manufacturers may choose to use to facilitate the preparation, submission, and authorization of EUAs for molecular and antigen diagnostics. Manufacturers can use alternative approaches. Manufacturers who intend to use alternative approaches should consider seeking FDA's feedback or recommendations to help them through the pre-EUA and EUA process. FDA encourages manufacturers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
Soon after receiving the EUA request, FDA intends to perform a preliminary review to identify if there are any problems with the performance data. If a problem is identified, FDA intends to work with the manufacturer to address the problem (e.g., through labeling or bench testing). If any problems are significant and cannot be addressed in a timely manner, FDA would expect the manufacturer to suspend distribution and conduct a recall of the test, which should include a notification concerning corrected test reports indicating prior test results may not be accurate. In such circumstances, FDA intends to remove the manufacturer/test from the website listing of notifications.
Issued EUAs are posted on FDA's website.
A manufacturer may request certain modifications to its EUA-authorized test as an amendment to the EUA as specified in the EUA's Conditions of Authorization. Where validation data supporting the modification have been submitted in the amendment, FDA does not intend to object to implementation of the modification while FDA conducts its review, except for modifications to add specimen types that have not been previously authorized with another test of the same technology.
#### 5. Clinical Testing
While awaiting FDA determination on the EUA request, FDA recommends that manufacturers make publicly available on their website the instructions for use, including a summary of assay performance.
### D. Commercial Manufacturer Development and Distribution and Laboratory Development and Use of Serology Tests Prior to or Without an EUA
The policy described in this subsection applies to developers of serology tests that identify antibodies (e.g., IgG, IgM) to SARS-CoV-2 from clinical specimens. Unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to laboratories certified to perform high complexity testing, and at the point-of-care when covered by the laboratory's CLIA certificate for high-complexity testing. This policy does not apply to at-home testing, including at-home specimen collection, due to additional considerations that require FDA review.
FDA does not intend to object to a commercial manufacturer's development and distribution of serology tests to identify antibodies to SARS-CoV-2 for a reasonable period of time, where the test has been validated and while the manufacturer is preparing its EUA request, where the manufacturer gives notification of validation to FDA as described in subsection D.2 below, and where the manufacturer includes information in the instructions for use as described in subsection D.3 below. FDA provided early market access through its March 16, 2020, updated guidance, but that access was premised on the understanding that tests should be validated before being marketed to fall under the enforcement discretion policy. Given that any test on the market under the March 16 enforcement discretion policy or this policy should already be validated by the manufacturer before being marketed, FDA believes that 10 business days (from the date of notification or the date of publication of this guidance, whichever is later) is a reasonable period of time to prepare an EUA submission for a test whose performance characteristics have already been validated.
If FDA becomes aware of questions or concerns about a test after notification, such as poor performance or misleading statements about the test, FDA will communicate those concerns to the manufacturer and provide the manufacturer an opportunity to address the questions or concerns. If the concerns cannot be or have not been addressed in a timely manner, and the manufacturer has already distributed the test, FDA would expect the manufacturer to suspend distribution of the test. FDA also intends to remove the test from the website listing of notifications and may take additional actions as appropriate.
While laboratories are encouraged to submit EUA requests for serology tests, FDA does not intend to object to the development and use of serology tests to identify antibodies to SARS-CoV-2 by laboratories that are certified under CLIA to perform high-complexity testing, where the test has been validated, notification is provided to FDA, and information is included in the test reports as described in subsection D.3 below. At this time, we believe it is most beneficial to focus our EUA review and authorization efforts on tests from commercial manufacturers, which have the potential to be distributed more broadly, rather than laboratory-developed serology tests that are not for diagnostic purposes, are being performed at one laboratory that is CLIA-certified to perform high-complexity testing, and that are validated in-house. However, if FDA becomes aware of questions or concerns about a laboratory-developed serology test, such as poor performance or misleading statements about the test, FDA will communicate those concerns to the laboratory and provide the laboratory an opportunity to address the questions or concerns. If the concerns cannot be or have not been addressed in a timely manner, FDA intends to remove the laboratory from the website listing of notifications and may take additional actions as appropriate.
#### 1. Validation
All clinical tests should be validated prior to use. In the context of a public health emergency, it is critically important that tests are validated because false results can negatively impact not only the individual patient but also can have broad public health impact. FDA has provided recommendations regarding testing that should be performed to ensure analytical and clinical validity in section V below. FDA encourages developers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV and additionally encourages developers to refer to the templates provided as examples in the Appendices to this guidance for serology test manufacturers and laboratories.
#### 2. FDA Notification
Following completion of assay validation, developers should notify FDA by email to CDRH-EUA-Templates@FDA.HHS.GOV that their assay has been validated and they intend to begin distribution or testing.
a. For tests developed and used by laboratories certified under CLIA that meet the CLIA regulatory requirements to perform high-complexity testing, this notification should include the name of the laboratory, name of the laboratory director, laboratory address, and contact person in this email. FDA will acknowledge receipt of this notification via auto-reply, and generally will add the laboratory name to FDA's website listing.
It would be helpful to FDA if laboratories provide information on testing capacity. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
b. For tests developed and distributed by commercial manufacturers, this notification should include the name of the manufacturer, address, contact person, and a copy of the instructions for use that includes a summary of assay performance. FDA will acknowledge receipt of this notification via auto-reply, and generally will add the name of the manufacturer and test to FDA's website listing. As noted above, FDA recommends that manufacturers submit a completed EUA request within 10 business days of the notification to FDA that the assay has been successfully validated, or the date of publication of this guidance, whichever is later. If an EUA request is not submitted within this timeframe, FDA intends to remove the manufacturer/test from its website listing of notified tests and may take additional actions as appropriate.
In circumstances where manufacturers use distributor(s) for their test, the manufacturer should identify the names of all distributors in their notification. Distributors should not provide separate notification.
It would be helpful to FDA if manufacturers provide information on test production capacity, the number of laboratories in the U.S. with the required platforms installed. This information will help the Agency and Department monitor the landscape as we work to ensure adequate testing capacity across the country.
#### 3. Labeling and Reporting of Results
In order to provide important information about the intended use of the test and its limitations, FDA recommends that instructions for use and patient test reports include information that helps users and patients understand the test results, such as the following:
- This test has not been reviewed by the FDA.
- Negative results do not preclude acute SARS-CoV-2 infection. If acute infection is suspected, direct testing for SARS-CoV-2 is necessary.
- Results from antibody testing should not be used to diagnose or exclude acute SARS-CoV-2 infection.
- Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.
#### 4. EUA Request
FDA has made available through download from our website templates that commercial manufacturers and laboratories may choose to use to facilitate the preparation, submission, and authorization of an EUA for a serology test. Developers can use alternative approaches. Developers who intend to use alternative approaches should consider seeking FDA's feedback or recommendations to help them through the EUA process. FDA encourages developers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
FDA may leverage data from testing at the National Institutes of Health's National Cancer Institute (NIH/NCI), or at another federal government laboratory designated by FDA, to inform decisions on EUA requests and other actions. FDA has issued an EUA for certain serology tests evaluated in the NIH/NCI independent validation study, or by another government agency designated by FDA, that are confirmed by FDA to meet certain specific performance and other criteria, and added to the EUA.
FDA will communicate any questions or concerns regarding a pre-EUA or EUA submission to the developer. FDA will also work collaboratively to address any potential concerns or safety considerations raised in the pre-EUA submission or EUA request and will contact the developer regarding a final determination on the EUA request.
Issued EUAs are posted on FDA's website.
If FDA is not able to issue an EUA, FDA intends to notify the manufacturer. Where the manufacturer has distributed tests, FDA also would expect the manufacturer to suspend distribution of the test, which should include a notification indicating that prior test results may not be accurate. FDA intends to remove the manufacturer/test from the website listing of notifications. FDA may also take other action as may be appropriate in the circumstances.
## V. Validation Study Recommendations Based on the Technological Principles of Tests
In this section, FDA provides recommendations for developers regarding testing that should be performed to demonstrate that a SARS-CoV-2 test is validated based upon the underlying technological principles of the test. Depending on the characteristics of your test, additional validation studies may be recommended. FDA encourages test developers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-templates@FDA.HHS.GOV.
### A. Molecular Diagnostic Tests
FDA defines SARS-CoV-2 molecular diagnostic tests as tests that detect SARS-CoV-2 nucleic acids from human specimens. FDA recommends that the following validation studies be conducted for molecular SARS-CoV-2 diagnostic tests:
#### (1) Limit of Detection
FDA recommends that developers document the limit of detection (LoD) of their SARS-CoV-2 assay. FDA generally does not have concerns with spiking RNA or inactivated virus into artificial or real clinical matrix (e.g., Bronchoalveolar lavage [BAL] fluid, sputum, etc.) for LoD determination.
FDA recommends that developers test a dilution series of three replicates per concentration with inactivated virus on actual patient specimen, and then confirm the final concentration with 20 replicates. For this guidance, FDA defines LoD as the lowest concentration at which 19/20 replicates are positive. If multiple clinical matrices are intended for clinical testing, FDA recommends that developers submit in their EUA requests the results from the most challenging clinical matrix to FDA. For example, if testing respiratory specimens (e.g., sputum, BAL, nasopharyngeal (NP) swabs, etc.), laboratories should include only results from sputum in their EUA request.
#### (2) Clinical Evaluation
The availability of positive samples has increased as the pandemic has progressed. As such, FDA now recommends that developers use positive clinical samples for clinical validation. Moreover, due to the increased availability of clinical samples, FDA recommends that developers confirm performance of their assay by testing a minimum of 30 positive specimens and 30 negative specimens as determined by an authorized assay. If you do not have access to clinical samples as determined by an authorized assay, contrived clinical specimens may be considered. Contrived reactive specimens can be created by spiking RNA or inactivated virus into leftover clinical specimens, of which the majority can be leftover upper respiratory specimens such as NP swabs, or lower respiratory tract specimens such as sputum, etc. If contrived samples are used, FDA recommends that twenty of the contrived clinical specimens be spiked at a concentration of 1x-2x LoD, with the remainder of specimens spanning the assay testing range. For this guidance, FDA defines the acceptance criteria for the performance as 95% agreement at 1x-2x LoD, and 100% agreement at all other concentrations and for negative specimens.
#### (3) Inclusivity
Developers should document the results of an in silico analysis indicating the percent identity matches against publicly available SARS-CoV-2 sequences that can be detected by the proposed molecular assay. FDA anticipates that 100% of published SARS-CoV-2 sequences will be detectable with the selected primers and probes.
#### (4) Cross-reactivity
FDA recommends cross-reactivity wet testing on common respiratory flora and other viral pathogens at concentrations of 10^6 CFU/ml or higher for bacteria and 10^5 pfu/ml or higher for viruses, except for SARS-Coronavirus and MERS-Coronavirus, which can be accomplished by in silico analysis. As an alternative, FDA believes an in silico analysis of the assay primer and probes compared to common respiratory flora and other viral pathogens can be performed. For this guidance, FDA defines in silico cross-reactivity as greater than 80% homology between one of the primers/probes and any sequence present in the targeted microorganism. In addition, FDA recommends that developers follow recognized laboratory procedures in the context of the sample types intended for testing for any additional cross-reactivity testing.
Additional information for the validation of molecular diagnostics is included in the manufacturer and developers EUA templates available for download on our website.
### B. Antigen Detection Tests
FDA defines SARS-CoV-2 antigen tests as those that detect proteins that are part of the SARS-CoV-2 virus directly from clinical specimens. FDA recommends that the following validation studies be conducted for a SARS-CoV-2 antigen test:
- Limit of Detection/Analytical Sensitivity
- Cross-reactivity/Analytical Specificity
- Microbial Interference
- Clinical Agreement Study
The clinical agreement study is intended to establish the performance characteristics (e.g., sensitivity/PPA, specificity/NPA) of the test. FDA believes that clinical agreement should be established on human specimens, preferably leftover specimens from patients with or without SARS-CoV-2 infection.
FDA has made available through download from our website, a template that antigen test developers may choose to use to facilitate the preparation, submission, and authorization of an EUA for an antigen test. See more information in Section VI. For antigen tests, the template includes further recommendations concerning the above validation studies and make additional recommendations about other information that should be provided to FDA as part of the pre-EUA/EUA submission process. Developers can use alternative approaches. FDA encourages developers to discuss any alternative approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
### C. Serological Tests
FDA defines SARS-CoV-2 serological tests as tests that identify antibodies (e.g., IgG, IgM) to SARS-CoV-2 from clinical specimens. FDA recommends that the following validation studies be conducted for a SARS-CoV-2 serological assay:
- Cross-reactivity/Analytical Specificity
- Class Specificity
- Clinical Agreement Study
The clinical agreement study is intended to establish the performance characteristics (e.g., sensitivity/PPA, specificity/NPA) of the test. FDA recommends that clinical accuracy should be established on human specimens from patients with microbiologically confirmed COVID-19 infection.
FDA has made available through download from our website templates that commercial manufacturers and laboratories may choose to use to facilitate the preparation, submission, and authorization of an EUA for a serology test. See more information in Section VI. For serological tests, these templates include further recommendations concerning the above validation studies and make additional recommendations about other information that should be provided to FDA as part of the pre-EUA/EUA submission process. Developers can use alternative approaches. FDA encourages developers to discuss any alternative approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
## VI. Availability of EUA Templates
FDA has made available through download from our website a series of templates that developers may choose to use to facilitate the preparation, submission, and authorization of an EUA for various types of COVID-19 tests. The templates reflect FDA's current thinking on the data and information that developers should submit to facilitate the EUA process. The templates provide information and recommendations, and we plan to update them as appropriate as we learn more about the COVID-19 disease and gain experience with the EUA process for the various types of COVID-19 tests.
Developers can use alternative approaches. Developers who intend to use alternative approaches should consider seeking FDA's feedback or recommendations to help them through the EUA process. FDA encourages developers to discuss any alternative technological approaches to validating their test with FDA through CDRH-EUA-Templates@FDA.HHS.GOV.
Members of the public can submit questions about the templates to CDRH-EUA-Templates@FDA.HHS.GOV, or they can submit comments regarding the templates to the public docket established for this guidance.
# 6,903 2020-05-29_FDA Template - Home Specimen Collection Molecular Diagnostic Template.md
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last updated: 2026-03-04 by BA
file_name: 2020-05-29_FDA Template - Home Specimen Collection Molecular Diagnostic Template.md
file_date: 2020-05-29
title: FDA Template - Home Specimen Collection Molecular Diagnostic Template
category: regulatory
subcategory: fda-policy
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summary_short: The FDA Home Specimen Collection Molecular Diagnostic Template provides detailed recommendations for data, validation, and labeling needed to support pre-EUA/EUA submissions for prescription home collection kits used with authorized SARS-CoV-2 molecular assays. It specifies requirements for device description, manufacturing, shipping stability, usability, and clinical validation to ensure samples collected at home remain suitable for accurate laboratory testing. The template enables manufacturers and laboratories to standardize submissions and safely expand access to home-based COVID-19 specimen collection during the public health emergency.
CONTENT
***INTERNAL TITLE:*** Home Specimen Collection Molecular Diagnostic Template
This template (the “template”) provides the Food and Drug Administration’s (FDA) current recommendations concerning what data and information should be submitted to FDA in support of a pre-EUA/EUA submission for prescription use only home collection devices used by an individual to collect certain clinical specimen(s) that are then sent to a clinical laboratory for testing with a molecular diagnostic for SARS-CoV-2 that is authorized for use with the home collection kit. This template does not cover non-prescription home collection devices or over the counter (OTC) tests for COVID-19 testing. This template is intended to help manufacturers provide appropriate validation data and other information to FDA, but alternative approaches can be used. It reflects FDA’s current thinking on the topic, and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should* means that something is suggested or recommended, but not required. For more information about EUAs in general, please see the FDA Guidance document: [*Emergency Use Authorization of Medical Products and Related Authorities*](https://www.fda.gov/media/97321/download).[2]
## GENERAL INFORMATION ABOUT THIS TEMPLATE
- Text highlighted in yellow ***\[Text\]*** should be completed by the collection device developer (sponsor) as applicable to its specific device. Text in ***bold italic*** outlines FDA’s additional recommendations for the sponsors’ consideration when completing the suggested information in each section.
- This template is intended for home collection kits for anterior nares swab or saliva specimens; if you are considering other types of respiratory specimens (e.g., sputum, throat/tongue swabs, or nasal aspirates) or non-respiratory specimens (e.g., stool, etc.), please contact FDA at CDRH-EUA-Templates ([CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov)) to discuss your validation strategy.
- Authorization of a home collection kit must be accompanied by authorization of one or more molecular assays that has been validated with specimens collected and transported with the subject home collection kit. This template includes FDA’s current recommendations concerning the data and information that should be submitted to FDA in support of an EUA submission for a home collection kit. Please refer to the [Molecular Diagnostic Template for Manufacturers](https://www.fda.gov/media/135900/download) or the [Molecular Diagnostic Template for Laboratories](https://www.fda.gov/media/135658/download) for FDA’s current recommendations concerning what data and information should be submitted to FDA in support of an accompanying molecular diagnostic for SARS-CoV-2, which may be submitted in the same EUA request as the home collection kit or in an accompanying EUA request.
- There are three options for how to authorize a molecular assay with a home collection kit:
- Within the same EUA at one time (i.e., when the same developer makes the home collection kit and molecular assay and seeks authorization at the same time for the assay and kit);
- In one or more EUAs (i.e., when the developer of the home collection kit is different from the developer(s) of the molecular assay(s)); or
- As an amendment to the EUA of a previously authorized assay to add home collection with the specific home collection kit.
- A home collection kit authorized under an EUA is only authorized for emergency use while the EUA is in effect.
- This is an EUA interactive review template for Pre-EUA/EUA submissions. We plan to update the template as appropriate as we learn more about the COVID-19 disease and gain experience with the EUA process for this home collection kit.
- FDA recommends distributors of home collection specimen kits contact the Pipeline and Hazardous Materials Safety Administration (PHMSA) within the Department of Transportation (DOT) to confirm their packaging and shipping instructions will ensure users are in compliance with the hazardous materials regulations for shipping medical material. PHMSA can be contacted at [HMInfo@dot.gov](mailto:HMInfo@dot.gov).
## EXAMPLE TEMPLATE:
### A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the ***\[name of collection device\]*** for the \[***collection or collection and stabilization***\] of ***\[add all claimed specimen types, i.e., nasal swabs and/or saliva\]*** in ***\[add transport media or dry tube\]*** to transport viral SARS-CoV-2 RNA, from patients suspected of COVID-19 by a healthcare provider. The specimen collection device is for use in conjunction with molecular diagnostic testing performed at a clinical laboratory using an *in vitro* diagnostic (IVD) test for the detection of SARS-CoV-2 that is authorized for use with the home collected kit.
### B. APPLICANT
***\[Official name, address and contact information of applicant\]***
### D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name - ***\[device name (home collection kit name)\]***
Established Name - ***\[device name (home collection kit name)\]***
### C. REGULATORY INFORMATION
***Approval/Clearance Status:***
The ***\[device name\]*** device is not cleared, approved, or subject to an approved investigational device exemption.
***Product Code:***
***QJR***
### D. PROPOSED INTENDED USE
##### *1) Intended Use:*
***The proposed IU will be finalized based on, among other things, the data and recommendations from Public Health authorities at the time of authorization – example text is provided below.***
***Example text for a home collection kit where the manufacturer does not hold the COVID-19 NAAT test EUA:***
The ***\[name of collection device\]***is intended for use by individuals to self-collect ***\[add all claimed specimen types, i.e., nasal swabs and/or saliva\]***at home, when determined by a healthcare provider to be appropriate based on \[***include mechanism via which the individual is determined to be appropriate for COVID-19 testing by a healthcare provider – to facilitate prescription use. For example (1) the results of an online COVID-19 questionnaire, or (2) telephone or online video appointment, etc. with a healthcare provider***\]. Specimens collected using the ***\[name of collection device\]*** are transported at ambient temperature for testing at a laboratory. SARS-CoV-2 RNA from the ***\[add all claimed specimen types, i.e., nasal swabs and/or saliva\]*** is maintained in the specimen packaging and is suitable for use in molecular diagnostic testing performed using an in vitro diagnostic (IVD) test for the detection of SARS-CoV-2 that has been issued an EUA for use with Home Collection Kits, that includes the ***\[name of collection device\]***.
Testing is limited to laboratories designated by ***\[name of manufacturer\]*** and certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests. Testing is also limited to molecular diagnostic tests that are authorized for use with Home Collection Kits for collection of nasal swab specimens, including the ***\[name of collection device\]***.
The ***\[name of collection device\]***is only for use under the Food and Drug Administration’s Emergency Use Authorization.
***Example text for a home collection kit where the manufacturer also holds the COVID-19 NAAT test EUA (e.g., an already issued EUA is being revised to authorize home specimen collection as an option):***
The \[***name of the EUA test***\] is a real-time reverse transcription polymerase chain reaction (rRT-PCR) test for the qualitative detection of nucleic acid from SARS-CoV-2 in \[***name typical respiratory specimens collected, e.g., upper and lower respiratory specimens such as nasal, nasopharyngeal or oropharyngeal swabs, sputum, lower respiratory tract aspirates, bronchoalveolar lavage, and nasopharyngeal wash/aspirate or nasal aspirate***\] collected from individuals suspected of COVID-19 by their healthcare provider.
This test is also for use with the \[***name of home collection device***\] to self-collect \[***name specimens, nasal swab or saliva***\] specimens at home by individuals when determined by a healthcare provider to be appropriate based on \[***include mechanism via which the individual is determined to be appropriate for COVID-19 testing by a healthcare provider – to facilitate prescription use. For example (1) the results of an online COVID-19 questionnaire, or (2) telephone or online video appointment, etc. with a healthcare provider***\].
Testing is limited to \[***specify laboratory/laboratories***\] certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in **\[*name specimen type, e.g. ***upper respiratory**\]** during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The ***\[test name\]*** is intended for use by **\[*include intended user, e.g., qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of real-time PCR and in vitro diagnostic procedures*\]**. The ***\[test name\]*** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
##### *2) Special Conditions for Use Statements:*
For Emergency Use Authorization (EUA) only.
For prescription use only.
For in vitro diagnostic use only.
For professional use only.
For use by people 18 years of age or older.
The ***\[name of collection device\]*** collection device is only authorized for use in conjunction with an in vitro diagnostic (IVD) test for the detection of SARS-CoV-2 that has been issued an EUA and is authorized for use with this collection device.
### E. DEVICE DESCRIPTION
***Example text has been added below, please modify for your specific collection device. Please note that for new technologies FDA may request additional detailed information so we can adequately assess the risks and benefits associated with the device.***
##### 1. *Device Description:*
***Describe the basic design of the collection device and the components included in the kit.***
The ***\[name of collection device\]*** collection device consists of a ***\[e.g., swabs, collection tube containing stabilizing liquid, gel pack, return shipping box/envelope, insulated pack, instructions\]***.
##### 2. *Home Collection Kit Ordering and Processing:*
***Describe how individuals are selected as acceptable for receiving the home collection kit and who writes the prescription for the test. For example, do individuals fill out an online questionnaire that is reviewed by a physician before the home collection kit is shipped to the requesting individual? You should note if the screening follows CDC recommendations for testing prioritization. As a prescription use device, the home collection kit is not to be dispensed to the patient before the prescription for the test is written. Describe how the specimen is collected and then transferred into the collection device. Include details of all reagents/materials included in the kit and their function. Include how the components of the collection device stabilize the specimen and protect the virus/viral RNA for shipment. Describe the shipping conditions during transit \[for example; use of a drop box, sample waiting for pick up outside, etc.\]and how the transit/shipping time will be tracked. How does the home user know where to send their specimens? Are there specific shipping instructions? Please identify the company(ies) shipping specimens and if specimens will be placed in drop boxes or mail boxes for pickup. You should have an accessioning SOP for all laboratories to use when accepting \[name of collection device\] samples for testing, before entering them into the work flow.***
Individuals may request the \[***name of collection device***\] collection device \[***describe the mechanism via which individuals request the home collection kit and how they are determined appropriate for COVID-19 testing by a prescribing healthcare provider***\].
The *\[**name of collection device**\]* collects and stabilizes \[***virus/viral RNA\]*** from *\[**add all claimed specimen types, i.e., nasal swabs and/or saliva\]*** specimen***(s)***; it can also be used for the transportation and \[***short/long‐term room temperature storage***\] of a sample. The ***\[name of collection device**\]* is a non‐invasive alternative for collecting high quality and quantity \[***virus/viral RNA**\]* by/from individuals who are suspected of COVID-19 by their healthcare provider for use in molecular COVID-19 diagnostic assays that are authorized for use with the *\[**name of collection device**\]*.
The *\[**name of collection device**\]* consists of \[***e.g., a swab, a collection tube, stabilizing liquid optional sponges for assisted collection***\]. The individual using the *\[**name of collection device**\]* to collect *\[**add all claimed specimen types, i.e., nasal swabs and/or saliva\]*** specimen***(s)*** performs the following steps to collect the initial specimen.
After *\[**add all claimed specimen types, i.e., nasal swabs and/or saliva\]*** specimen***(s)*** is collected, the \[***swab is inserted, stabilizing liquid is mixed with the sample***\].
Upon contacting \[***e.g. clinical specimen, saliva cells, the stabilizing liquid lyses cellular and nuclear membranes to release and stabilize nucleic acids***\]. For device shipping, the individual must \[***describe steps and expected timeframe***\].
Specimens received at the clinical laboratory for testing with the \[***name of EUA test***\] undergo the following accessioning prior to acceptance for testing \[***describe the specimen log in, acceptance and rejection criteria, mechanism for handling rejected specimens, etc.***\]
Test results are communicated back to individuals that used the ***\[name of collection device***\] via ***\[describe the mechanism via which results are returned to patients that use the home collection device\].***
##### 3. *Specimen Collection Control:*
***The accessioning process should include some type of control for adequate human specimen. This could include using an EUA authorized assay that includes some form of human sample control (e.g. RNaseP) to determine if sufficient sample was collected by the user. Alternatively, the laboratory could run a separate RT PCR in parallel for each sample type that targets a human housekeeping gene. A design feature of the collection device, such as changing color in the presence of human material, may also be an appropriate control. Sample collection visually observed by a healthcare provider through a telemedicine visit, and a method/procedure for the laboratory to confirm this, could also serve as this control.***
##### 4. *Partnering Laboratories:*
***Fill out the table below to identify all laboratories that samples will be sent to and all tests that will be run with the samples at each laboratory.***
| Laboratory | EUA Assay | Lab Testing Capacity (per day or week) |
| --- | --- | --- |
| Lab Name Address Phone: CLIA #: | Assay Name Identify if Commercial Assay or LDT | |
||
***We recommend requesting a letter from the developer of each test permitting FDA to discuss their submission with you.***
***Additionally, each test developer should submit an EUA or EUA amendment for authorization with \[collection device name\]. Please provide a right of reference to each test developer to allow the data validating your home collection device to be incorporated by reference in the test developer’s EUA request.***
### F. PRODUCT MANUFACTURING
The ***\[name of collection device\]*** has been validated using only the components referenced in this submission.
##### 1. *Overview of Manufacturing and Distribution:*
The product will be manufactured at \[***manufacturer’s name and FDA registration number (if applicable******)\]*** by \[***manufacturer name***\] personnel consistent with practices for the production of **\[*types of devices*\]** based on \[***type of quality system\****\]**.** Material manufactured by \[***manufacturer’s name***\] may be bottled and kitted by \[***packager name***\] manufacturing facility.
The current manufacturing capabilities include the ability to manufacture approximately **\[*please insert the approximate number of units/products that can currently be manufactured per week at the manufacturing facility*\]** products per week; however, in the event of a surge in demand, this could be increased to **\[*please insert the approximate maximum number of units/products that could potentially be manufactured per week at the manufacturing facility if there was a surge in demand*\]** product per week within a **\[*please specify in weeks/months the expected timeframe required to increase product production if required*\]** timeframe.
The product will be distributed by **\[*please describe the distribution plan for the product and list all current distributors*\]**.
##### 2. *Components Included with the Home Collection Kit*
Components manufactured by \[***manufacturer’s name and FDA registration number (if applicable)***\] and supplied with the home collection kit include:
**List all components and reagents provided for your home collection kit, including a description, volumes, concentrations, quantities, buffer components, etc. If you plan to use non-traditional sources of swabs or media, please describe your qualification testing and validation procedures. Collection media that contains hazardous or irritating materials (such as guanidinium salts) should not be used for home collection unless the collection device has specific safety features to reduce the risk of patient exposure (such as releasing preservative only when the container lid is closed). FDA will conduct a safety review of all collection media and containers. **
**Kit components**
| Name | Description | Quantity | Material Supplier |
|------|-------------|----------|-------------------|
||
##### 3. *Collection Device Stability:*
***Briefly describe stability test plan for \[name of collection device\]* *reagents and include any accelerated stability information if available. Please note that reagent stability studies do not need to be completed at the time of EUA issuance, however the study design should be agreed upon during interactive review and the stability studies started immediately following authorization, if not before. When designing your stability study, general recommendations are outlined below, for your consideration.***
- For EUAs, you may follow the current FDA recognized CLSI Standard EP25 – Evaluation of Stability of In Vitro Diagnostic Reagents; Approved Guideline when evaluating the suitability of stability study designs. If you are planning to pursue a De Novo/510(k) for your device, we recommend discussing in more detail your stability design to facilitate potential use of the EUA data in your regular premarket submission.
- We recommend testing a known positive diluted patient sample at 3-5x LoD rather than positive control material to establish reagent stability.
- You should design your study to provide data for a timeframe that is about 10% longer than the one to be claimed – for example; a claim of 18 months should be supported by stability data out to 20 months and a claim of 7 days should include stability data out to 8 days.
- FDA considers 15-30°C to represent room temperature conditions. Ideally you should evaluate stability at both 15°C and 30°C, however, for the purposes of the EUA evaluation at 30°C is acceptable as the worse-case scenario.
- Shelf-Life Stability- Unopened kit:
- You should evaluate real-time kit stability studies with unopened kits stored at the claimed storage temperature for your test.
- Accelerated stability evaluations for unopened kits may be included in EUA submissions while the real-time studies are on-going. However, please note real-time stability data may be needed to meet the required statutory standard for pre-market approval/clearance and for EUA issuance.
- Shipping Stability - Unopened kit: Study should evaluate the anticipated handling and shipping times and temperatures expected for unopened kits.
- FDA analysis recommendations for real time stability studies are as follows:
- Baseline of the study (t=0 of stability study) should not exceed a month from bottling
- Clear baselines should be described (e.g., a month from bottling) for each stability claim under each study
- Claims should be determined based on regression analysis. Any %change (%shift) from time zero (baseline) should be calculated between the target claim and the zero-time as (Ttest-Tbaseline)/ Tbaseline\*100 with 95%CI using the regression equation obtained from plotting the mean values. When formulating your acceptance criteria for evaluating the shift from baseline you should consider the reproducibility of your device. However, generally, the shift at the target claim due to storage should not exceed 10-15%. The target stability is the next to last tested point that was within +/- 10% of time zero.
- Acceptance criterion may be different, depending on the test samples analyte concentration distribution in the intended use population and the risk, in other words, the impact of false results to public health.
### G. PERFORMANCE EVALUATION
***The following recommended validation studies should be performed during your device development:***
##### Home Collection Sample Stability Study Design
***If your kit will use foam or wrapped polyester nasal swabs transported in 0.9% saline, PBS or dry tubes you may reference stability studies conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group and do not have to perform your own separate stability study for sample transport. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.***
***If you are shipping a dry swab you should also provide a rehydration SOP for laboratories to use and provide validation data for the rehydration protocol.***
The proposed study design is for validation of home sample collection for nasal swab samples in media (you should test all media you intend to use for shipping), or saliva. Testing should include 20 spiked samples at 2xLoD (low positives) and 10 spiked samples at 5-10x LoD (high positives). We also recommend testing 10 negative samples to monitor for false positives. Spiked samples for swab samples should be generated by spiking virus onto swabs and placing the swab in media, if appropriate. **Diluted clinical samples** can be used for spiking. Ideally, spiking material should be prepared with clinical matrix to most closely replicate a clinical specimen.
**Table1: Sample Panel**
| Sample | Replicates | Titer |
|---------------|------------|-----------|
| Low Positive | 20 | 2xLoD |
| High Positive | 10 | 5-10x LoD |
| Negatives | 10 | N/A |
| **Total** | **40** | |
||
The shipping study is designed to simulate the following situations in one study during home sample collection and shipping:
- Storage of samples before the customer ships the sample
- Sample sitting in mailbox or drop box waiting for pick-up
- Shipping conditions after pick up, when the sample is shipped to testing lab
Total \# of samples: 40
**General Acceptance Criteria:
**Low Positive Samples: ≥95% agreement with expected results. High Positive Samples: 100% agreement with expected results. Negative Samples: 100% agreement with expected results.
The table below describe each temperature profile to replicate worst case scenario shipping conditions (for spring/summer) for an 8 hour wait at the customer’s house before shipping and then a subsequent 48-hour shipping cycle. We also included a Winter Profile for testing if you plan to continue shipping your product past August 2020. If you plan to allow testing of samples that have been shipped by 3-5-day mail, please expand the shipping study times below. The sample panel in Table 1 should be cycled through the temperatures & times below and then tested with an assay that your lab will use that produces a Ct value. FDA expects that the samples not only remain positive but that the Ct value does not appreciably increase (more than 3 Ct).
**Table 2: Summer Profile \***
| **Temperature** | **Cycle Period** | **Cycle Period Hours** | **Total Time Hours** |
|-----------------|----------------|----------------------|-------------------|
| 40°C | 1 | 8 | 8 |
| 22°C | 2 | 4 | 12 |
| 40°C | 3 | 2 | 14 |
| 30°C | 4 | 36 | 50 |
| 40°C | 5 | 6 | 56 |
||
**Winter Profile\***
| **Temperature** | **Cycle Period** | **Cycle Period Hours** | **Total Time Hours** |
|-----------------------|-----------------|-----------------|-----------------|
| -10C | 1 | 8 | 8 |
| 18C | 2 | 4 | 12 |
| -10C | 3 | 2 | 14 |
| 10C | 4 | 36 | 50 |
| -10C | 5 | 6 | 56 |
||
\*Shipping conditions for cycle periods 2 through 5 are modeled after ISTA 7D 2007 shipping standard (48-hour domestic freight transport) where for cycle period 3 and 5 the temperature has been increased from 35°C to 40°C. The cycle period 1 (8 hours) has been included for the time delay between collection of the sample and shipment of the sample. The remaining time (48 hours) covers the domestic shipment within the continental U.S. Cycle periods are sequential with the "cycle period hours" required per cycle listed in the table. After each cycle period, the "total time hours" increments by the number of hours in the cycle period.
##### Clinical Validation of Saliva as a sample type (if the COVID-19 NAAT test EUA does not have saliva as an acceptable validated sample type):
***If you seek a claim for alternative respiratory specimens, such as saliva, oral fluid, buccal swabs, etc., you should test at least 30 paired, positive nasopharyngeal swabs and 30 of the same type of alternative respiratory specimen (e.g., all saliva). To minimize the occurrence of discordant results, the samples should be collected within short time of each other and both tested using your candidate EUA assay. FDA believes ≥95% positive agreement with similar Ct values for the paired specimen types is generally acceptable clinical performance. Please provide detailed information regarding the type of collection device and transport medium you validated for use with your assay.***
***If you plan to conduct this study, we strongly suggest you submit a short study design to FDA for review before commencing. ***
##### Flex studies:
For oral saliva - Sample Volume Tolerance: You should conduct a study to evaluate the effect of over or under filling the collection device.
##### Human Usability Study: for home-collection and mailing the sample to a CLIA-certified lab for testing:
- Testing should include a minimum of 30 participants and takes place in an actual use environment or simulated environment.
- The entire workflow should be performed by each individual participant using the kit, including kit registration, sample collection, packaging of the sample, and mailing to the laboratory with pre-prepared label.
- The participants should be observed (either in person or by remote visual monitoring, such as a video conference) during sample collection and all difficulties should be noted.
- After the entire process is completed the user should be given the questionnaire to indicate the ease of use of the kit and sample collection as well as understanding the consequences if steps are not performed correctly. The participant should be able to provide comments if needed.
- The laboratory personnel should inspect the packaging and sample upon delivery and note all packaging errors and acceptability of the sample for testing.
- The samples collected during the study should be tested for specimen adequacy using a human sample control assay. This could include using an EUA authorized assay that includes a human sample control (e.g. RNaseP) to determine if sufficient sample was collected by the user. Alternatively, the laboratory could run a separate RT PCR for each sample that targets a human housekeeping gene. A design feature of the collection device, such as changing color in the presence of human material, may also be an appropriate control.
- Participants should include individuals representing varying education levels and ages. Participants with prior medical or laboratory training should be excluded. Participants who have prior experience with self-collection should be excluded.
- The study should have pre-defined acceptance criteria and defined strategy to mitigate risk of errors identified in the study (e.g., modifying the instructions).
We encourage sponsors to submit their usability study protocols and questions for participants for FDA review prior to conducting the study.
##### User Labeling:
You should submit for review your packaging and directions for your specimen collection kit. FDA will review these documents for their ease of use and clarity of instructions. We recommend all directions be written at a 7^th^ grade reading level or below.
### H. UNMET NEED ADDRESSED BY THE PRODUCT
**This section will be completed by FDA.**
### I. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for specimen self-collection in conjunction with a laboratory-based molecular in vitro diagnostic EUA test for the detection of the SARS-CoV-2 have been approved/cleared by FDA.
### J. BENEFITS AND RISKS:
**This section will be completed by FDA.**
### K. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
**As set forth in the EUAs, Fact Sheets for Patients and Healthcare Providers generally are to be provided with the assays that will be used with the home collection kit *- see examples for authorized EUA tests on our website and templates will be made available.***
### L. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
**Include Instructions for Use, Box Labels, Vial Labels and any other proposed labeling for the test and/or home collection kit. You should also include copies of any questionnaires used to determine eligibility of the patient to receive the home collection kit.**
### M. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
If authorized, conditions would likely be included in the EUA to require the following -
\[***Manufacturer name***\] will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report adverse events, and this website is referenced through the \[***Manufacturer name***\] Product Support website: \[***Include link to Website***\]. Each report of an adverse event will be processed according to \[***Manufacturer name******\]***’s Non-Conformance Reporting Requirements, and Medical Device Reports will be filed with the FDA as required. Through a process of inventory control, \[***Manufacturer name******\]*** will also maintain records of device usage/purchase. \[***Manufacturer name******\]*** will collect information on the performance of the test, and report to FDA any suspected occurrence of false positive or false negative results of which \[***Manufacturer name******\]*** becomes aware. \[***Manufacturer name******\]*** will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
[1] This template is part of the [Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised) - Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised).
[2] [https://www.fda.gov/media/97321/download](https://www.fda.gov/media/97321/download).
# 704 2020-07-21_FDA Letter - Serology IVD Umbrella Revocation.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2020-07-21_FDA Letter - Serology IVD Umbrella Revocation.md
file_date: 2020-07-21
title: FDA Letter - Serology IVD Umbrella Revocation
category: regulatory
subcategory: fda-policy
tags:
source_file_type: pdf
xfile_type: docx
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pdf_gdrive_url: https://drive.google.com/file/d/1oYZw2TXJUthcT1Nw7FARgjj17adCS06x
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2020-07-21_FDA%20Letter%20-%20Serology%20IVD%20Umbrella%20Revocation.pdf
conversion_input_file_type: pdf
conversion: claude
license: Public Domain
tokens: 704
words: 483
notes:
summary_short: The FDA Serology IVD Umbrella Revocation letter announces the July 21, 2020 revocation of the April 28, 2020 umbrella EUA for certain SARS-CoV-2 antibody tests evaluated through NIH/NCI or other designated government validation. It explains that FDA shifted to issuing individual EUAs to allow test-specific indications, conditions of authorization, and more flexible amendments, even though no tests had been added to the umbrella EUA’s authorized list. This change tightened oversight and enabled more tailored regulatory control over serology test performance and labeling.
CONTENT
July 21, 2020
To Manufacturers and Other Stakeholders:
This letter is to notify you of the revocation of the Emergency Use Authorization (EUA) issued April 28, 2020, for emergency use of certain in vitro diagnostic SARS-CoV-2 Antibody Tests[^1] intended for use as an aid in identifying individuals with an adaptive immune response to SARS-CoV-2, indicating recent or prior infection, by detecting antibodies (IgG, or IgG and IgM, or total) to SARS-CoV-2 in human plasma and/or serum.
The authorization of a device for emergency use under section 564 of the Federal Food, Drug, and Cosmetic Act (the Act) (21 U.S.C. 360bbb-3) may, pursuant to section 564(g)(2) of the Act, be revised or revoked when the criteria under section 564(b)(1) of the Act no longer exist, the criteria under section 564(c) of the Act for issuance of such authorization are no longer met, or other circumstances make such revision or revocation appropriate to protect the public health or safety.
FDA has determined that circumstances make revocation of this EUA appropriate to protect the public health or safety. Any SARS-CoV-2 Antibody Tests added to the list of authorized devices in Appendix A of the April 28, 2020, letter of authorization would have been authorized for: (1) human plasma and/or serum samples only, (2) use only at laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) to perform moderate or high complexity tests, and (3) the detection of IgG only, IgG and IgM, or total antibodies (i.e., not for the detection and differentiation of IgA from other immunoglobulins). To date, no device has been listed in Appendix A.
Based on information and experience since issuance of the umbrella EUA, FDA has determined that circumstances support revocation of the umbrella EUA so that FDA may issue individual EUAs. Individual EUAs will allow for broader indications and scopes of authorization, individualized conditions of authorization to address any issue unique to a specific test, and more streamlined EUA amendments, such as additional uses that would not fall under this umbrella EUA. Accordingly, FDA has decided to revoke this EUA. Instead, FDA will issue individual EUAs for SARS-CoV-2 Antibody Tests that meet the requisite EUA statutory criteria.
FDA has determined that circumstances make revocation of this EUA appropriate to protect the public health or safety for purposes of section 564(g)(2)(C) of the Act.
Accordingly, pursuant to section 564(g)(2) of the Act, FDA revokes the EUA issued on April 28, 2020.
Notice of this revocation will be published in the Federal Register, pursuant to section 564(h)(1) of the Act.
Sincerely,
__________________________
RADM Denise M. Hinton
Chief Scientist
Food and Drug Administration
^1^ The SARS-CoV-2 Antibody Tests eligible for authorization under this EUA were Lateral Flow or Enzyme-linked immunosorbent assay (ELISA) tests that had been evaluated in an independent validation study performed at the National Institutes of Health's (NIH) National Cancer Institute (NCI), or by another government agency designated by FDA.
# 20,960 2020-07-28_FDA Template - Molecular Diagnostic Template for Commercial Manufacturers.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2020-07-28_FDA Template - Molecular Diagnostic Template for Commercial Manufacturers.md
file_date: 2020-07-28
title: FDA Template - Molecular Diagnostic Template for Commercial Manufacturers
category: regulatory
subcategory: fda-policy
tags:
source_file_type: docx
xfile_type: docx
gfile_url: https://docs.google.com/document/d/1FWhHbpMOCezPXxhqFQ4lcSdcWr9ymoPK
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pdf_gdrive_url: https://drive.google.com/file/d/1tyB60wMUVIcWN_lubM6rveH69LIqiKsd
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2020-07-28_FDA%20Template%20-%20Molecular%20Diagnostic%20Template%20for%20Commercial%20Manufacturers.pdf
conversion_input_file_type: docx
conversion: pandoc
license: Public Domain
tokens: 20960
words: 15074
notes:
summary_short: The FDA Molecular Diagnostic Template for Commercial Manufacturers is a detailed regulatory framework outlining recommended data, validation studies, and documentation for pre-EUA and EUA submissions of SARS-CoV-2 molecular diagnostic tests. It standardizes how manufacturers present analytical, clinical, manufacturing, and pooling performance information to FDA during the COVID-19 public health emergency.
CONTENT
***INTERNAL TITLE:*** Molecular Diagnostic Template for Commercial Manufacturers
This template (the “template”) provides FDA’s current recommendations concerning what data and information should be submitted to FDA in support of a pre-EUA/EUA submission for a molecular diagnostic for SARS-CoV-2. As outlined in Section V.A. of the FDA guidance document [*Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised), [2] FDA recommends that the following validation studies be conducted for a SARS-CoV-2 molecular diagnostic assay: Limit of Detection, Clinical Evaluation, Inclusivity, and Cross-reactivity. This template is intended to help manufacturers provide these validation data and other information to FDA, but alternative approaches can be used. It reflects FDA’s current thinking on the topic, and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should* means that something is suggested or recommended, but not required. For more information about EUAs in general, please see the FDA Guidance document: [*Emergency Use Authorization of Medical Products and Related Authorities*](https://www.fda.gov/media/97321/download).[3]
## GENERAL INFORMATION ABOUT THIS TEMPLATE
- Text highlighted in yellow ***\[Text\]*** should be completed by the test manufacturer (sponsor) as applicable to their specific test. Text in **bold** outlines the Food and Drug Administration’s (FDA) additional recommendations for the sponsors’ consideration when completing the suggested information in each section.
- This template is intended for testing with respiratory specimens; if you are considering non-respiratory specimens (e.g., blood, stool, etc.), please contact FDA at CDRH-EUA-Templates (CDRH-EUA-Templates@fda.hhs.gov) to discuss your validation strategy.
- A test authorized under an EUA is only authorized for emergency use while the EUA is in effect.
- This is an EUA interactive review template for Pre-EUA/EUA submissions. We plan to update the template as appropriate as we learn more about the COVID-19 disease and gain experience with the EUA process for this test.
## EXAMPLE TEMPLATE:
### A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the ***\[test name\]*** to ***\[indicate labs, if applicable\]*** for the *in vitro* qualitative detection of RNA from the SARS-CoV-2 in ***\[add all claimed specimen types, e.g., nasopharyngeal/ oropharyngeal swabs, sputa, BAL, etc.\]*** ***\[select appropriate testing population, e.g.,*** ***from patients suspected of COVID-19 by a healthcare provider or for screening of individuals without symptoms or other reasons to suspect COVID-19.\]******.*** Additional testing and confirmation procedures should be performed in consultation with public health and/or other authorities to whom reporting is required. Test results should be reported in accordance with local, state, and federal regulations.
***If you plan to include a sample pooling protocol in your instructions for use please include a brief description of the pooling strategy in your EUA request.***
***If you plan to request authorization to test specimens collected with a home specimen collection kit, please refer to the*** [Home Specimen Collection Molecular Diagnostic Template](https://www.fda.gov/media/138412/download) ***and include any relevant information in this request.***
### B. MEASURAND
Specific nucleic acid sequences from the genome of the SARS-CoV-2 **\[*please specify the targeted gene(s) of the pathogen*\]**.
### C. APPLICANT
***\[Official name, address and contact information of applicant\]***
### D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name - ***\[test name\]***
Established Name - ***\[test name\]***
### E. REGULATORY INFORMATION
***Approval/Clearance Status:***
The ***\[test name\]*** test is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
***Product Code:***
QJR
### F. PROPOSED INTENDED USE
#### 1) Intended Use:
***The proposed IU will be finalized based on the performance data and recommendations from Public Health authorities at the time of authorization – example text is provided below for a qualitative molecular test that detects organism RNA but may be adapted according to the specific emergency situation addressed by the device.***
\[***Test name***\] is a \[***specify test technology such as, real-time RT-PCR test***\] intended for the \[***presumptive***\] qualitative detection of RNA from the SARS-CoV-2 in \[***describe all the specimen types, e.g. ***nasopharyngeal, nasal, and oropharyngeal swab specimens and lower respiratory tract, BAL, sputum\] ***\[If your test is intended for testing multiple respiratory pathogens, please list the specific analytes detected by your test.\] \[describe intended use population, e.g., from individuals suspected of COVID-19 by their healthcare provider or for screening of individuals without symptoms or other reasons to suspect COVID19 infection.\].*** Testing is limited to \[***laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories***\]. ***\[Describe the sample pooling approach and maximum number of specimens which can be pooled, as applicable.\]***
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in **\[*name specimen type, e.g. upper respiratory*\]** during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
The ***\[test name\]*** is intended for use by **\[*include intended user, e.g., qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of real-time PCR and in vitro diagnostic procedures*\]**. The ***\[test name\]*** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
***\[Depending on the performance data submitted and patient population included in the clinical evaluation, additional limitations may be recommended and/or your intended use may be modified to include the following, as applicable:***
- ***Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.***
- ***Negative results from pooled samples should be treated as presumptive and, if inconsistent with clinical signs and symptoms or necessary for patient management, pooled samples should be tested individually. Negative results do not preclude SARS-CoV-2 infection and must not be used as the sole basis for patient management decisions. Negative results must be considered in the context of a patient’s recent exposures, history, presence of clinical signs and symptoms consistent with COVID-19.***
- ***Use of the \[test name\] in a general, asymptomatic screening population is intended to be used as part of an infection control plan, that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. Negative results should be considered presumptive and do not preclude current or future infection obtained through community transmission or other exposures. Negative results must be considered in the context of an individual’s recent exposures, history, presence of clinical signs and symptoms consistent with COVID-19.\]***
If your test is intended for use at point of care settings the following statement should be included: ***Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, that meet the requirements to perform high, moderate, or waived complexity tests. The \[test name\] is authorized for use at the Point of Care (POC), i.e., in patient care settings operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation.***
#### 2) Special Conditions for Use Statements:
For Emergency Use Authorization (EUA) only
For prescription use only
For in vitro diagnostic use only
#### 3) Special Instrument Requirements:
The ***\[test name\]*** test is to be used with the \[***list all RT-PCR Instruments, software requirements, automated extraction instruments***\].
### G. DEVICE DESCRIPTION AND TEST PRINCIPLE
***Example text has been added under each of the sub-headings below for a fluorescence based rRT-PCR test for detection of organism RNA. If a different test principle is used by the test for the detection of a specific analyte please modify the description accordingly to capture the salient points in each of the sub-headings below. Please note that for new investigative technologies FDA may request additional detailed information so we can adequately assess the risks and benefits associated with the device.***
#### Product Overview/Test Principle:
***Describe the technology of the test and how this technology works to identify the measurand, the instruments employed/required to perform the test from sample collection to result (include all claimed extraction and PCR detection instruments), and the specimen types for which you claim to have specific performance characteristics as described below**. **If applicable, list all primer and probe sets and briefly describe what they detect. Please include the nucleic acid sequences for all primers and probes used in the test. Please indicate if the test uses biotin-Streptavidin/avidin chemistry in any of the steps for coupling reagents. Please note that an alignment with available reference genomes for different strains of the target pathogen is requested as part of the inclusivity evaluation (Section J).***
The ***\[test name\]*** is a real-time reverse transcription polymerase chain reaction (rRT -PCR) test. The SARS-CoV-2 primer and probe set(s) is designed to detect RNA from the SARS-CoV-2 in ***\[list all the specimens\]*** from patients suspected of COVID-19 by their healthcare provider.
#### Description of Test Steps:
***List and describe in detail all the steps of the test sequentially from specimen collection to detection.***
Nucleic acids are isolated and purified from ***\[specimens\]*** using ***\[please describe the method(s) of extraction (please specify the*** ***specimen input volume for extraction and/or test, the nucleic acid elution volume and whether isolation/purification is manual and/or automated)\]******.*** The purified nucleic acid is reverse transcribed using ***\[enzyme mix/kits – please specify the input volume of purified nucleic acid added to the rRT-PCR reaction mix\]*** into cDNA which is then subsequently amplified in ***\[please describe the instrument(s) and enzyme mix\]***. In the process, the probe anneals to a specific target sequence located between the forward and reverse primers. During the extension phase of the PCR cycle, the 5’ nuclease activity of Taq polymerase degrades the probe, causing the reporter dye to separate from the quencher dye, generating a fluorescent signal. With each cycle, additional reporter dye molecules are cleaved from their respective probes, increasing the fluorescence intensity. Fluorescence intensity is monitored at each PCR cycle by ***\[please describe the detection instrument(s)\]***.
#### Control Material(s) to be Used with* \[*test name*\]*:
***List all control materials (provided with the test kit and/or required but not provided with the test kit and describe what they are, how they are expected to work, where in the testing process they are used, and the frequency of use. If a control is commercially available, provide supplier’s name and catalog number or other identifier; if your device relies on external controls that are manufactured by a third party please note that these controls should also be validated within your analytical and clinical studies described below in Section J.***
Controls that will be provided with the test kit include:
1. A “no template” (negative) control is needed to ***\[describe need\]*** and is used ***\[describe use – please also specify frequency of use\]***
2. A positive template control is needed to ***\[describe need\]*** and is used ***\[describe use – please specify the concentration of the positive control relative to the LoD of your test (note that ideally the positive control concentration should be such that it is close to the LoD of your test) and also specify frequency of use\]***
3. An extraction control ***\[describe control\]*** is needed to ***\[describe need\]*** and is used ***\[describe use – please also specify frequency of use\].*** **Please note that if the no template control and positive control, are taken through the entire sample processing procedure, including the extraction, then a separate extraction control is not required**.
4. An internal control ***\[describe control\]*** is needed to ***\[describe need\]*** and is used ***\[describe use\]***.
Controls that are required but not provided with the test kit include ***\[describe control – provide recommended sources of the control materials – either a separate control kit for purchase that you the applicant develops or a control material that can be purchased from a third party\].*** This/these control(s) is/are needed to ***\[describe need\]*** and is used ***\[describe use – please also specify frequency of use\]***.
***Please note that any control recommended to be used with your device (provided with the kit or not) should be validated in the context of your analytical and clinical study (i.e., you will need to run these controls as part of your studies). In instances where control material is not readily available through 3^rd^ party vendors (which is often the case at the beginning of an outbreak) FDA may request that you include suitable control material with your device. Please note that external control materials are considered particularly important when GMP requirements are waived and reagent stability studies are limited.***
### H. INTERPRETATION OF RESULTS
All test controls should be examined prior to interpretation of patient results. If the controls are not valid, the patient results cannot be interpreted. ***Please describe if a Ct cutoff is used as part of your testing algorithm and/or if the end user is required to review fluorescent curves for weakly positive samples before final interpretation. Although not typical for molecular-based tests, if the test result involves the use of an algorithm/calculation, for example a ratio value, when determining the final patient test result, please include a detailed description and any additional calibration materials that may be required.***
#### \[Test name\] Controls – Positive, Negative and Internal
***Describe in detail the expected results generated, including acceptance criteria, for all the controls described in detail in Section G above. Describe the measured values (if applicable) for valid and invalid controls and outline the recommended actions the laboratory should take in the event of an invalid control result.***
#### Examination and Interpretation of Patient Specimen Results:
***Describe when clinical specimen test results should be assessed and outline the criteria for test validity**. **Example text**:* Assessment of clinical specimen test results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
***Clearly indicate how to interpret numeric test values (if applicable) as positive or negative for presence of the*** SARS-CoV-2***. Indicate if the end user is required to review fluorescent curves for weakly positive samples before final interpretation and how to identify indeterminate/inconclusive results (if they exist) results and how the user should resolve them, e.g. if repeat testing may be required.***
***When applicable, provide a table clearly describing the possible combinations of test result values for each primer/probe set, and how they should be combined into a final interpretation of the result for your test. If the test produces result that will be used as part of a CDC recommended testing algorithm, please indicate what follow-up testing/process should be conducted, if applicable.***
### I. PRODUCT MANUFACTURING
#### Overview of Manufacturing and Distribution:
The product will be manufactured at \[***manufacturer’s name and FDA registration number (if applicable)***\] by \[***manufacturer name***\] personnel consistent with practices for the production of **\[*types of devices*\]** based on \[***type of quality system\****\]**.** Material manufactured by \[***manufacturer’s name***\] may be bottled and kitted by \[***packager name***\] manufacturing facility.
The current manufacturing capabilities include the ability to manufacture approximately **\[*please insert the approximate number of units/products that can currently be manufactured per week at the manufacturing facility*\]** products per week, however in the event of a surge in demand this could be increased to **\[*please insert the approximate maximum number of units/products that could potentially be manufactured per week at the manufacturing facility if there was a surge in demand*\]** product per week within a **\[*please specify in weeks/months the expected timeframe required to increase product production if required*\]** timeframe.
The product will be distributed by **\[*please describe the distribution plan for the product and list all current distributors*\]**.
**\*Under the Emergency Use Authorization (EUA) any of the 21 CFR Part 820 Quality System Regulation (QSR) requirements can be waived for the duration of the EUA but FDA recommends that developers follow comparable practices as much as possible if such requirements are waived. Among other things, FDA may consider previous compliance history when determining whether or not to waive certain QSR requirements for a specific product. Please note adverse events, as per 21 CFR Part 803, have to be reported for authorized devices (see Section P).**
#### Components Included with the Test
Components manufactured by \[***manufacturer’s name and FDA registration number (if applicable)***\] and supplied with the test include:
**List all components and reagents provided for your test, including a description of the primers and probes, volumes, concentrations, quantities, buffer components, etc.**
#### Components Required But Not Included with the Test
Components required but not included with the test:
***List all components and reagents not included with the test that must be supplied by the user to perform the test, with specific supplier names and catalog numbers or other identifiers for obtaining these components and reagents. Please include here all specific consumables that were validated for use with your device, that are not interchangeable with other products and that are needed to guarantee device performance as established in the EUA validation studies listed in Section J below.***
#### Software Validation
***If you are introducing a system onto the market which has not been previously reviewed by FDA, we recommend providing evidence that the software has been validated to ensure that:***
- ***The inputs and outputs of the software are appropriate to fulfill the system and assay requirements;***
- ***All expected inputs produce the expected outputs for all functions critical for system operation; and***
- ***The system will be provided to the customer free of defects or defects will be known and mitigated.***
***If this evidence is not available prior to authorization, they may be incorporated into the conditions of authorization. If changes which impact assay performance or safety and effectiveness of the system are needed to address validation failures post-authorization, then these may be required to be submitted as an EUA amendment in a condition of authorization. If no changes are needed or changes which do not impact assay performance or safety and effectiveness of the system are implemented, then the condition of authorization may require that validation data be kept on file.***
***We recommend you:***
- ***Perform electromagnetic compatibility (EMC) testing to International Electrotechnical Commission (IEC) 60601-1-2 Edition 4.0:2014;***
- ***Evaluate cybersecurity of your system to ensure user and patient safety in the intended use environment;***
- ***Complete validation of all systems and software to ensure that all functions of the system perform as labeled. For more information on system validation please see the following FDA guidance documents and resources:***
- ***[Guidance for the Content of Premarket Submissions for Software Contained in Medical Devices](https://www.fda.gov/media/73065/download);***
- ***[General Principles of Software Validation; Final Guidance for Industry and FDA Staff](https://www.fda.gov/media/73141/download);***
- ***[Off-The-Shelf Software Use in Medical Devices](https://www.fda.gov/media/71794/download); and***
- ***[21 CFR 820.30 Subpart C](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=820.30) – Design Controls of the Quality System Regulation.***
#### Testing Capabilities
***Briefly describe current sample throughput capacity, total time required to perform the test (from clinical specimen collection, specimen transport to result), and number of tests that can be performed per instrument run and per day.***
#### Reagent Stability:
***Briefly describe stability test plan for reagents and include accelerated stability information, if available. Please note that reagent stability studies do not need to be completed at the time of EUA issuance, however the study design should be agreed upon during interactive review and the stability studies started immediately following authorization, if not before. You should consider the following recommendations when designing your stability study:***
- ***For EUAs you may follow the current FDA recognized CLSI Standard EP25 – Evaluation of Stability of In Vitro Diagnostic Reagents; Approved Guideline when evaluating the suitability of stability study designs. If you are planning to pursue a De Novo/510(k) for your device we recommend discussing in more detail your stability design to facilitate potential use of the EUA data in your regular premarket submission.***
- ***We recommend testing a known positive diluted patient sample at 3-5x LoD rather than positive control material to establish reagent stability.***
- ***If you are claiming multiple clinical specimen types in which similar LoDs are determined, you should use the most challenging clinical matrix for this study.***
- ***We typically recommend your stability study design includes the evaluation of at least 5 replicates. You should also evaluate, if available, 3 different lots of reagents.***
- ***You should design your study to provide data for a timeframe that is about 10% longer than the one to be claimed – for example; a claim of 18 months should be supported by stability data out to 20 months and a claim of 7 days should include stability data out to 8 days.***
- ***FDA considers 15-30°C to represent room temperature conditions. Ideally you should evaluate stability at both 15°C and 30°C, however, for the purposes of the EUA evaluation at 30°C is acceptable as the worse-case scenario.***
- ***Shelf-Life Stability- Unopened kit:***
- ***You should evaluate real-time kit stability studies with unopened kits stored at the claimed storage temperature for your test.***
- ***Accelerated stability evaluations for unopened kits is acceptable for EUA submissions while the real-time studies are on-going. However, please note real-time stability data is required to support regular pre-market submissions and for the final claim of an EUA.***
- ***Shipping Stability - Unopened kit: Study should evaluate the anticipated handling and shipping times and temperatures expected for unopened kits.***
- ***In-use/Opened Kit Stability: Depending on your device your stability study design should also support in-use stability of the kit reagents once the kit has been opened, e.g., storage at 2-8 ^o^C for 7 days. This includes on board stability once reagents have been placed on the instrument (if applicable).***
- ***Inverted stability (if applicable): Study should support inverted stability for of kits.***
- ***Freeze-thaw Stability: If you recommend aliquoting the reagents to meet the end-users needs following the initial thaw this recommendation should be supported by a freeze-thaw stability study, including the specific number of allowed freeze-thaw cycles.***
- ***FDA analysis recommendations for real time stability studies are as follows:***
- ***Baseline of the study (t=0 of stability study) should not exceed a month from bottling***
- ***Clear baselines should be described (e.g., a month from bottling) for each stability claim under each study***
- ***Claims should be determined based on regression analysis. Any %change (%shift) from time zero (baseline) should be calculated between the target claim and the zero-time as (Ttest-Tbaseline)/ Tbaseline\*100 with 95%CI using the regression equation obtained from plotting the mean values. When formulating your acceptance criteria for evaluating the shift from baseline you should consider the reproducibility of your device. However, generally, that the shift at the target claim due to storage cannot exceed 10-15%. The target stability is the next to last tested point that was within +/- 10% of time zero.***
- ***Acceptance criterion may be different, depending on the test samples analyte concentration distribution in the intended use population and the risk, in other words, the impact of false results to public health.***
#### Sample Stability:
***Please provide sample stability information, including the study design and results if the sample is shipped to a testing site from a location other than healthcare settings, e.g. samples collected at home.***
### J. PERFORMANCE EVALUATION
***The following validation studies should be performed during your assay development:***
#### Limit of Detection (LoD) - Analytical Sensitivity:
***You should determine the LoD of the test utilizing all components of the test system from sample preparation to detection.* *Testing quantified inactivated virus (e.g., heat treated or irradiated virus) spiked into real clinical matrix (e.g., BAL fluid, sputum, nasopharyngeal swab, etc.) for LoD determination is recommended since the inactivated virus most closely reflects live virus in a clinical sample.*** ***If you are unable to acquire inactivated virus, FDA believes that viral genomic RNA is the next best material to use to generated contrived samples for testing.*** ***As positive natural clinical specimens are increasingly becoming available, a quantified known positive clinical specimen as determined by an EUA authorized test can also be used to create dilutions in ******clinical matrix for LoD determination. Respiratory swab matrix should derive from swab specimens collected from SARS-CoV-2 negative individuals. FDA recommends that preliminary LoD be determined by testing a 2-3 fold dilution series of three replicates per concentration. The lowest concentration that gives positive results 100% of the time is defined as the preliminary LoD. The final LoD concentration should be confirmed by testing 20 individual extraction replicates at the preliminary LoD. FDA defines LoD as the lowest concentration at which 19/20 replicates are positive. If multiple clinical matrices are intended for clinical testing, you should submit to FDA the results from one representative matrix of each claimed clinical matrix type. For example:***
***- If testing common upper respiratory tract specimens (e.g., nasopharyngeal (NP) swabs, oropharyngeal (OP), swabs, nasal swabs, anterior nasal swabs, mid-turbinate nasal swabs, nasal aspirates, and nasal washes etc.), please submit results from the most challenging upper respiratory matrix. FDA considers nasopharyngeal (NP) swabs to be the most challenging upper respiratory matrix.***
***- If claiming common lower respiratory tract specimens (e.g., tracheal aspirates, sputum, etc.), please submit results from the most challenging lower respiratory matrix. FDA considers sputum to be the most challenging lower respiratory matrix.***
***- If claiming both, upper and lower respiratory matrixes, submitting results from sputum samples may suffice to support both upper and lower respiratory matrices.***
***- If claiming alternative respiratory specimens, such as saliva, oral fluid, buccal swab, etc., please submit results from testing each of the claimed uncommon respiratory specimen type.***
***- If needed, FDA recommends that you follow the most current version of the CLSI standard, Evaluation of Detection Capability for Clinical Laboratory Measurement Procedures (CLSI EP17).***
**\[*Please describe your LoD study, the specific material used (e.g., live or in-activated viral stocks, viral RNA), the specific clinical matrix used, and the LoD (with appropriate units) for your assay*\]**
#### Inclusivity (analytical sensitivity):
***Laboratories should document the results of an inclusivity study that demonstrates the strains of SAR-CoV-2 that can be detected by the proposed molecular assay. It is acceptable to conduct an in silico analysis of published SARS-CoV-2 sequences using the assay’s primers and probes. FDA anticipates that 100% of published SAR-CoV-2 sequences will be detectable with the selected primers and probes.***
***\[Please describe your Inclusivity study and confirm that there was 100% detection of all SARS-CoV-2 strains.\]* *If sequences with less than 100% homology with any of the primers and probes in your test are identified, please provide a risk assessment on how such mismatches may impact the performance of your test.***
#### Cross-reactivity (Analytical Specificity):
***Cross-reactivity studies are performed to** **demonstrate that the test does not react with related pathogens, high prevalence disease agents and normal or pathogenic flora that are reasonably likely to be encountered in a clinical specimen. For respiratory specimen claims excluding saliva and oral fluid, the recommended list of organisms to be analyzed in silico and by wet testing is provided in the table below. For non-respiratory matrices or saliva and oral fluid, an appropriate list of organisms should be tested, please see previous FDA decision summaries for recommended organisms or contact FDA for recommended organisms. For wet testing, concentrations of 10^6^ CFU/ml or higher for bacteria and 10^5^ pfu/ml or higher for viruses is recommended. In silico analyses alone may be acceptable for organisms that are difficult to obtain. FDA defines in silico cross-reactivity as greater than 80% homology between one of the primers/probes and any sequence present in the targeted microorganism. ***
**Recommended List of Organisms to be Analyzed *in silico*
and by Wet Testing**
| **Other high priority pathogens from the same genetic family** | **High priority organisms likely present in a respiratory specimen** |
|----------------------------------|--------------------------------------|
| **Human coronavirus 229E** | **Adenovirus (e.g. C1 Ad. 71)** |
| **Human coronavirus OC43** | **Human Metapneumovirus (hMPV)** |
| **Human coronavirus HKU1** | **Parainfluenza virus 1-4** |
| **Human coronavirus NL63** | **Influenza A & B** |
| **SARS-coronavirus** | **Enterovirus (e.g. EV68)** |
| **MERS-coronavirus** | **Respiratory syncytial virus** |
| | **Rhinovirus** |
| | ***Chlamydia pneumoniae*** |
| | ***Haemophilus influenzae*** |
| | ***Legionella pneumophila*** |
| | ***Mycobacterium tuberculosis*** |
| | ***Streptococcus pneumoniae*** |
| | ***Streptococcus pyogenes*** |
| | ***Bordetella pertussis*** |
| | ***Mycoplasma pneumoniae*** |
| | ***Pneumocystis jirovecii* (PJP)** |
| | **Pooled human nasal wash - *to represent diverse microbial flora in the human respiratory tract*** |
| | ***Candida albicans*** |
| | ***Pseudomonas aeruginosa*** |
| | ***Staphylococcus epidermis*** |
| | ***Streptococcus salivarius*** |
||
*Microbial Interference Studies:* ***If in silico analysis reveals ≥ 80% homology between the cross-reactivity microorganisms and your test primers/ probe(s), we recommend that you either perform (1) a microbial interference study with SARS-CoV-2 and the microorganisms that your test primers/ probe(s) have homology to, or (2) as an alternative to the microbial interference study, you may provide justification as to why (e.g., amount of primer(s)/ probe(s) included in your master mix) the performance of your test would not be impacted by the presence of a causative agent of a clinically significant co-infection, or (3) explain why the in silico results are clinically irrelevant (e.g., low prevalence of MERS-CoV, etc.). Competitive microbial interference testing should be conducted for multiplex panels. The study should assess the effects of clinically relevant co-infections by testing selected microorganisms commonly found in the claimed specimen matrix in the presence of SARS-CoV-2 at low concentration. The interference should be evaluated by testing with a minimum of 3 sample replicates spiked at a low (≤3x LoD) SARS-CoV-2 concentration and a high interferent level (preferably microorganisms), to represent the worst-case scenario. The interferent microorganisms can be tested individually or as a pool (of four or five) in the presence of low concentration of SARS-CoV-2. Each microorganism of a pool should be tested individually, if that pool shows interference. If you plan to claim both upper and lower respiratory clinical specimens, the study should be performed in the most challenging specimen matrix, i.e., sputum. If interference is observed at the level tested, an additional titration study should be performed to determine the highest microorganism interferent level your test can achieve the stated performance.***
*Endogenous Interference Substances Studies*: ***The extent of testing for endogenous interference substances depends on the matrix that is claimed for the device as well as on the technology of the device, e.g., if a nucleic acid extraction procedure is performed prior to testing or not. If your test uses extraction methods not previous reviewed by FDA as part of premarket submission or the test does not use an extraction procedure, we recommend testing of potential interferents. Please contact FDA to discuss the appropriate study designs.***
#### Clinical Evaluation
#### a) Claims for testing respiratory specimens from patients suspected of COVID-19 by their healthcare provider:
***FDA recommends using natural clinical specimens in the clinical evaluation. Please refer to the following table for additional information regarding clinical study design:***
***Note: Clinical study recommendations listed in the table below do not apply to claims for screening individuals without symptoms or other reasons to suspect COVID-19 and to saliva or other alternative respiratory specimen type claims.***
| Minimum Number of Positive Specimens | A minimum of 30 individual natural (prospective or retrospective or leftover samples) positive clinical specimens should be collected from patients suspected of SARS-CoV-2 infection by a healthcare provider in COVID-19 disease endemic region(s). Samples can be a mixture of specimen types, if you are seeking an upper respiratory claim (e.g., nasopharyngeal (NP) swab, oropharyngeal (OP) swab, nasal swab (NS)). If you are seeking a sputum claim, and any other respiratory specimen claim except alternative respiratory specimen types (e.g., saliva), we recommend a combination of 15 NP and 15 sputum samples. Specimens collected from different anatomical sites from the same patient may be used to support claims for multiple specimen types. The use of frozen samples is acceptable. Specimens representing a wide range of viral load including low positive samples should be tested. The use of samples previously tested positive by another EUA RT-PCR assay may be acceptable without additional comparator testing. You should indicate the source of the samples, provide results for each tested sample, indicate specimen type, and initial test date. |
| --- | --- |
| Minimum Number of Negative Specimens | A minimum of 30 individual negative samples acquired from the following sources are acceptable; (1) prospective samples from the individuals suspected of COVID-19 by their healthcare provider, (2) archived/retrospective respiratory samples collected from patients with signs and symptoms of respiratory infection, and (3) other subjects that are expected to be negative for SARS-CoV-2, such as specimens collected prior to COVID-19 pandemic in the US. |
| Recommended Comparator Method for percent agreement performance calculations | Positive percent agreement should be calculated in comparison to an EUA RT-PCR test. We recommend using only a high sensitivity EUA RT-PCR assay which uses a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction). If available, FDA recommends selecting a comparator assay that has established high sensitivity with an internationally recognized standard or FDA SARS-CoV-2 Reference Panel. Please contact CDRH-EUA-Templates@fda.hhs.gov to discuss options to establish the sensitivity of your comparator method. Please see the following website for the most recent list of FDA authorized 2019-nCoV tests: https://www.fda.gov/medical-devices/emergency-situations-medical-devices/emergency-use-authorizations . Negative result agreement may be calculated in comparison to an EUA RT-PCR test (prospectively collected samples) or as agreement with expected results if samples were collected from individuals known to be negative for SARS-CoV2 (e.g. collected before December 2019). The comparator assay may have the same, or different, targets as your assay. False results can be investigated using an additional EUA RT-PCR assay, and/or Sanger sequencing. The results of the discordant analysis can be footnoted in your final performance table but cannot be used to change the final performance calculations. |
| Acceptance Criteria | FDA believes a minimum of 95% positive and negative agreement is acceptable clinical performance. |
| Natural Clinical Specimens IRB/Informed Consent Note | Prospective collection of clinical specimens to support the EUA request should be done in accordance with regulations for human subject protection, including IRB approval and informed consent. Use of leftover de-identified samples may follow the policy outlined in the FDA Guidance on Informed Consent for In Vitro Diagnostic Device Studies Using Leftover Human Specimens that are Not Individually Identifiable ( https://www.fda.gov/media/122648/download ). |
| Testing Approach Note 1 | All clinical specimens tested in your study should be evaluated in accordance with your proposed diagnostic algorithm (i.e., tested using the procedure in the instructions for use), including retesting when appropriate. The limited volume of natural specimens may preclude retesting. In instances where retesting is indicated but not performed, for the purposes of performance evaluation, initial results will be analyzed for performance and equivocal/indeterminate/inconclusive results should count against your final performance. |
| Testing Approach Note 2 | Specimens should be tested in a blinded fashion, e.g., positive and negative samples should be presented to the end user in a blinded fashion. The end user should also be blinded to the results of any comparator method testing. |
||
#### b) Testing alternative specimens (i.e., other than respiratory specimens) from patients suspected of COVID-19 by their healthcare provider:
***If you seek a claim for alternative specimens, such as saliva, oral fluid, buccal swabs, etc., you should test two paired specimens from at least 30 positive and 30 negative patients. Consecutively collected specimens are preferred. Specimens representing a wide range of viral load including low positive samples should be tested. One specimen from each patient should be collected by a healthcare worker using a nasopharyngeal (NP) swab and tested with an assay authorized for use with NP specimens. FDA recommends selecting a comparator assay that has established high sensitivity with an internationally recognized standard or FDA SARS-CoV-2 Reference Panel. Please contact to discuss options to establish the sensitivity of your comparator method. The other specimen from each patient should be the alternative specimen and should be tested with your candidate EUA assay, provided it is authorized for testing of NP specimens, or using a previously authorized test with an NP swab claim. To minimize the occurrence of discordant results due to biological variability, both samples should be collected within a short time period. FDA believes ≥95% positive percent agreement with similar Ct values for the paired specimen types is acceptable performance.***
***Please provide detailed information regarding the type of collection device and transport media you propose to validate for use with your assay. Please note that some transport media may not be compatible with assays that do not use a nucleic acid extraction step. In addition, some transport medium may not be acceptable for use for at-home collection due to the presence of hazardous chemicals. For additional information that may be needed to support at-home sample collection and transport, please review the [Home Specimen Collection Molecular Diagnostic Template](https://www.fda.gov/media/138412/download) or contact FDA at .***
#### c) Screening individuals without symptoms or other reasons to suspect COVID-19 with a previously unauthorized test
***The recommendations below reflect FDA’s current thinking. The study design and recommendations may change as additional information becomes available regarding asymptomatic infections, including but not limited to viral titer dynamics and transmission rates in this population.***
***If you seek claims for screening individuals without symptoms or other reasons to suspect COVID-19, FDA recommends that you conduct a clinical study in the intended population. In the clinical study, you should compare results from for your assay and a comparator assay for each patient enrolled. Please consider the following when designing your clinical validation study:***
- ***The number of enrolled patients should be sufficient to ensure at least 20 positive samples are prospectively collected in the intended use population and be sufficient to demonstrate the following minimum performance:***
***PPA ≥95% (Lower Bound of the two-sided 95% confidence interval >76%)***
***NPA ≥98% (Lower Bound of the two-sided 95% confidence interval >95%)***
***The total number of samples needed will depend on the prevalence of SARS-CoV-2 in the intended use population.***
- ***Samples for the candidate test should be collected according to the instruction for use.***
- ***Samples for comparator method testing should be healthcare provider collected NP swabs. If an NP swab cannot be collected, a nasal swab may be used, however, both anterior nares should be sampled with the same swab. Sampling for the candidate test and comparator method should occur within a short timeframe to avoid biological variability in viral load.***
- ***If available, FDA recommends selecting a comparator assay that has established high sensitivity with an internationally recognized standard or the FDA SARS-CoV-2 Reference Panel. Please contact to discuss options to establish the sensitivity of your test.***
- ***In general, we recommend that you collect samples at a minimum of three geographically diverse sites, especially if you are planning to use the same data to support a subsequent De novo/510k submission. If this is not possible, FDA will consider samples collected at one or two sites in the context of an EUA.***
- ***It may be possible to use archived samples that were collected from asymptomatic patients. We recommend you contact FDA to discuss such an approach prior to initiating your study.***
#### d) Adding population screening of individuals without symptoms or other reasons to suspect COVID-19 to an authorized test.
***Alternative approaches may be acceptable for tests that have been previously authorized with clinical data for symptomatic patients. For example:***
- ***If your assay is highly sensitive as determined by testing with the FDA SARS-CoV-2 Reference Panel or a recognized international standard, a post-authorization study may be appropriate. We recommend testing a minimum of 20 consecutively collected asymptomatic positive specimens and at least 100 consecutively collected negative specimens based on the results of the candidate test. All specimens should then be tested with another EUA authorized molecular assay. Using estimates of the predictive values and the percentage of positive results, this study can be used to establish the sensitivity (PPA) and specificity (NPA) of your test in a general, asymptomatic population, as this is an important performance metric for tests intended for screening of large populations without symptoms or other reasons to suspect COVID-19. The FDA expectation is that PPA should be >95% (lower bound of the two-sided 95% confidence interval >76%) and NPA should be ≥98% (with a lower bound of the two-sided 95% confidence interval >95%). If you do not have access to either the FDA SARS-CoV-2 Reference Panel or a recognized international standard then please contact to discuss options.***
- ***If you can demonstrate that performance of your assay in both populations is likely similar (i.e., the percent of positive individuals with Ct values representing low viral loads are similar in individuals suspected and not suspected of COVID-19 by their healthcare provider) you may include both populations in your evaluation. We encourage the use of historic data (i.e., existing or published data) for this evaluation.***
***FDA is open to considering additional alternative study designs to demonstrate that the performance of your assay is appropriate for screening individuals without symptoms or other reasons to suspect COVID-19. We recommend contacting FDA to discuss alternative study designs prior to beginning such a study.***
#### e) Specimen Pooling
- ***The recommendations below reflect FDA’s current thinking. The study design and other recommendations may change as additional information becomes available. At this time, the need for testing remains greater than available resources. Combining multiple patient samples to create one pooled sample for testing could enable broader access to testing.***
- ***To establish performance of your test with pooling, FDA recommends conducting a clinical validation study in the intended use population that includes testing each sample individually and using your proposed pooling strategy.***
- ***Currently FDA recommends two approaches to patient specimen pooling: 1) pooling aliquots of transport media which each contain a single patient sample (sample/media pooling) or 2) adding swabs from multiple patients into a single volume of transport media (swab pooling). As more data become available and new approaches are identified, our recommendations may evolve.***
***Monitoring:***
- ***Commercial test kit manufacturers should provide instructions for laboratories to incorporate ongoing monitoring of the pooling strategy by addressing the following in their Instructions for Use:***
- ***Before implementation of pooling, evaluate existing test data in the testing population from the previous 7-10 days to estimate the initial positivity rate.***
- ***When implementing a pooling strategy, continue to test a random sampling of patient samples without pooling to:***
- ***evaluate the positivity rate and percent of weak positive samples in the testing population and***
- ***identify differences in positivity rate between those tested individually and those tested through pooling.***
- ***Calculate the percent of positive results after implementation of pooling using a moving average (such as a rolling average updated daily using data from the previous 7-10 days) to determine whether there is a change in the positivity rates between individual testing and pooled testing. Reevaluate testing strategy if the moving average of the positivity rate for pooled samples starts trending in a positive or negative direction.***
- ***Finally, when resource availability is sufficient to meet testing demand, FDA recommends considering whether the risks of reduced test sensitivity with pooling continue to outweigh the benefits of resource conservation.***
***e.1) Sample/Media Pooling***
***A simple, or Dorfman, approach involves testing an “n-sample pool,” where n is the number of transport media samples included in the pool. A negative result implies that all samples in the pool are negative. A positive result indicates that at least one sample in the pool is positive. When an n-sample pool is positive, each sample within the pool must be individually tested to determine which is/are positive. When used effectively, n-sample pooling can generally enable testing of more individuals despite limited testing resources.***
- ***When pooling transport media, rather than swabs, one individual sample is defined as a single specimen swab collected from a subject and placed in a specific volume of transport media. In this type of pooling, an aliquot of each individual sample is combined into non-overlapping pools of n samples and each n-sample pool is tested. Therefore, the volume of samples initially collected from an individual must be sufficient for both the pooled testing and individual follow-up testing, if needed.***
- ***N-sample pooling should be considered in the context of the positivity rate of a test in the test population, analytical sensitivity of the test, and the percent of weak positive subjects in the tested population. Pooling of n samples reduces the analytical sensitivity of the test (increase in the LoD) because samples are diluted. The impact of decreased analytical sensitivity depends on the percent of subject specimens with viral genetic material concentrations close to the LoD (weak positives) in the tested population. Therefore, analytical sensitivity of the test with n-sample pools should be evaluated.***
- ***FDA believes an n=5 is a reasonable starting point for validation of pooling for a high-sensitivity test in populations with a positivity rate of approximately 5% to 6%. In populations with lower prevalence, larger sample pools may be feasible. In populations with higher prevalence, smaller sample pools may be needed. FDA recommends that developers begin by validating their tests for pooling using an n=5. Tests validated and authorized for n=5 can then be used with any n≤5 depending on testing needs and taking into consideration local prevalence. In cases where a developer wants to validate an n>5, or is considering alternate pooling schemes, FDA recommends that developers reach out to FDA at or submit a pre-EUA to discuss their approach and validation plan.***
- ***The table below presents calculated n-sample pool sizes with the maximal efficiency (a maximum increase in the number of tested patients because of n-sample pooling strategy) for different positivity rates P. This n with maximal efficiency (n~maxefficiency~) should be a starting pool size for validation of pooling with positivity rate P. If the accuracy of the test with regard to missed positive patients because of n~maxefficiency~ samples pooling is not acceptable, n < n~maxefficiency~ should be considered and accuracy of pooling with this n should be evaluated.***
| P, percent of positive subjects in the tested population | n~maxefficiency~ (n corresponding to the maximal efficiency) | Efficiency of n-sample pooling (a maximum increase in the number of tested patients when Dorfman n-pooling strategy used) |
| --- | --- | --- |
| 1% | 11 | 5.11 |
| 2% | 8 | 3.65 |
| 3% | 6 | 3.00 |
| 4% | 6 | 2.60 |
| 5% | 5 | 2.35 |
| 6% | 5 | 2.15 |
| 7% | 4 | 1.99 |
| 8% | 4 | 1.87 |
| 9% | 4 | 1.77 |
| 10% | 4 | 1.68 |
| 11% | 4 | 1.61 |
| 12% | 4 | 1.54 |
| 13% | 3 | 1.48 |
| 14% | 3 | 1.43 |
| 15% | 3 | 1.39 |
| 16% | 3 | 1.35 |
| 17% | 3 | 1.31 |
| 18% | 3 | 1.28 |
| 19% | 3 | 1.25 |
| 20% | 3 | 1.22 |
| 21% | 3 | 1.19 |
| 22% | 3 | 1.16 |
| 23% | 3 | 1.14 |
| 24% | 3 | 1.12 |
| 25% | 3 | 1.10 |
||
***Because a single positive sample in a pool requires individual retesting of each sample in the pool, the efficiency of any pooling strategy depends on the positivity rate. The efficiency (F) of n-sample pooling for positivity rate (P) can be calculated with the following formula F=1/(1+1/n-(1-P)^n^). The efficiency (F) indicates how many more patients can be tested with n-sample pools compared to individual testing. For example, a 3-sample pooling strategy increases the number of tested patients by 1.48 times for positivity rate P of 13% (F=1.48) and by 1.22 times for positivity rate P of 20% (F=1.22). At F=1.48, 1,000 tests can cover testing of 1,480 patients. Likewise, at F=1.22, 1,000 tests can cover testing of 1,220 patients.***
- ***A test validated for a specific n-sample pooling strategy is also considered to be validated for any number of pooled samples below n. For example, a test validated for a 5-sample pooling strategy can be performed for any n≤5.***
- ***Different specimen types should not be pooled together.***
- ***FDA recommends that your instructions for use specify a sample volume great enough to allow for individual and pooled testing so that, during clinical use, any samples in a positive pool can be re-tested without the need for a second sample collection.***
- ***Due to the reduction in analytical sensitivity, a pooling strategy should include risk mitigations such as additional language in the report noting that pooling was used during testing.***
***Validation:***
- ***Test developers should characterize the reduction in assay analytical sensitivity (i.e., shift in Ct value for RT-PCR assays) with respect to the number (n) of samples to be pooled to ensure the selected n-sample pooling strategy will maintain appropriate sensitivity. This maximum number of samples acceptable to pool should be determined and validated using the recommendations below for each specimen type you intend to pool.***
- ***We strongly recommend that you develop and validate a system for deconvoluting pooled test data which is intended to accurately identify individual patient samples composing each pooled sample. If you plan to use a software solution intended to deconvolute pooled SARS-CoV-2 diagnostic test data then we recommend providing validation data establishing that the software can achieve its intended use. For example, we recommend providing evidence that the software has been validated to ensure that:***
- ***The inputs and outputs of the software are appropriate for the intended use of the assay;***
- ***All expected inputs produce the expected outputs for all functions critical for system operation; and***
- ***The system will be provided to the customer free of defects or defects will be known and mitigated.***
**A) Sample pooling: adding a pooling strategy to a previously authorized (EUA) test**
***When requesting to add an n-sample pooling strategy to the authorized uses and the authorized Instructions for Use for your own previously authorized assay, you should submit an EUA amendment request with the appropriate validation data as described below. To add a pooling strategy to a previously authorized test, you generally do not need to establish performance with a separate comparator assay.***
***You should conduct a clinical study with at least 20 individual positive samples, comparing the performance of the EUA-authorized assay when testing single specimens according to the authorized Instructions for Use to the performance of the assay when testing n-sample pools. We strongly encourage you to work with your customers to gather existing data (e.g., 100 Ct values from individually tested positive patient samples) and evaluate the percentage of samples with Ct values close to your assay LoD (i.e., weak positives). A theoretical Ct shift of Log~2~(n) can be estimated for most RT-PCR tests (e.g., for n=5, a Ct shift of 2.3 would be expected). Therefore, if a large percentage of positive patient samples are close to your assay LoD, you may want to consider a smaller n, which will reduce the observed Ct shift and maintain higher sensitivity.***
***Please consider the following when designing your clinical validation study with 20 individually tested positive samples:***
- ***If archived individual samples are available and have enough volume for testing with n-sample pools, we recommend that you use at least 20 archived positive samples. If these samples are not available with sufficient volume, we recommend that you enroll enough patients to collect at least 20 positive samples and an appropriate number of individual negative samples from the intended use population. For example, for a 5-sample pooling strategy, a total of 80 unique comparator method negative samples are recommended in order to make up 20 5-sample pools with the 20 positive samples (20 positives + 4x20 negatives). Additionally, 100 comparator method negative samples are recommended to make up 20 5-sample negative pools (5x20 negatives) as described below. If there is sufficient volume, the same negative patient samples can be used to create positive and negative pooled samples.***
- ***We recommend that at least 25% of the validation samples be within 2-3 Ct of the cut off, and no more than within 2-4 Ct.***
- ***Samples should be collected according to the instructions for use, keeping in mind that additional sample volume will be needed to test using an n-sample pooling strategy (n-sample pooling will need 1+1/n times the volume needed for individual testing).***
- ***All samples should be individually tested by your assay, either previously for archived specimens or prospectively, and have recorded Ct values if using an RT-PCR test.***
- ***To characterize the performance of your assay when testing pooled samples, those samples with positive results when tested individually should each be pooled with n-1 (e.g., where n=5, n-1=4) randomly selected negative samples. The resulting 20 pools, each consisting of 1 positive sample and n-1 negative samples, should be tested by your assay.***
- ***To confirm that negative samples remain negative in n-sample pools, we recommend testing 20 pools each consisting of n (e.g., n=5) negative samples. If there is sufficient volume, the same negative patient samples can be used to create positive and negative pooled samples.***
***Analysis of data***
- ***You should report estimates of positive and negative percent agreement comparing the performance of your test for pooled samples to the expected result. With regard to positive percent agreement (PPA), using a study design with 20 positives, you should calculate the percent of pools (1 positive and n-1 negative) with positive results. It is anticipated that all samples that were identified individually as positive by your test should still be positive when tested in pools with n-1 negative samples (PPA=100%); lower levels of PPA in the range of 85-90% may be acceptable depending on pooling efficiency and other factors. The n that allows a test to meet 85% or higher PPA should be validated for each test.***
- ***Additionally, for RT-PCR tests, you should provide an analysis of Ct values for each target detected by your test. We recommend presenting the Ct values for the n-sample pools on the Y-axis and Ct values for the individually tested samples on the X-axis. The clinical validation study should demonstrate that individual positive samples with viral loads close to the assay’s LoD (i.e., weak positives) are accurately detected by your test in a pool with (n-1) negative samples.***
- ***We recommend that you provide an appropriate type of regression analysis with slope and intercept along with 95% confidence interval. Using regression analysis, we recommend that you evaluate the shift in Ct values for the positive patient samples diluted with negative patient samples.***
**B) Sample pooling: new test (not previously authorized)**
***When requesting to include an n-sample pooling strategy for a new test, you should submit an EUA request with the appropriate validation data for individual testing in your proposed intended use population and for pooled testing, as described below. This should involve using a high-sensitivity comparator assay to characterize performance of your candidate test.***
***You should conduct a clinical study with at least 30 individual positive samples, as identified by the comparator assay, comparing the performance of the candidate assay both when testing single specimens and when testing n-sample pools to the performance of the comparator assay.***
***Please consider the following when designing your clinical validation study:***
- ***The number of enrolled patient specimens should be sufficient to ensure at least 30 comparator method positive samples and an appropriate number of comparator method negative samples are collected from the intended use population. The number of comparator method negative samples depends on the pooling strategy. For instance, for a 5-sample pooling strategy, a total of 120 unique comparator method negative samples are recommended in order to make up 30 5-sample pools with the 30 positive samples (30 positives + 4x30 negatives). Additionally, 150 comparator method negative samples should make up 30 5-sample negative pools (5x30 negatives) as described below. If there is sufficient volume, the same negative patient samples can be used to create positive and negative pooled samples.***
- ***Samples for comparator method testing should be healthcare provider collected NP swabs. If an NP swab cannot be collected, a nasal swab can be used however both anterior nares should be sampled with the same swab. Sampling for the candidate test and comparator method should occur within a short timeframe, such as during the same visit, to avoid biological variability in viral load.***
- ***If available, FDA recommends selecting a comparator assay that has established high sensitivity with an internationally recognized standard or the FDA SARS-CoV-2 Reference Panel. Please contact to discuss options to establish sensitivity.***
- ***Samples for the candidate test should be collected according to the instructions for use. Depending on the sample volume required for your test, a single specimen collected from each study participant may be sufficient for individual and pooled sample testing.***
- ***In general, we recommend that you collect samples at a minimum of three geographically diverse sites, especially if you are planning to use the same data to support a subsequent De novo/510k submission. If this is not possible, FDA recommends samples collected at one or two sites in the context of an EUA.***
- ***It may be possible to use archived positive samples that were collected from the intended use population. We recommend you contact FDA to discuss such an approach prior to initiating your study. If archived samples are available, we recommend that at least 25% of the validation samples should be within 2-3 Ct of the cut off, and no more than within 2-4 Ct.***
- ***All samples should be individually tested by the comparator assay and individually tested by the candidate assay to characterize the performance of your assay when testing individual samples.***
- ***To characterize the performance of your assay when testing n-sample pools, those samples with positive results by the comparator method should each be pooled with n-1 (e.g., where n=5, n-1=4) randomly selected comparator method negative samples. The resulting 30 pools, each consisting of 1 comparator method positive sample and n-1 comparator method negative samples, should be tested by your candidate assay.***
- ***To confirm that samples with comparator method negative results remain negative in n-sample pools, we recommend testing 30 pools each consisting of n (e.g., n=5) comparator method negative samples.***
***Analysis of data***
- ***You should report estimates of positive and negative percent agreement comparing individual results from your test and the comparator test, as well as performance of pooled samples to the expected results (i.e., a pool which includes a comparator method positive sample is expected to remain positive when pooled). With regard to positive percent agreement (PPA), using a study design with 30 positives, you should calculate the percent of pools (1 positive and n-1 negative) with positive results. It is anticipated that all samples that were identified individually as positive should still be positive when tested in pools with n-1 negative samples (PPA=100%); lower levels of PPA in the range of 85-90% may be acceptable depending on pooling efficiency and other factors. The n that allows a test to meet 85% or higher PPA should be validated for each test.***
- ***Additionally, for RT-PCR tests, you should provide an analysis of Ct values of each target detected by your test. We recommend presenting the Ct values for the n-sample pools on the Y-axis and Ct values for the individually tested samples on the X-axis. The clinical validation study should demonstrate that individual positive samples with viral load close to the assay’s LoD (i.e., weak positives) are accurately detected by your test in a pool with (n-1) negative samples.***
- ***We recommend that you provide an appropriate type of regression analysis with slope and intercept along with 95% confidence interval. Using regression analysis, we recommend that you evaluate the shift in Ct values for the positive patient samples diluted with negative patient samples.***
**C) Example of validation and data presentation.**
The information below is included as an example of how data can be presented to FDA in a pre-EUA or EUA request. It is for illustrative purposes only and is not reflective of data from any specific test nor the only way to present such information. This example is based on a 5-sample pooling strategy using an extraction method requiring a 500 uL sample.
1. ***Used the candidate assay to individually test 500 uL aliquots of 30 comparator positive samples and 150 comparator negative samples.***
***Example of table for presenting calculation of PPA and NPA of the candidate test results for samples tested individually vs the comparator test results:***
| ***Samples Tested Individually*** | ***Comparator Method Result*** | |
|------------------------|------------------------|------------------------|
| ***Candidate Test Result*** | ***Positive*** | ***Negative*** |
| ***Positive*** | | |
| ***Negative*** | | |
||
1. ***Created expected positive 5-sample pools by combining 100 uL of one (1) individual positive patient sample with 100 uL aliquots from each of four (4) unique comparator method negative patient samples. This was done for all positive patient samples thereby creating 30 5-sample pools (i.e., a total of 30 positives combined with a total of 120 negatives).***
2. ***Created expected negative 5-sample pools by combining 100 uL of five (5) individual negative patient samples using a total of 150 unique negative samples. When there was sufficient volume, the same negative patient samples were used to create positive and negative pooled samples.***
3. ***Tested all 5-sample pools by following the instructions for use of the candidate test. All previous results were unknown to the user (i.e., an individual other than the user performing the testing prepared the samples such that testing was performed “blinded”).***
4. ***Calculated the percent agreement of the pooled samples with respect to the expected results (i.e., if a positive patient sample was included in the 5-sample pools, the expected result was positive).***
***Example of table for presenting calculation of PPA and NPA of the candidate test results for samples tested in 5-sample pools vs expected results (where expected results are based on the individual testing):***
| ***Samples Tested in 5-sample pool*** | ***Expected Result*** | |
|------------------------|------------------------|------------------------|
| ***Pooled Test Result*** | ***Positive*** | ***Negative*** |
| ***Positive*** | | |
| ***Negative*** | | |
||
1. ***If the candidate assay is an RT-PCR test and cycle threshold values (Ct value) are available, we recommend that you provide a data plot (example below) of the positive sample Ct values of an individual tested positive (i.e., the Ct value of the individual positive sample used to create the positive pooled sample) and the positive pooled sample. We recommend that you include a diagonal line with a slope of 1 and a y-intercept of 0. We recommend that you provide an appropriate type of regression analysis with slope and intercept along with 95% confidence interval. Using the regression analysis, we recommend that you evaluate the shift in Ct values for the positive patient samples diluted with negative patient samples.***
_Scatter plot example showing individual positive sample Ct values (x-axis) vs. pooled positive sample Ct values (y-axis) with a diagonal reference line (slope=1, y-intercept=0) and regression analysis._
1. ***Agreement should also be presented in a stratified manner so that performance over the range of Ct values can be evaluated. For example, if the cut-off for the candidate test is Ct = 40 then the following table should be provided:***
| Samples Tested in a 5-sample Pool | Expected Result Individual Samples with 37 < Ct < 40 | |
| --- | --- | --- |
| Pooled Test Result | Positive | Negative |
| Positive | | |
| Negative | | |
| | Expected Result Individual Samples with 34 < Ct < 37 | |
| Positive | | |
| Negative | | |
| | Expected Result Individual Samples with Ct < 34 | |
| Positive | | |
| Negative | | |
| | Expected Result All Individual Samples | |
| Positive | | |
| Negative | | |
||
#### e.2) Swab Pooling
***Swab pooling is an approach which conserves transport media and has the potential to maintain sensitivity of the test; however, deconvolving which swab was positive cannot be done without collecting another specimen. This approach also results in a high concentration of swab specimen in transport media, therefore inhibition may be observed. The effects of inhibition due to high concentrations of swab specimens (e.g., mucin) and high concentrations of virus when there are multiple positive swabs in the swab pool should be investigated. We recommend performing swab pooling validation using the two studies described below using the highest number of swabs that is both desired and deemed feasible. If the data does not meet the acceptance criteria noted below we recommend evaluating a lower number of swabs until the recommended acceptance criteria are met. Laboratories can proceed testing with any number of pooled swabs up to the highest number of pooled swabs that was successfully validated.***
***In your instructions for use, you should provide a detailed procedure describing a method to combine swabs into a single volume of transport media. The procedure should include recommendations to maximize the amount of specimen resuspended into the transport media from the swab and help ensure that the user performs sample and swab handling in a manner consistent with current infection control procedures, which should also reduce the chance of carryover between sample pools.***
***The maximum number of swabs that can be pooled for maximum efficiency can be calculated the same way as the maximum number of samples as discussed above for Dorfman pooling.***
***To establish performance of your test with swab pooling, FDA recommends conducting a clinical validation study in the intended use population that includes testing each sample individually and using your proposed pooling strategy. Examples of clinical validation studies for adding pooling to a previously authorized (EUA) tests or to include pooling in an EUA request for a new test are included in the sample/media pooling section above. These studies can be adjusted to validate a swab pooling strategy.***
***For n-swab pooling strategies, the two studies below should also be conducted:***
1. ***We recommend establishing performance related to test interference from multiple swab specimens in a single volume of transport media. N-swab samples containing the maximum number of swabs you intend to validate in the minimum volume of transport media you intend to validate should be tested with an analyte concentration of 2-3X LoD. The swabs should contain clinical matrix negative for SARS-CoV-2. The acceptable range of transport media volume should be noted in your instructions for use and interference performance should be validated by testing in the minimum recommended volume. We recommend testing replicates of three n-swab pooling samples at the same analyte concentration both with and without clinical matrix. Each n-swab pooling sample should contain maximum number of swabs you recommend pooling in your instructions for use.***
***For example, if you recommend pooling three swabs (n = 3) then we recommend acquiring a total of nine confirmed negative swabs from individual subjects and adding three unique swabs to three unique tubes of transport media thereby making three n-swab pooling samples. Each n-swab pooling sample should be spiked with either positive patient sample (in transport media), live virus, or inactivated virus at a concentration of 2-3X the LoD of your assay. We recommend testing a total of at least 20 replicates which can be composed of equal numbers of aliquots taken from each n-swab pooling sample (i.e., 7 replicates from each sample in this example). Ideally, negative n- swab sample matrix should be tested prior to spiking to ensure that the matrix is negative. Acceptance criteria should be at least 95% agreement with the expected results and an invalid rate of < 5%. We recommend providing the Ct value line data (if applicable) for analysis.***
1. ***We recommend evaluating the effect of high viral concentrations on assay performance. It appears that patients with SARS-CoV-2 infection can exhibit unusually high viral loads. This, combined with the possibility of pooling multiple positive swabs into a single volume of transport media, could result in unexpectedly high viral titer in the pooled sample. We recommend evaluating existing data on viral loads in infected subjects and, in combination with your existing LoD data, propose a maximum expected viral titer per swab. Using this number, estimate the expected viral titer in transport media with at least three positive swabs. For instance, if you expect a maximum of 100,000X LoD per swab we recommend spiking a single negative n-swab sample with 300,000X LoD target analyte and testing with 10 replicates. It is anticipated that all replicates are either positive or have an invalid rate of ≤5%.***
#### Studies to Support Point of Care Indication
***If your device is intended for near patient or Point of Care (POC) testing, please provide data to demonstrate that non-laboratory personnel can perform the test accurately in the intended use environment*** ***(i.e. a non-laboratorian healthcare provider accuracy study).*** ***Please also provide data to demonstrate the robustness of your device for near patient testing (e.g., as applicable, studies to demonstrate the impact of adding different volumes of sample, different volumes of reagents, incorrect order of sample or reagent application, etc.). For assays intended for use with a test system that was previously CLIA waived by the FDA, testing is generally only needed to establish the performance of the SARS-CoV-2 assay chemistry. In general, additional test data is not needed to demonstrate that the system is simple enough for use at the point-of-care, unless there is a feature of the SARS-CoV-2 assay that would make performing the test more complicated than assays previously cleared for use on the test system.***
##### Clinical Evaluation
***The clinical study design should mimic how the test will be used in clinical practice.*** ***It is expected that a test with “POC” designation will be widely used in CLIA waived medical facilities (e.g., physician office, outpatient clinic, ER), but also in less traditional settings, such as tents, schools, etc. with health care worker oversight of testing. This clinical study design does not apply to testing sites where NO HCWs are present.***
1. ***Sites and Test Users (Operators):***
***You should select one or two non-laboratory sites in the United States (U.S.) to assure that the operators are representative of operators in the U.S., e.g., doctor’s office, ER, outpatient clinic, drive-through testing facility, or another area in a medical facility outside the central laboratory where samples are collected and tested in real time. This would allow evaluation of the sample collection and handling, including addition into the sample port/well of the test, both of which may be significant sources of error. Four to six operators, representing healthcare professionals, but who are not laboratory trained (e.g., nurses, nursing assistants and doctors) should participate in the study. Testing should be performed using only Quick Reference Instructions (QRI); supplemental materials, such as a video or an app that can be easily accessed by the user, are encouraged but should not be used during the study (mimicking worst case scenario).***
1. ***Comparator Method:***
***All patients tested during the clinical study with the POC device should also be tested by an FDA authorized SARS-CoV-2 molecular assay. The comparator method selected should be one of the more sensitive EUAs on the FDA website (supported by peer reviewed literature, comparative studies testing the FDA reference material, etc.) that uses a chemical lysis step followed by solid phase extraction of nucleic acid. Ideally the same comparator would be used for all samples. The comparator should be authorized for use with the specimen type and transport medium (if applicable) that is being tested. Typically, the standard of care specimen is collected first, so as not to compromise the medical care of the patient. After the standard of care specimen has been collected, swabs taken from the same area for the comparator and subject device (e.g., nasal swabs, OP swabs, etc.) should be randomized to ensure that bias is not introduced due to an unequal distribution of viral materials. Randomizing collection when two distinct anatomical sites are being assessed may not be needed (e.g., saliva compared to NP swabs).***
1. ***Clinical Samples***
***A total of 30 prospectively collected positive (confirmed by an authorized test) and 30 negative natural clinical specimens should be tested (mock clinical samples are not acceptable). Testing should be conducted for at least 2 weeks. If an insufficient number of positive results is observed after such time (<30), you may collect samples at another site to ship to the testing site or use banked specimens to supplement your positive specimens. Banked specimens should not be pre-selected based on Ct value and should be presented blinded (mixed with negatives) to the testing site. Ideally, the same comparator method should be used for banked and prospectively collected specimens.***
***A molecular POC test should demonstrate positive and negative agreement of ≥ 95%. However positive agreement of ≥ 80% may be considered with appropriate limitations added to the intended use that would mitigate the risk of false negative results.*** ***For example, negative results may be considered presumptive negative if the demonstrated PPA is lower than 95%.***
1. ***Notification of public health authorities***
***When setting up the study, you should have a clear strategy for reporting test results to the CDC and/or local public health authorities both during the study and after authorization.***
##### Post Market Clinical Study
***If prospective clinical study results are not available at the time of the test authorization, manufacturers of new POC tests should conduct a post-market prospective clinical study to collect at least 30 positive and 30 negative natural clinical specimens to demonstrate the assay performance relative to an FDA-authorized comparator method. You should propose a post-market study design in your EUA submission for FDA review and feedback. Generally, a final study design will be agreed upon before authorization and will be a condition of authorization.***
##### Performance around LoD
***You should conduct testing with samples prepared in clinical matrix with SARS-CoV-2 viral load near the LoD of your assay. The testing should be performed by inexperienced users at the clinical sites. The test samples should consist of 10 low positives (<2x LoD) and 10 negatives (matrix) per site. The blinded and randomized samples should be distributed among the operators; we recommend that each operator tests at least 3 low positive and 3 negative samples integrated into the site’s workflow with the clinical samples above.***
##### Flex Studies
***Flex studies assess the robustness of an assay performed with the device in its final design/format and should be performed in-house by staff who have been trained in the use of the test. The flex studies should evaluate the most common or likely sources of error based on the use locations and test procedure. Flex studies should be conducted by testing negative sample and a low positive (at 1.5x - 2x LoD) samples, under each condition being evaluated. In general, the flex studies should be conducted to the point of failure to determine the maximum deviation that will still generate accurate results. We recommend testing 3 replicates per condition per sample concentration. Line data for each condition evaluated should be provided. If erroneous results are observed during studies evaluating the robustness of the device, adequate mitigation(s) should be provided.***
***Each study should be performed using a pre-defined study protocol that includes the following:***
1. ***The objective of the study***
2. ***Detailed test procedure***
3. ***Materials used***
***Examples of conditions that may be evaluated as potential user errors and anticipated environmental stresses (temperature and humidity extremes) are shown below:***
- ***40°C and 95% RH (mimicking hot and humid climates) applicable to small portable devices that could be used outdoors (tents, mobile vans, etc.)***
- ***Delay in sample testing***
- ***Delay in operational steps***
- ***Delay in reading results***
- ***Sample volume variability***
- ***Buffer volume variability***
- ***Environmental stability of electronics (temperature and humidity, in combination)***
- ***Vibrations***
- ***Disturbance during analysis***
- ***Placement on non-level surface***
- ***If hand-held, positioning at 90° angle***
- ***Sensitivity to power failures (e.g., surge protection, battery power failure)***
- ***Error reporting and device failure handling instructions***
- ***Electrical interference testing (e.g., validation of system functions in the presence of potential EM interference sources including cell phones, Bluetooth, Wi-Fi radios, medical equipment expected in the intended environment, etc.)***
***Please see Appendix A for more in-depth Flex Study designs. Alternative sources of information on Flex Studies that may be applicable to your device can be found on the FDA CDRH website containing CLIA Waiver by Application Decision Summaries (https://www.fda.gov/about-fda/cdrh-transparency/clia-waiver-application-decision-summaries).***
#### Multi-analyte Respiratory Panels Under EUA:
An emergency declaration by the HHS Secretary allowing for the issuance of EUAs is typically specific for a pathogen/ disease (i.e., there is a publicly declared health emergency involving a particular etiologic agent). Therefore, for tests, the EUA pathway is generally only an option for testing patients for that single agent in a given emergency. Given the overlap in signs and symptoms between SARS-CoV-2 and other respiratory viral infections, including influenza, FDA has authorized multi-analyte respiratory panels for the qualitative detection and differentiation of nucleic acid from multiple pathogens, including the SARS-CoV-2 virus. These panels are useful to efficiently detect and differentiate between multiple pathogens that are relevant to the event/disease outbreak that is the subject of the specific emergency declaration. They may also be useful in preserving critical testing resources during the public health emergency by reducing the number of tests, and therefore supplies, needed per patient.
When determining whether to issue an EUA for a multi-analyte respiratory panel FDA takes into consideration the use of the test (multi-analyte pathogen detection as an aid in differential diagnosis), clearance/approval status of IVDs for the other panel members, whether the proposed Intended Use fits within the HHS emergency declaration and how the panel test would fit into current public health authority patient testing algorithm recommendations. If you are requesting an EUA for a multi-analyte respiratory panel, analytical and clinical evaluations for each target analyte should be provided. We recommend you contact FDA at for specific feedback on this type of EUA request.
1. ***Addition of SARS-CoV-2 to previously FDA-cleared Multi-Analyte Respiratory Panels***
***To add the SARS-CoV-2 target to respiratory panels previously cleared by the FDA where the SARS-CoV2 reagents are run in a separate well (or tube) and no modifications are required to the cleared portion of the assay, only studies for validation of the SARS-CoV-2 reagents described in this template are recommended.***
***To add the SARS-CoV-2 target to respiratory panels previously cleared by the FDA where the SARS-CoV-2 reagents are combined in the same well as the reagents for previously cleared analytes (in a multiplex reaction), the following studies should be conducted to validate the SARS-CoV-2 reagents and the modifications made to the cleared respiratory panel:***
- ***Studies described in this template to validate the SARS-CoV-2 reagents***
- ***LoD confirmation of the previously cleared analytes by conducting side by side testing of 3-5 replicates of serially diluted viruses with modified and original versions of the test to show that the LoD is unchanged due to modifications***
- ***Testing 10 retrospective positive samples for each previously cleared analyte***
- ***Competitive inhibition study with clinically relevant titers of each analyte in the panel (viruses 10^5^ PFU/mL, bacteria 10^6^ CFU/mL)***
1. ***Multi-analyte Panels not Previously Cleared by the FDA***
***To support an EUA for a multi-analyte respiratory panel that was not previously cleared by FDA, analytical and clinical evaluations for each target analyte should be provided. The following analytical studies should be conducted and data provided to the FDA for review:***
- ***Limit of Detection (Analytical Sensitivity)***
- ***Cross-Reactivity / Microbial Interference ***
- ***Inclusivity / Analytical Reactivity ***
- ***Collection Media Equivalency - each claimed additional sample collection media not used in your clinical study should be validated (if appropriate for study designs) ***
- ***Co-infection (Competitive Interference) ***
- ***Interfering Substances Study (Endogenous and Exogenous) ***
- ***Clinical Specimen Stability ***
- ***Reagent Stability testing protocol ***
- ***Carry over/Cross-Contamination (if a new instrument previously not reviewed by the FDA is used) ***
- ***Reproducibility and Repeatability (if a new instrument previously not reviewed by the FDA is used) ***
- ***Fresh vs. Frozen If you intend submit data testing archived frozen specimens in support of your EUA, please conduct an analytical study to demonstrate that preservation of samples (e.g., by freezing at ≤-70°C) does not affect the accuracy of test results compared to freshly collected samples.***
***Clinical Performance***
***To evaluate the clinical performance of your multi-analyte test, a prospective clinical study should be conducted. Considering the public health needs in the current emergency, a clinical performance study in support of the EUA application may be conducted at one site testing archived positive and negative clinical samples with known specimen types. The pre-selection of archived positive samples should represent a range of viral load or Ct values including low positive samples near the assay cut-off.***
***Since your device has not been FDA-cleared for the respiratory pathogens included in your test, and it is likely that your test would be used in patients with respiratory symptoms in lieu of an FDA-cleared respiratory panel, FDA generally intends to include a condition of authorization that you conduct a post EUA prospective clinical study. The prospective clinical study should include a minimum of three sample collection sites and three testing sites, prospectively enrolling patients with general respiratory symptoms. You may consider conducting a prospective clinical study in Southern Hemisphere countries during their typical influenza/respiratory season to increase the likelihood of obtaining a sufficient number of positive samples (e.g., for influenza at least 50 positive Flu A and 30 positive Flu B samples) in a timely fashion.***
***The FDA performance expectation for SARS-CoV-2 is that PPA and NPA should be >95% (with a lower bound of the two-sided 95% confidence interval >85%); for Flu A/B, and other respiratory viruses,*** ***PPA should be >90% (with a lower bound of the two-sided 95% confidence interval >80%), and the NPA should be >95% (with a lower bound of the two-sided 95% CI >90%) in comparison to an EUA RT-PCR test. We recommend using only a high sensitivity EUA RT-PCR assay which uses a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction).***
***We recommend that you submit a Pre-EUA with an outline of the studies that you plan to conduct to support the FDA-authorization or contact FDA at for specific feedback.***
**Claiming Multiple Instruments and/or Extraction Methods:**
***FDA recommends the following analytical and clinical validation for use of multiple instruments and/or extraction methods where the elution volumes from the extraction methods and PCR volumes on the different RT-PCR instruments are identical.***
- ***Limit of Detection (LoD): These studies should be repeated for each clinical matrix claimed in the Intended Use. Pick one RT-PCR instrument and determine the tentative LoD (using 5 replicates in 10-fold dilution) followed by the confirmatory LoD (20 replicates spiked at tentative LoD) for each extraction method on the chosen instrument. Note: If you detect 20/20 replicates in your confirmatory LOD study you should test the next lower concentration, using a 3-fold dilution, until you achieve a hit rate of <20/20.***
- ***If the different extraction methods yield the same LoD (≤3xLOD) on the RT-PCR instrument chosen for initial testing, pick one extraction method for further LoD determination on the remaining RT-PCR instruments and follow the recommendations below.***
- ***If the extraction methods do not yield the same LoD on the chosen RT-PCR instrument, please choose the extraction method with the worst LoD for further comparison of the LoD on all RT-PCR instruments.***
***For all other RT-PCR instruments you should use the following adaptive LoD study design:***
- ***Please perform a refined tentative LoD study with 5 replicates at 0.5x, 1x, and 1.5 to 2x LoD. If you detect 4/5 replicates as positive at all the tested levels, you need to include the next higher concentration (i.e., 3x LoD). If you obtain 5/5 replicates at 0.5x LoD, you need to test the next lower concentration (i.e., 0.25x LoD). You will test in this manner until you find the lowest concentration that gives you 5/5 positive results for the tested RT-PCR instrument. This concentration should be used for a confirmatory LoD study for the given RT-PCR instrument using 20 replicates.***
***Final reported LoD: Please list all RT-PCR instruments with their respective LoDs if different LoDs are obtained. LoDs are considered comparable if they are between 1-3xLoD. These studies should be repeated for each clinical matrix claimed in the Intended Use.***
- ***Interference Substances Studies (if applicable): FDA recommends evaluating interfering substances with the extraction method and RT-PCR instrument combination that has the worst overall LoD.***
- ***Inclusivity Testing: FDA recommends evaluating inclusivity with the extraction method and RT-PCR instrument combination that has the worst overall LoD.***
- ***Exclusivity Testing: FDA recommends evaluating exclusivity with any extraction/instrument combination.***
- ***Clinical study: If an LoD study confirms equivalency for all RT-PCR instruments (between 2-3xLoD), then the clinical study may be conducted with any RT-PCR instrument. If one or more RT-PCR instruments have different LoDs, we recommend conducting the clinical study with the extraction method / RT-PCR instrument combination with the worst LoD.***
***Note, if there are differences in the extraction input volume, extraction elution volume and PCR input volume (extracted nucleic acid) then the LoD should be confirmed for each.***
**K. UNMET NEED ADDRESSED BY THE PRODUCT**
**This section will be completed by FDA.**
**L. APPROVED/CLEARED ALTERNATIVE PRODUCTS**
Currently no methods for the detection of the SARS-CoV-2 have been approved/ cleared by FDA.
**M. BENEFITS AND RISKS:**
**This section will be completed by FDA.**
**N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:**
**Include proposed Fact Sheets for Patients and Healthcare Providers *- see examples for authorized EUA tests on our website and templates will be made available.***
**O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:**
**Include Instructions for Use, Box Labels, Vial Labels and any other proposed labeling.**
**P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:**
\[***Manufacturer name***\] will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report on adverse events, and this website is referenced in the Fact Sheet for Health Care providers as well as through the \[***Manufacturer name***\] Product Support website: \[***Include link to Website***\]. Each report of an adverse event will be processed according to \[***Manufacturer name******\]***’s Non-Conformance Reporting Requirements, and Medical Device Reports will be filed with the FDA as required. Through a process of inventory control, \[***Manufacturer name******\]*** will also maintain records of device usage/purchase. \[***Manufacturer name******\]*** will collect information on the performance of the test, and report to FDA any suspected occurrence of false positive or false negative results of which \[***Manufacturer name******\]*** becomes aware. \[***Manufacturer name******\]*** will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
### Appendix A: Flex Study Design Details. Perform as applicable for the device.
If incorrect results are observed under the test conditions, the sponsor should implement adequate mitigations to prevent reporting of erroneous results.
1. **Reading Time:**
**Recommend evaluating test results at reading times four times below and three times above the recommended reading time. For example, for a test where the recommended read time is 20 minutes, reading time times would be performed to evaluate at least read times of 5, 10, 15, 20, 30, and 60 minutes.**
2. **Specimen Volume:**
**Recommend evaluating test results at specimen volumes two times below and two times above the recommended specimen volume, and the maximum possible added. For example, for a test where the recommended specimen volume is 10 µL, specimen volume testing should be performed to evaluate at least specimen volumes of 5, 10, 20 µL and maximum volume. If incorrect results are observed at either 5 or 20 µL, additional testing at 7.5 and/or 15 uL may be needed. The diluent/buffer amount added should be that specified in the instructions for use.**
3. **Sample Diluent Volume:**
**Recommend evaluating test results at diluent/buffer volumes at two times below and two times above the recommended diluent/buffer volume and the maximum volume. For example, for a test where the recommended buffer/diluent volume is 2 drops, sample diluent volume testing would be performed to evaluate at least sample diluent volumes of 1, 2, 3, 4 drops and whole bottle. The sample volume added should be that specified in the instructions for use.**
4. **Sample Elution:**
**Recommend evaluating how mixing the swab in elution buffer (or other reagent) affects results. You should evaluate all extremes from not-mixing to vigorous shaking, generating bubbles as well as intermediate mixing, i.e. swirling 1 or 2 times, instead of the prescribed number from the instructions.**
5. **Temperature and Humidity:**
**Recommend evaluating test results at temperature and humidity extremes that are likely to occur in the United States. For example, 40°C and 95% RH, mimicking hot and humid climate, and 5°C and 5% RH mimicking cold and dry climates.**
6. **Light:**
**Recommend evaluating of test results in different lighting conditions that would be expected during use of the device, for visually read devices. For example, fluorescent, incandescent, and natural lighting mimicking the outside environment.**
7. **Disturbance during analysis:**
**You should evaluate the effect on expected test results of moving the device while the test is running. This could include; dropping the test while it is being run, moving the test to another surface, unplugging the test, receiving a phone call while the mobile app is running, etc.**
8. **Device Orientation:**
**Recommend evaluating unique device characteristics, as determined by a robust risk analysis. For example, if the device is intended to be run upright, evaluating test results if the device is used horizontally, or vice versa.**
[1] This template is part of the [Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised) - Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised)
[2]
[3] https://www.fda.gov/media/97321/download
# 9,546 2020-07-29_FDA Template - For Manufacturers of Molecular and Antigen Diagnostic COVID-19 Tests for Non-Laboratory Use.md
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summary_short: The FDA Template for Manufacturers of Molecular and Antigen Diagnostic COVID-19 Tests for Non-Laboratory Use outlines recommended data, validation studies, and submission structure for pre-EUA and EUA requests covering home and other non-laboratory testing settings. It emphasizes analytical performance, usability, flex studies, clinical evaluation in symptomatic and asymptomatic users, and result reporting to public health authorities. The template guides manufacturers in designing and documenting tests intended for lay users while addressing the higher risk of user error outside traditional laboratories.
CONTENT
***INTERNAL TITLE:*** Template for Manufacturers of Molecular and Antigen Diagnostic COVID-19 Tests for Non-Laboratory Use
This template (the “template”) provides FDA’s current recommendations concerning what data and information should be submitted to FDA in support of a pre-EUA/EUA submission for a molecular or antigen diagnostic test for SARS-CoV-2 for use in a non-laboratory setting. Such settings are likely to include a person’s home or certain non-traditional sites such as offices, sporting events, airports, schools etc. This template does not apply to home collection kits.
As outlined in Section V.A. and V.B. of the FDA guidance document [*Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised), [2] FDA recommends that the following validation studies be conducted for a SARS-CoV-2 molecular or antigen diagnostic assay: Limit of Detection, Clinical Evaluation, Inclusivity, Cross-reactivity, Usability and Flex Studies. This template is intended to help manufacturers provide these validation data and other information to FDA, but alternative approaches can be used. This template reflects FDA’s current thinking on the topic, and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should* means that something is suggested or recommended, but not required. For more information about EUAs in general, please see the FDA Guidance document: [*Emergency Use Authorization of Medical Products and Related Authorities*](https://www.fda.gov/media/97321/download).[3]
## GENERAL INFORMATION ABOUT THIS TEMPLATE
- Text highlighted in yellow ***\[Text\]*** should be completed by the test manufacturer (sponsor) as applicable to their specific test. Text in **bold** outlines the Food and Drug Administration’s (FDA) additional recommendations for the sponsors’ consideration when completing the suggested information in each section.
- This template is intended for testing with respiratory specimens or saliva; if you are considering non-respiratory specimens (e.g., blood, stool, etc.), please contact FDA at CDRH-EUA-Templates (CDRH-EUA-Templates@fda.hhs.gov) to discuss your validation strategy.
- This template applies to developers of molecular or antigen diagnostic tests, for use in non-laboratory settings (such as person’s home or certain non-traditional sites such as offices, sporting events, airports, schools etc.), intended to detect SARS-CoV-2 from individuals.
- A test authorized under an EUA is only authorized for emergency use while the EUA is in effect.
- This is an EUA interactive review template for Pre-EUA/EUA submissions. We plan to update the template as appropriate as we learn more about the COVID-19 disease and gain experience with the EUA process for these kinds of tests.
## EXAMPLE TEMPLATE:
### A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the ***\[test name\]*** to ***\[indicate non-laboratory testing sites\]*** for the *in vitro* qualitative detection of ***\[RNA or antigen\]*** from the SARS-CoV-2 in ***\[add all claimed specimen types, e.g., nasal swab or saliva\]***. This test is for ***\[prescription use at home and other non-laboratory sites and/or OTC use at home and other non-laboratory sites\]***. All test results will be reported to healthcare providers and relevant public health authorities in accordance with local, state, and federal requirements, using appropriate LOINC and SNOMED codes, as defined by the [Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests](https://www.cdc.gov/csels/dls/sars-cov-2-livd-codes.html) provided by CDC.
### B. MEASURAND
Specific nucleic acid sequences from the genome of the SARS-CoV-2 **\[*please specify the targeted gene(s) of the pathogen*\]**.
***OR***
Specific antigen(s) from the SARS-CoV-2 **\[*please specify the targeted antigen(s)*\]**.
### C. APPLICANT
***\[Official name, address and contact information of applicant\]***
### D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name - ***\[test name\]***
Established Name - ***\[test name\]***
### E. REGULATORY INFORMATION
***Approval/Clearance Status:***
The ***\[test name\]*** test is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
***Product Code:***
QJR-molecular diagnostic for SARS-CoV-2
**OR**
QKP-antigen diagnostic for SARS-CoV-2
### F. PROPOSED INTENDED USE
#### 1) Intended Use for Molecular Assays:
**The proposed Intended Use will be finalized based on the available information including data and recommendations from public health authorities at the time of authorization – example text is provided below for a home use qualitative molecular test that detects organism RNA in adults and children 2 years and older, but may be adapted according to the specific emergency situation addressed by the device*. ***
\[***Test name***\] is a \[***specify test technology such as, real-time RT-PCR test******, lateral flow immunoassay***\] intended to detect \[***RNA, \[protein name\] antigen***\] from the SARS-CoV-2 virus that causes COVID-19 in \[***describe all the specimen types, e.g.,* nasal swab, saliva**\] from ***\[individuals age 2 years and older\]*** or ***\[for prescription use only tests, describe the patient population requested, such as symptomatic individuals who are suspected of COVID-19 by a healthcare provider, or individuals with or without symptoms or other epidemiological reasons to suspect COVID-19 infection\]***.
Persons who test positive with the ***\[Test name\]*** should seek follow up care with their physician or healthcare provider as additional testing and public health reporting may be necessary. Positive results do not rule out bacterial infection or co-infection with other viruses. Persons who test negative and continue to experience COVID-19 like symptoms of fever, cough and/or shortness of breath may still have SARS-CoV-2 infection and should seek follow up care with their physician or healthcare provider.
All test results will be reported to healthcare providers and relevant public health authorities in accordance with local, state, and federal requirements, using appropriate LOINC and SNOMED codes, as defined by the [Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests](https://www.cdc.gov/csels/dls/sars-cov-2-livd-codes.html) provided by CDC.
The ***\[test name\]*** is intended for self-use ***\[and/or, as applicable for a lay user testing another person\]*** in a non-laboratory setting ***\[and, as applicable for healthcare provider testing of another person in laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C 263a to perform moderate or high complexity tests and as applicable, Point of Care (POC) testing at patient care settings operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation\].*** The ***\[test name\]*** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
#### 2) Special Conditions for Use Statements:
For Emergency Use Authorization (EUA) only
*\[**For prescription use only or For prescription use and over-the-counter use.**\]*
For in vitro diagnostic use only
#### 3) Special Instrument Requirements:
The ***\[test name\]*** test is to be used with the \[***list all instruments, smart phones, operating systems, camera and software requirements***\].
### G. DEVICE DESCRIPTION AND TEST PRINCIPLE
**We recommend providing a Device Description and Test Principle consistent with the recommendations in the Antigen Template for Manufacturers or Molecular Diagnostic Template for Manufacturers, as applicable. Please note that for new technologies, FDA is more likely to request additional detailed information so we can adequately assess the risks and benefits associated with the device.**
**Because of the greater potential for error in specimen collection at home, FDA recommends that the assay, which per the intended use allows specimens to be collected outside of a healthcare facility, have an internal control to indicate that adequate human sample was collected and placed into the test for analysis. If your assay does not have such a control you should address this risk using another mitigation, such as video observation of user by a trained professional or a design feature of the collection device.**
#### 1. Product Overview/Test Principle:
**Describe the technology of the test and how this technology works to identify the measurand, the instruments employed/required to perform the test from sample collection to result (include all instruments, software, mobile app, etc.), and the specimen types for which you claim to have specific performance characteristics as described below**. **If applicable, list all primer and probe sets and briefly describe what they detect. Please include the nucleic acid sequences for all primers and probes used in the test. Please indicate if the test uses biotin-Streptavidin/avidin chemistry in any of the steps for coupling reagents.**
#### 2. Description of Test Steps:
**List and describe in detail all the steps of the test sequentially from specimen collection to detection.** **Please note that FDA generally does not consider self-collection of nasopharyngeal, and oropharyngeal swabs by lay persons to be safe because such collection requires training to accurately collect the sample from the proper anatomical location. Moreover, incorrect technique can result in patient harm such as nose bleeds or esophageal spasms and choking. As such, we recommend that your test use either anterior nares (nasal) swabs, mid-turbinate swabs or saliva as sample types.**
#### 3. Control Material(s) to be Used:
This section only applies to devices intended for high-volume use in non-laboratory settings. FDA believes that having control materials available for quality control and training is important in these non-laboratory settings and does not believe such materials will be necessary when these tests are intended only for use in an individual’s home or other non-laboratory low-volume settings.
**List all control materials (provided with the test kit and/or required but not provided with the test kit) and describe what they are, how they are expected to work, where in the testing process they are used, and the frequency of use. If a control is commercially available, provide supplier’s name and catalog number or other identifier.**
**Please note that any control recommended to be used with your device (provided with the kit or not) should be validated in the context of your analytical and clinical study (i.e., you should run these controls as part of your studies). In instances where control material is not readily available through 3^rd^ party vendors (which is often the case at the beginning of an outbreak), FDA may request that you include suitable control material with your device. Please note that external control materials are considered particularly important when GMP requirements are waived and reagent stability studies are limited.**
#### 4. Quick Reference Instructions:
**You should develop a test procedure that will be easy to follow in the format of a Quick Reference Instructions (QRI). Because these tests are intended for use in non-laboratory settings and may be intended for parents to test children, we recommend you develop and test for usability and develop at least two sets of instructions: one for self-testing and one for a lay user testing another person (child and/or adult as appropriate per your IFU). User instructions should be oriented to users at no higher than a 7^th^ grade level. It is highly recommended that sponsors consider adding pictures and diagrams to facilitate performance of the test by a lay user and that the instructions be limited to 1-2 pages. Web or mobile application-based material such as videos may be particularly helpful**. **We recommend you perform Human Usability Studies on your device using the QRI before conducting your final clinical study as the final QRI should be evaluated in the clinical study. The QRI should be provided in both English and Spanish at a minimum.**
#### 5. Test Result Reporting:
All test results will be reported to healthcare providers and relevant public health authorities in accordance with local, state, and federal requirements, using appropriate LOINC and SNOMED codes, as defined by the [Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests](https://www.cdc.gov/csels/dls/sars-cov-2-livd-codes.html) provided by CDC.
**You should describe how you will ensure all users of the test can report** **all test results to public health and/or other authorities to whom reporting is required, in accordance with local, state, and federal requirements. The approach adopted should facilitate reporting by all users and be easy to use and understand. There are several options to allow for reporting of test results including, but not limited to: *automatic reporting through mobile app, instructions directing users to a website where reporting is easily facilitated, etc.* FDA is open to alternative approaches to reporting that ensure appropriate reporting.**
**You should also describe how test reporting will capture the appropriate LOINC and SNOMED codes, in addition to location data, and other patient information that may be relevant or required. **
#### 6. Mobile Applications and Software
**Any smartphone application should be simple. Error messages should be readily understandable, and troubleshooting should be included in the device instruction. The display should promote understanding of results and what patients should do next, including how to care for themselves and when to seek follow up care.**
**Please list and describe any mobile applications, software or web applications used with the test. You should include the following information:**
**Verification & Validation:**
- **To validate use of your App with a Smartphone, you should develop a set of minimum Smartphone specifications (e.g., memory, processor capability, minimum Operating System (OS) requirements, etc.). You should validate the software on models of Smartphones for each OS that meet those minimum hardware specifications.**
- **You should summarize the verification and validation performed on your software/app.**
- **Full functionality for the application should be demonstrated for the full range of platforms intended for use (e.g., if a web application, then demonstrating on popular modern browsers such as Chrome, FireFox, Microsoft Edge; if a mobile application, then demonstrating on popular modern smartphones and other mobile devices such as Android, and iOS based devices, etc.).**
- **You should address the cybersecurity of your device and any private health information that may be contained on your device or in a mobile app or web application.**
- **You should have a software update plan that covers mobile app updates, algorithm updates and web application updates that may impact the performance of the device**
- **The application should automatically report all test results when appropriate in accordance with local, state, and federal requirements.**
### H. INTERPRETATION OF RESULTS
**Results that are displayed to the user should be simple and easy to interpret (e.g., positive, negative, and invalid).**
**Please describe the testing algorithm/calculation that is used by the device to return the simple qualitative result, for example a ratio value, fluorescence reading, cycle threshold and cut-off, etc. Please also provide any text for users that will accompany test results.**
**Please clearly indicate how invalid results will be displayed to the user and how the user will resolve invalid results, e.g. if repeat testing may be required, call hotline for replacement, etc.**
**You should also describe how results will be reported in accordance with local, state, and federal requirements. Please note whether identified information will be sent to local public health authorities and/or if de-identified information will be sent to CDC. If the test produces results that will be used as part of a CDC recommended testing algorithm, please indicate what follow-up testing/process should be conducted, if applicable.**
**Additional information about negative results should also be provided that instruct the user to seek follow up care from a healthcare physician if their symptoms persist or if they are concerned about their health.**
### I. PRODUCT MANUFACTURING
#### 1. *Overview of Manufacturing and Distribution:*
The product will be manufactured at \[***manufacturer’s name and FDA registration number (if applicable)***\] by \[***manufacturer name***\] personnel consistent with practices for the production of **\[*types of devices*\]** based on \[***type of quality system\****\]**.** Material manufactured by \[***manufacturer’s name***\] may be bottled and kitted by \[***packager name***\] manufacturing facility.
The current manufacturing capabilities include the ability to manufacture approximately **\[*please insert the approximate number of units/products that can currently be manufactured per week at the manufacturing facility*\]** products per week, however in the event of a surge in demand this could be increased to **\[*please insert the approximate maximum number of units/products that could potentially be manufactured per week at the manufacturing facility if there was a surge in demand*\]** product per week within a **\[*please specify in weeks/months the expected timeframe required to increase product production if required*\]** timeframe.
The product will be distributed by **\[*please describe the distribution plan for the product and list all current distributors*\]**.
**\*Under the Emergency Use Authorization (EUA) any of the 21 CFR Part 820 Quality System Regulation (QSR) requirements can be waived for the duration of the EUA but FDA recommends that developers follow comparable practices as much as possible if such requirements are waived. Among other things, FDA may consider previous compliance history when determining whether or not to waive certain QSR requirements for a specific product. Please note adverse events, as per 21 CFR Part 803, have to be reported for authorized devices (see Section P).**
#### 2. *Components Included with the Test*
Components manufactured by \[***manufacturer’s name and FDA registration number (if applicable)***\] and supplied with the test include:
**List all components and reagents for your test, including a description of the primers and probes, volumes, concentrations, quantities, buffer components, etc.**
**If you plan to use non-traditional sources of swabs or media, please describe your qualification testing and validation procedures. Collection media and other test components that contains hazardous or irritating materials (such as guanidinium salts) should not be used for home (or other non-laboratory) testing unless the collection device has specific safety features to reduce the risk of patient exposure. FDA will conduct a safety review of all test components. **
#### 3. *Testing Capabilities*
**Briefly describe current sample throughput capacity, total time required to perform the test (from clinical specimen collection, to result), and, if applicable, number of tests that can be performed per instrument run and per day.**
#### 4. EMC (electrical and mechanical safety) Testing:
**We recommend that EMC testing be conducted on any device that uses a battery or power source. Please provide FDA with any standards that were followed for EMC testing.**
#### 5. Reagent Stability:
**Briefly describe stability test plan for reagents and include accelerated stability information, if available. Based on FDA’s experience thus far, FDA believes that reagent stability studies generally would not need to be completed at the time of EUA issuance, however, the study design generally will be agreed upon during interactive review and the stability studies started immediately following authorization, if not before. You should consider the following recommendations when designing your stability study:**
- **You could follow the current FDA recognized CLSI Standard EP25 – Evaluation of Stability of In Vitro Diagnostic Reagents; Approved Guideline when evaluating the suitability of stability study designs. If you are planning to pursue a De Novo/510(k) for your device we recommend discussing in more detail your stability design to facilitate potential use of the EUA data in your premarket submission.**
- **We recommend testing a known positive diluted patient sample at 3-5x LoD rather than positive control material to establish reagent stability. Use of DNA material is unlikely to be appropriate.**
- **If you are claiming multiple clinical specimen types in which similar LoDs are determined, you should use the most challenging clinical matrix for this study.**
- **We typically recommend your stability study design includes the evaluation of at least 5 replicates. You should also evaluate, if available, 3 different lots of reagents.**
- **You should design your study to provide data for a timeframe that is about 10% longer than the one to be claimed – for example, a claim of 18 months should be supported by stability data out to 20 months and a claim of 7 days should include stability data out to 8 days.**
- **FDA considers 15-30°C to represent room temperature conditions. Ideally you should evaluate stability at both 15°C and 30°C, however, for the purposes of the EUA evaluation 30°C is acceptable as the worse-case scenario.**
- **Shelf-Life Stability - Unopened kit:**
- **You should evaluate real-time kit stability studies with unopened kits stored at the claimed storage temperature for your test.**
- **Accelerated stability evaluations for unopened kits is acceptable for EUA submissions while the real-time studies are on-going. However, please note real-time stability data is generally needed to support regular pre-market submissions.**
- **Shipping Stability - Unopened kit: You should evaluate the anticipated handling and shipping times and temperatures expected for unopened kits.**
- **In-use/Opened Kit Stability: Depending on your device, your stability study design should also support in-use stability of the kit reagents once the kit has been opened, e.g., storage at 2-8 ^o^C for 7 days.**
- **Inverted stability (if applicable): Study should support stability for kits if stored inverted or in the wrong orientation.**
- **FDA recommendations for analysis of real time stability studies are as follows:**
- **Baseline of the study (t=0 of stability study) should not exceed a month from bottling**
- **Clear baselines should be described (e.g., a month from bottling) for each stability claim under each study**
- **Claims should be determined based on regression analysis. Any %change (%shift) from time zero (baseline) should be calculated between the target claim and the zero-time as (Ttest-Tbaseline)/ Tbaseline\*100 with 95%CI using the regression equation obtained from plotting the mean values. When formulating your acceptance criteria for evaluating the shift from baseline you should consider the reproducibility of your device. However, generally, the shift at the target claim due to storage should not exceed 10-15%. The target stability is the next to last tested point that was within +/- 10% of time zero.**
- **Acceptance criterion may be different, depending on the intended use population and the risk of false results to public health.**
### J. PERFORMANCE EVALUATION
**We recommend including the studies listed below (as applicable) in your EUA request. Please note that, particularly for new technologies, FDA may request additional studies so we can adequately assess the risks and benefits associated with the device:**
#### 1. Limit of Detection (LoD) - Analytical Sensitivity
**Please provide information consistent with the recommendations in the Antigen Template for Manufacturers or Molecular Diagnostic Template for Manufacturers.**
#### 2. Inclusivity (analytical sensitivity)
**Please provide information consistent with the recommendations in the Antigen Template for Manufacturers or Molecular Diagnostic Template for Manufacturers.**
#### 3. Cross-reactivity (Analytical Specificity)
**Please provide information consistent with the recommendations in the Antigen Template for Manufacturers or Molecular Diagnostic Template for Manufacturers. For all tests intended for use in a non-laboratory setting (e.g., a complete home test), FDA recommends wet testing of Cross-reactivity and Microbial Interference in addition to in silico analysis.**
a. Cross-reactivity (organisms tested in the absence of SARS-CoV-2)
b. Microbial Interference Studies (organisms tested in the presence of SARS-CoV-2)
c. Endogenous Interference Substances Studies (including common household items such as cleaners, lotions, soap etc.)
#### 4. High-dose Hook Effect Study for antigen tests
**Please provide information consistent with the recommendations in the Antigen Template for Manufacturers.**
#### 5. Biotin interference, if applicable
**Please provide information consistent with the recommendations in the Antigen Template for Manufacturers.**
#### 6. Flex Studies
**Flex studies assess the robustness of an assay performed with the device in its final design/format and should be performed in-house by staff who have been trained in the use of the test. The flex studies should evaluate the most common or likely sources of error based on the use locations and test procedure. Flex studies should be conducted by testing a negative sample and a low positive sample (at 1.5x - 2x LoD) for each condition being evaluated. In general, the flex studies should be conducted to the point of failure to determine the maximum deviation that will allow for generating accurate results. We recommend 3 replicates per condition per sample concentration. Data for each condition evaluated (i.e., line data) should be provided. If erroneous results are observed during studies evaluating the robustness of the device, adequate mitigation(s) should be provided. Each study should be performed using a pre-defined study protocol that includes the following:**
i. **The objective of the study**
ii. **Detailed test procedure**
iii. **Materials used**
**An example of some conditions that may be evaluated as potential user errors and anticipated environmental stresses (temperature and humidity extremes) are shown below:**
iv. **40°C and 95% RH (mimicking hot and humid climates)**
v. **Delay in sample testing**
vi. **Delay in operational steps**
vii. **Delay in reading results**
viii. **Sample volume variability (if applicable)**
ix. **Buffer volume variability (if applicable)**
x. **Mixing/swab expression variability (if applicable)**
xi. **Disturbance during analysis**
xii. **Placement on non-level surface**
xiii. **Impact of different light sources (if applicable)**
xiv. **If hand-held, positioning at 90° angle (simulating placing device in pocket or lifting to see result display screen)**
**Please see Appendix A for more in depth study designs for Flex Studies. Alternative sources of information that may be applicable to your device can be found on the FDA CDRH website containing CLIA Waiver by Application Decision Summaries (https://www.fda.gov/about-fda/cdrh-transparency/clia-waiver-application-decision-summaries).**
#### 7. Human Usability Study
- **Testing should include a minimum of 100 participants for non-prescription (OTC) tests and 30 participants for prescription only tests, and take place in an actual use environment or simulated environment. For OTC tests for use at non-laboratory sites, we recommend you split the usability study into two sections: 50 participants testing themselves and 50 participants testing another person (child or adult, depending on your intended use population). For prescription only tests for use on children, you should have 15 of the 30 usability participants be parents or legal guardians performing the test on their children.**
- **The entire workflow should be performed by each individual participant using the kit, including kit registration, sample collection, testing, and results interpretation (if possible: we recommend users see a mock result to interpret).**
- **You should collect data for your assay on any controls that are run during the test to assess sample adequacy. The data from this Usability Study should support that patients can effectively collect an adequate sample and run the assay without introducing contaminants or inhibitors.**
- **The participants should be observed (either in person or by remote visual monitoring, such as a video conference) during sample collection and all difficulties should be noted.**
- **After the entire process is completed the user should be given the questionnaire to indicate the ease of use of sample collection, test procedure and results interpretation as well as understanding the consequences if steps are not performed correctly. The participant should be able to provide comments if needed.**
- **Participants should represent varying education levels and ages. A portion of your users should be Spanish speaking, and should be provided with instructions written in Spanish. A portion of your users should collect samples from themselves, while a subset should collect samples from others, including children. Participants with prior medical or laboratory training should be excluded. Participants who have prior experience with self-collection or self-testing (including glucose testing) should also be excluded.**
- **The study should have pre-defined acceptance criteria and defined strategy to mitigate risk of errors identified in the study (e.g. modifying the instructions).**
**We encourage sponsors to submit their usability study protocols and questions for participants for FDA review prior to conducting the study. It may be possible to combine the Human Usability with the Clinical Evaluation; however, this study design does involve more risk as problems with the instructions for use could lead to a failed clinical study. FDA strongly recommends you discuss this option with FDA before design and execution.**
#### 8. Clinical Evaluation:
**FDA recommends using natural clinical specimens for the clinical evaluation. You should conduct a clinical study to evaluate your device’s performance in symptomatic and asymptomatic individuals. This study design evaluates performance in asymptomatic individuals as well as symptomatic individuals. Since there is no mechanism to limit OTC testing to symptomatic individuals, FDA recommends this study design for all developers requesting an OTC claim. This study design is also recommended for developers requesting prescription use, unless the test is intended to be limited to symptomatic individuals.**
##### 1. Testing Sites
- **The sponsor should attempt to set up a minimum of 2 testing sites to encourage diverse enrollment or recruit for an at home clinical study through the internet. Conducting the study at home will generally be acceptable, but the following issues may arise and should be considered:**
- **Comparator samples should be collected at home using an FDA authorized home collection kit and SARS-COV-2 molecular assay.**
- **Recruitment by internet, especially if using monetary incentives, can drastically bias the population who enrolls in the study. We recommend that you consult FDA before starting a recruitment involving a monetary incentive.**
- **Possible injury during sample collection (applies to mid-turbinate swabs).**
- **Observed usability study recommended prior to at home clinical study to evaluate clarity and demonstrate robustness in using the instructions for use, etc.**
- **Testing sites should be set up such that when a user is performing the test, they are unable to see/hear other patients performing the test (can be in separate rooms or areas partitioned with curtains)**
- **The following testing situations are possible, all of which should have an observer present:**
- **Parent or legal guardian collects a sample from their child (e.g., age 3-13) and parent performs the test. The age of children that are tested by their parent or legal guardian should be consistent with the device’s intended use.**
- **Older child (e.g., age 14-17) self-collects sample and child performs the test (parent or legal guardian should not be present to intervene). The age range of children that self-collect should be consistent with the device’s intended use.**
- **Adults (age 18 and older) self-collect the sample and perform the test themselves.**
- **Adult (adult 1) collects a sample from another adult (adult 2) and adult 1 performs the test.**
##### 2. Patient Enrollment
- **Study population should include individuals across all ages 2y-65+y**
- **<14 years of age (target ~20%)**
- **14-24 years of age (target ~10-15%)**
- **24-64 years of age (24-64y target ~30-35%)**
- **≥65 years of age (target ~35%)**
- **Parents or legal guardians must consent for children as required by law**
- **Enrollment population should represent different socioeconomic and educational backgrounds**
- **Study should include symptomatic and asymptomatic individuals**
- **High risk individuals should not be excluded from the study**
- **You should exclude participants who regularly use home use diagnostic tests, such as glucose meters.**
##### 3. Reference Sample/Comparator method
- **FDA recommends the comparator be either a health care provider-collected NP swab sample (collected from each patient in the study within a reasonable time frame from when the test sample was obtained/tested same visit preferred) or a home-collected nasal or mid-turbinate swab. If you will conduct the study remotely, in a way where patients do not have in person visits with health care professionals, the comparator should be an FDA authorized home collected nasal or mid-turbinate swab. If you have difficulty in sourcing NP swabs, finding patients who consent to the NP swab procedure or finding clinical sites willing to collect NP swabs, please contact FDA about potential alternative swab types, such as mid-turbinate, oropharyngeal and nasal and the additional considerations for these comparator samples.**
- **All comparator samples should be tested with a comparator method. The comparator method selected should be one of the more sensitive EUAs on the FDA website (supported by peer reviewed literature, comparative studies in lab, etc.) that uses both a chemical lysis step and solid phase extraction method. Ideally the same comparator would be used for all samples.**
##### 4. Discrepant analysis
- **A plan for discrepant testing should be developed and should be implemented if a large number of discordant results are obtained in the clinical study.**
- **Like with the original comparator method, discordant samples should be tested with a second EUA from FDA’s website that has also demonstrated high sensitivity, and which uses both a chemical lysis step and solid phase extraction method.**
- **Discrepant analysis should not be used to alter the performance data but may be added to the performance table as a footnote.**
- **If necessary, to help with discrepant resolution, positive samples can also be serially diluted and tested in parallel with the test device and a comparator method to demonstrate reduced or improved analytical sensitivity.**
##### 5. Study Size
**All Comers Testing**
- **Patients should be enrolled in an “all comers” style, including both symptomatic and asymptomatic patients. Study testing should be continued until 30 positives are obtained. The overall study size should not be less than 150 individuals.**
- **You should aim to have at least 10 positives from asymptomatic individuals.**
- **If you would like to enrich your study to obtain positives more rapidly, you can enrich your population by including patients who have already tested positive by another assay. Please contact FDA for feedback on potential alternatives for enriching prospective positive patients in a clinical study.**
##### 6. Performance
- For non-prescription (OTC) tests intended for use in non-laboratory settings, FDA recommends that tests have a PPA and NPA as follows: **Positive Percent Agreement (PPA) ≥90% for asymptomatic and symptomatic**
- **Negative Percent Agreement (NPA) ≥99% (LB >95%)**
#### 9. Additional Studies
**FDA Reference Material Testing**
- **All assays for use in non-laboratory settings should demonstrate high analytical sensitivity as determined by testing with the FDA SARS-CoV-2 Reference Panel or a recognized International Standard. If you do not have access to either the FDA SARS-CoV-2 Reference Panel or a recognized international standard then please contact to discuss options.**
#### 10. Alternative Clinical Study Approaches:
#### A) Adding Asymptomatic Testing Post-Authorization
**If your assay is already authorized for non-laboratory use without an asymptomatic claim, you may request the addition of asymptomatic testing through a post-authorization study. For a post-authorization study we generally recommend testing a minimum of 20 consecutively collected asymptomatic positive specimens and at least 100 consecutively collected negative specimens based on the results of the candidate test. All specimens should then be tested with another EUA authorized molecular assay. Using estimates of the predictive values and the percentage of positive results, this study can be used to establish the sensitivity (PPA) and specificity (NPA) of your test in an asymptomatic population, as this is an important performance metric for tests intended for asymptomatic screening of large populations. The FDA generally expects that PPA should be >95% and NPA should be ≥98% (with a lower bound of the two-sided 95% confidence interval >95%). **
#### B) Symptomatic Patient Testing (prescription use only)
**If you wish to limit your assay to symptomatic individuals you may do this by offering your test by prescription only. Since there is no mechanism to limit OTC testing to symptomatic individuals, FDA recommends developers requesting an OTC claim consider the clinical study and performance recommendations for asymptomatic testing, as described above.**
**For a Prescription Non-Laboratory Test for symptomatic patients, you should follow the study design above with the recommended changes to Study Size and Performance below.**
**Study Size For Prescription Non-Laboratory Use Only**
- Testing in symptomatic individuals should be continued until 30 positives and 30 negatives are obtained. (a population size of 150, in a prospective study, would be expected to yield 30 positive results if prevalence is 20%).
**Lower PPA and NPA may be acceptable for prescription non-laboratory use assays for symptomatic patients because the inclusion of symptoms as a requirement for testing increases the pre-test probability of a positive result (higher prevalence) and therefore increases the Positive Predictive Value of the test. FDA believes that a Positive Predictive Value of a test with below 90% PPA would be insufficient without this mitigation (confirming symptoms).**
**Performance For Symptomatic Use Only**
**For symptomatic use only tests, FDA recommends that the test have a PPA and NPA as follows:**
- Positive Percent Agreement (PPA) ≥80% for symptomatic
- Negative Percent Agreement (NPA) ≥99% (LB >95%)
### K. UNMET NEED ADDRESSED BY THE PRODUCT
**This section will be completed by FDA.**
### L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the detection of the SARS-CoV-2 have been approved/cleared by FDA.
### M. BENEFITS AND RISKS:
**This section will be completed by FDA.**
### N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
**Include proposed Fact Sheets for Patients and Healthcare Providers *- see examples from authorized EUA tests on our website. Templates will be made available at sponsor’s request.***
### O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
**Include Instructions for Use, Box Labels, Vial Labels and any other proposed labeling.**
### P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
**As allowed by Section 564(e) of the FD&C Act, FDA may require certain conditions as part of an emergency use authorization. FDA will generally include the following record keeping and reporting information requirements in the EUA which FDA believes are necessary to protect the public health.**
\[***Manufacturer name***\] will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report on adverse events, and this website is referenced in the Fact Sheet for Health Care providers as well as through the \[***Manufacturer name***\] Product Support website: \[***Include link to Website***\]. Each report of an adverse event will be processed according to \[***Manufacturer name******\]***’s Non-Conformance Reporting Requirements, and Medical Device Reports will be filed with the FDA as required. Through a process of inventory control, \[***Manufacturer name******\]*** will also maintain records of device usage/purchase. \[***Manufacturer name******\]*** will collect information on the performance of the test, and report to FDA any suspected occurrence of false positive or false negative results of which \[***Manufacturer name******\]*** becomes aware. \[***Manufacturer name******\]*** will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
### Appendix A: Recommended Flex Study Design Details, as appropriate for the device:
1. **Reading Time:**
**You should evaluate test results at reading times four times below and three times above the recommended reading time. For example, for a test where the recommended read time is 20 minutes, reading time times would be performed to evaluate at least read times of 5, 10, 15, 20, 30, and 60 minutes. If incorrect results are observed, the sponsor should propose adequate mitigations for how the incorrect timing can be addressed.**
2. **Specimen Volume:**
**You should evaluate test results at specimen volumes two times below and two times above the recommended specimen volume, and the maximum possible added. For example, for a test where the recommended specimen volume is 10 μL, specimen volume testing would be performed to evaluate at least specimen volumes of 5, 10, 20 μL and 100uL (whole volume). If incorrect results are observed at either 5 or 20 uL, additional testing at 7.5 and/or 15 uL may be needed. The diluent/buffer amount added should be that specified in the instructions for use**
3. **Sample Diluent Volume:**
**You should evaluate test results at diluent/buffer volumes at two times below and two times above the recommended diluent/buffer volume and the maximum volume. For example, for a test where the recommended buffer/diluent volume is 2 drops, sample diluent volume testing would be performed to evaluate at least sample diluent volumes of 1, 2, 3, 4 drops and whole bottle. The sample volume added should be that specified in the instructions for use.**
4. **Sample Elution:**
**You should evaluate how mixing the swab in elution buffer (or other reagent) affects results. You should evaluate all extremes from not-mixing to vigorous shaking, generating bubbles as well as intermediate mixing, i.e. Swirling 1 or 2 times, instead of the prescribed number from the instructions.**
5. **Temperature and Humidity:**
**You should evaluate test results at temperature and humidity extremes that are likely to occur in the United States. For example, 40°C and 95% RH, mimicking hot and humid climate, and 5°C and 5% RH mimicking cold and dry climates.**
6. **Light:**
**You should evaluate test results in different lighting conditions that would be expected during use of the device, for visually read devices. For example, fluorescent, Incandescent, and natural lighting mimicking the outside environment.**
7. **Disturbance during analysis:**
**You should evaluate the effect of moving the device while the test is running on expected test results. This could include; dropping the test while it is run, moving the test to another surface, unplugging the test, receiving a phone call while the mobile app is running, etc.**
8. **Device Orientation:**
**You should evaluate unique device characteristics, as determined by a robust risk analysis. For example, if the device is intended to be run upright, evaluating test results if the device is used horizontally, or vice versa.**
[1] This template is part of the [Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised) - Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised)
[2]
[3] https://www.fda.gov/media/97321/download
# 2,787 2020-08-04_FDA Policy IVD - Sensitivity and Specificity Study Outline ABBREVIATED STUDY.md
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last updated: 2026-03-04 by BA
file_name: 2020-08-04_FDA Policy IVD - Sensitivity and Specificity Study Outline ABBREVIATED STUDY.md
file_date: 2020-08-04
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summary_short: The FDA Sensitivity and Specificity Study Outline (Abbreviated/Minimum Requirement) specifies a standardized protocol for evaluating SARS-CoV-2 diagnostic device performance using the FDA SARS-CoV-2 Reference Panel, including matrix suitability checks, LoD range-finding and confirmation (up to 20 replicates), and Ct-based reporting. It guides manufacturers on preparing dilution series, running blinded controls (T2–T5), and summarizing results (including a mean Ct vs log10 concentration plot) so FDA can compare new devices against previously authorized tests.
CONTENT
***INTERNAL TITLE:*** FDA Sensitivity and Specificity Study Outline – ABBREVIATED STUDY/ MINIMUM REQUIREMENT
## Purpose:
To provide the procedure to be used to evaluate **COVID-19** device sensitivity and specificity. Besides establishing an LoD for the device using the **COVID-19** strain supplied for this study, the study will enable FDA to compare sensitivity and specificity of new and previously authorized devices.
## Materials Provided:
- FDA Verification Panel (FDA SARS-CoV-2 Reference Panel)– contains one heat-inactivated **COVID-19** strain and one heat-inactivated **MERS-CoV** in cell culture media obtained through collaboration with Center for Biologics Evaluation and Research (CBER). Panel contents:
- T1 – concentrated stock 1 (USA-WA1/2020: NR-52281, concentration ~**1.8x10^8^** RNA NAAT detectable units/ mL)
- T2 – control 1 (blinded testing)
- T3 – control 2 (blinded testing)
- T4 – control 3 (blinded testing)
- T5– control 4 (blinded testing)
*Note*: The controls in the validation panel were prepared to generate specific RNA NAAT detectable units/mL. These units may not be equivalent to units provided in copies/mL.
*Note 2*: Please store the stock at -80°C until use. Prior to use, please thaw the stock at room temperature, prepare dilutions, and test the samples the same day.
*Note 3*: Both vials of T1 are Sars-CoV-2. One vial of T1 is provided for the LoD determination study and another one for the LoD corroboration study. MERS-CoV is part of the unknowns.
**Do not store diluted reference material over-night, or freeze-thaw the stock since it will produce a decrease in performance due to degradation.**
## Materials Not Provided:
- Negative matrix of choice
*Note*: If several specimen types are claimed, please choose NP clinical matrix. If NP is not a specimen type claimed by your device, please contact the FDA.
*Note 2*: For devices authorized for use with dry swab specimens only, please adjust the protocol for your assay as follows:
-dilution series could be done using NP swabs collected from individuals negative for COVID-19 diluted in saline or other diluent appropriate for analytical testing for your particular device
-prepare each dilution so there is sufficient volume to perform replicates as per FDA’s protocol below
-test each dilution following the number of replicates requested by the FDA’s protocol below
For devices authorized for use with dry swab specimens only, prepare mock swabs by pipetting 50 μL of each diluted virus stock onto a swab, let the swab dry for a minimum of 20 minutes, and test the swab following the Instructions for Use for the device.
Please provide a detail description of the workflow of your dry swab assay (including input volumes at each step).
- Device to be evaluated may contain the following:
- Real-time RT-PCR Primer and Probe Set
- Real-time RT-PCR Control Set
- Mastermix
- Extraction method authorized (or to be authorized) with the new device
- Instrument(s) to be authorized with the device
*Note*: If you determine that one or more instrument(s) has/have a different LoD please select the extraction/ instrument combination with the worst LoD (anything that is within 1 to 2x of the established LoD in a side-by-side comparison is considered comparable).
## Study Outline for Negatives:
To ensure that your matrix of choice will not interfere with the results produced by the reference material, you should first demonstrate that unspiked matrices generate valid *negative results* for all virus-specific primer and probe (i.e., are positive for your internal control and negative for SARS-CoV-2 targets). To this end, unspiked clinical matrix should be extracted 10-20 times. Each extracted nucleic acid matrix should be tested once by your assay before using the matrix for spiking as explained below.
## Study Outline for Sensitivity using T1:
### 1. Preparation of spiked NP samples for extraction:
- To start, please prepare a 1:10 dilution of the provided material T1.
For example:
- Pipette 0.9 mL of NP matrix (swab eluted in VTM) into 1 vial labeled T1.1.
- From the FDA Verification Panel stored at -80°C, remove T1 and thaw it at room temperature (RT), vortex and briefly centrifuge.
- Transfer 0.1 mL of T1 to one of the vials -labeled T1.1- containing the 0.9 mL of clinical matrix. Total volume should now be 1 mL and the concentration in the order of ~1.8x10^7^ RNA NAAT detectable units/ mL.
- Place lid on vial and vortex to mix.
- Centrifuge briefly to prevent aerosol upon opening the tube.
### 2. Range-finding:
- **For the NP clinical matrix** spiked with T1 as described in 1:
- Prepare a 10-fold dilution series in matrix – 7 dilutions total for each (1.8x10^6^ down to 1.8x10^0^) in addition to T1.1 prepared in step 1. Change tips between dilutions.
We suggest pipetting 4.5 mL of normal matrix into 7 additional vials labeled T1.2-T1.8. Transfer 0.5 mL of the T1.1 to the T1.2 vial, place lid on vial and vortex to mix. Centrifuge briefly to prevent aerosol upon opening the tube.
Proceed with 1:10 dilutions until T1.8 is generated.
- Extract T1.2-T1.8 three times each by the method authorized (or to be authorized) with the new device.
- Test each of the extracted T1.2-T1.8 replicates with your assay.
### 3. Sensitivity Confirmation: All the LoD corroboration study should BE COMPLETED ON A SINGLE DAY. Storage of diluted material is not recommended as degradation of material may occur.
- For each dilution series of virus T1 in clinical matrix, identify the lowest concentration for which all three replicates generate positive results. This is the target dilution for confirmation for each virus.
- The initial dilution window to be further tested includes the target dilution(s) identified in the previous step.
- Using the same extraction method used in the range finding study that has been authorized (or to be authorized) with the device:
- For the targeted dilution for confirmation, if the confirmation is performed the same day of the range finding, 17 additional replicates should be tested from extraction to amplification/detection. Please add any triplicates from the range finding to the 17 replicates of the confirmatory study as applicable. If confirmation is performed on a following day, 20 replicates should be tested from extraction to amplification/detection for the targeted dilution to limit variability in Ct values.
- Test each individually extracted nucleic acid sample once by your assay.
A. If you obtained 19/20 or 20/20 positive results, this dilution will be considered your LoD.
B. If you obtained 20/20 positive results, you may choose to further define the LoD of your assay by testing one 3-fold dilution below the identified target(s). Dilutions should continue further down until at least 1of the 20 samples generate one negative result.
C. If you obtained less than 19/20 positive results, you must still define the LoD of your assay by testing one 3-fold dilution above the identified target(s). Dilutions should continue further up until only 1of the 20 samples generate a negative result.
For both B and C:
- Using the extraction method authorized (or to be authorized) with the device (also used in range-finding):
- For any of the two dilutions bracketing the targeted level for confirmation, 20 replicates should be tested from extraction to amplification/detection.
- Test each individually extracted nucleic acid sample once by your assay.
### 4. Graphical Summary:
- Please provide a plot of Mean Ct (with error bars) versus log~10~ (RNA NAAT detectable units/ mL).
## Study Outline for Blinded Controls using T2-T5:
- Prepare a 1:10 dilution and a 1:100 dilution of provided material T2 to T5 in NP matrix as shown in Figure 1 and test the dilutions in red.
Figure 1. Panel Dilution Scheme
_Diagram showing the panel dilution scheme: serial dilution of SARS-CoV-2 reference material into multiple tubes at decreasing concentrations for limit of detection determination and confirmation._
For a 10 mL final volume:
- Pipette 9 mL of normal human matrix into eight vials; designate two vials for each blinded control T2 (T2 and T2.1), T3 (T3 and T3.1), T4 (T4 and T4.1), and T5 (T5 and T5.1).
- From the FDA Verification Panels stored at -80°C, remove T2-T5 and thaw them at RT, vortex and briefly centrifuge.
- Transfer 1 mL of each of T2-T5 to its designated vial containing clinical matrix. Total volume should now be 10 mL in each vial.
- Place lid on vial and vortex to mix.
- Centrifuge briefly to prevent aerosol upon opening the tube.
- Use these final T3 and T4 (all 1:10 dilutions) dilution for testing.
- For T2, T3, T4 and T5 (all 1:10 dilutions), transfer 1 mL of T2 into the vial labeled T2.1., 1 mL of T3 into the vial labeled T3.1,1 mL of T4 into the vial labeled T4.1, and 1 mL of T5 into the vial labeled T5.1 to generate the 1:100 dilution. Use these final T2.1, T3.1, T4.1 and T5.1 (all 1:100) dilutions for testing.
- Place lid on vial and vortex to mix.
- Centrifuge briefly this vial to prevent aerosol upon opening the tube.
- For each spiked matrix with T2.1 (1:100), T3 (1:10), T3.1(1:100), T4 (1:10), T4.1 (1:100) and T5.1 (1:100):
- Extract each control five times using the extraction method authorized (or to be authorized) with the new device. You will have half of the preparation unused in this case,
- Test the diluted specimens with your assay.
- For each Ct value obtained for the blinded controls (30 values in total), please provide an estimated value of RNA NAT detectable units/ mL by comparing the Ct values of the controls to the corresponding 10-fold dilution with known concentrations in units/ mL used to construct the graph above.
*Note*: Please do not include the dilution factor in your estimation; provide the NAAT detectable units as measured in the sample tested.
*Note 2*: Please run all the unknowns on the same day.
*Note 3:* Please provide individual Ct values, average Ct values, error of the mean Ct values, and number of positive hits over total replicates in each step of the study.
*Summary of the vials provided:*
| Tube # | Volume (mL) | Number of tubes | Dilution to be tested |
| --- | --- | --- | --- |
| 1 | 0.6 | 2 | Serial dilution: one vial is for LoD determination and another one for LoD confirmation |
| 2 | 1.5 | 1 | 1:100 |
| 3 | 1.5 | 1 | 1:10 and 1:100 |
| 4 | 1.5 | 1 | 1:10 and 1:100 |
| 5 | 1.5 | 1 | 1:100 |
||
For a more robust study, please use the protocol entitled: **FDA Sensitivity and Specificity Study Outline – FULL STUDY**, which details a more extensive LoD corroboration study and additional blinded sample testing.
*Note: The material cannot be used for other purposes than the ones specified in this protocol.*
For additional questions, please contact Mayra Garcia, Ph.D., M.B.A., at (240) 402-7213 or at
# 2,684 2020-08-04_FDA Policy IVD - Sensitivity and Specificity Study Outline FULL STUDY.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2020-08-04_FDA Policy IVD - Sensitivity and Specificity Study Outline FULL STUDY.md
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summary_short: The FDA Sensitivity and Specificity Study Outline (Full Study) is a step-by-step protocol for evaluating SARS-CoV-2 test performance using the FDA Verification Panel, including LoD determination/corroboration, dilution schemes, replicate testing, and blinded controls (T2–T5). It standardizes how developers generate and report Ct-based sensitivity/specificity results—plus a required Ct vs. log10 concentration plot—so FDA can compare new and previously authorized COVID-19 assays under consistent conditions.
CONTENT
***INTERNAL TITLE:*** FDA Sensitivity and Specificity Study Outline – FULL STUDY
## Purpose:
To provide the procedure to be used to evaluate **COVID-19** device sensitivity and specificity. Besides establishing an LoD for the device using the **COVID-19** strain supplied for this study, the study will enable FDA to compare sensitivity and specificity of new and previously authorized devices.
## Materials Provided:
- FDA Verification Panel (FDA SARS-CoV-2 Reference Panel)– contains one heat-inactivated **COVID-19** strain and one heat-inactivated **MERS-CoV** in cell culture media obtained through collaboration with Center for Biologics Evaluation and Research (CBER). Panel contents:
- T1 – concentrated stock 1 (USA-WA1/2020: NR-52281, concentration ~**1.8x10^8^** RNA NAAT detectable units/ mL)
- T2 – control 1 (blinded testing)
- T3 – control 2 (blinded testing)
- T4 – control 3 (blinded testing)
- T5– control 4 (blinded testing)
*Note*: The controls in the validation panel were prepared to generate specific RNA NAAT detectable units/mL. These units may not be equivalent to units provided in copies/mL.
*Note 2*: Please store the stock at -80°C until use. Prior to use, please thaw the stock at room temperature, prepare dilutions, and test the samples the same day.
*Note 3*: Both vials of T1 are Sars-CoV-2. One vial of T1 is provided for the LoD determination study and another one for the LoD corroboration study. MERS-CoV is part of the unknowns.
**Do not store diluted reference material over-night, or freeze-thaw the stock since it will produce a decrease in performance due to degradation.**
## Materials Not Provided:
- Negative clinical matrix of choice
*Note*: If several specimen types are claimed, please choose NP clinical matrix. If NP is not a specimen type claimed by your device, please contact the FDA.
*Note 2*: For devices authorized for use with dry swab specimens only, please adjust the protocol for your assay as follows:
-dilution series could be done using NP swabs collected from individuals negative for COVID-19 diluted in saline or other diluent appropriate for analytical testing for your particular device
-prepare each dilution so there is sufficient volume to perform replicates as per FDA’s protocol below
-test each dilution following the number of replicates requested by the FDA’s protocol below
For devices authorized for use with dry swab specimens only, prepare mock swabs by pipetting 50 μL of each diluted virus stock onto a swab, let the swab dry for a minimum of 20 minutes, and test the swab following the Instructions for Use for the device.
Please provide a detail description of the workflow of your dry swab assay (including input volumes at each step).
- Device to be evaluated may contain the following:
- Real-time RT-PCR Primer and Probe Set
- Real-time RT-PCR Control Set
- Mastermix
- Extraction method authorized (or to be authorized) with the new device
- Instrument(s) to be authorized with the device
*Note*: If you determine that one or more instrument(s) has/have a different LoD please select the extraction/ instrument combination with the worst LoD (anything that is within 1 to 2x of the established LoD in a side-by-side comparison is considered comparable).
## Study Outline for Negatives:
To ensure that your matrix of choice will not interfere with the results produced by the reference material, you should first demonstrate that unspiked matrices generate valid *negative results* for all virus-specific primer and probe (i.e., are positive for your internal control and negative for SARS-CoV-2 targets). To this end, unspiked clinical matrix should be extracted 20 times. Each extracted nucleic acid matrix should be tested once by your assay before using the matrix for spiking as explained below.
## Study Outline for Sensitivity using T1:
### 1. Preparation of spiked NP samples for extraction:
- To start, please prepare a 1:10 dilution of the provided material T1.
For example:
- Pipette 0.9 mL of NP matrix (swab eluted in VTM) into 1 vial labeled T1.1.
- From the FDA Verification Panel stored at -80°C, remove T1 and thaw it at room temperature (RT), vortex and briefly centrifuge.
- Transfer 0.1 mL of T1 to one of the vials -labeled T1.1- containing the 0.9 mL of clinical matrix. Total volume should now be 1 mL and the concentration in the order of ~1.8x10^7^ RNA NAAT detectable units/ mL.
- Place lid on vial and vortex to mix.
- Centrifuge briefly to prevent aerosol upon opening the tube.
### 2. Range-finding:
- **For the NP clinical matrix** spiked with T1 as described in 1:
- Prepare a 10-fold dilution series in matrix – 7 dilutions total for each (1.8x10^6^ down to 1.8x10^0^) in addition to T1.1 prepared in step 1. Change tips between dilutions.
We suggest pipetting 4.5 mL of normal matrix into 7 additional vials labeled T1.2-T1.8. Transfer 0.5 mL of the T1.1 to the T1.2 vial, place lid on vial and vortex to mix. Centrifuge briefly to prevent aerosol upon opening the tube. Proceed with 1:10 dilutions until T1.8 is generated.
- Extract T1.2-T1.8 three times each by the method authorized (or to be authorized) with the new device.
- Test each of the extracted T1.2-T1.8 replicates with your assay.
### 3. Sensitivity Confirmation:
- For each dilution series of virus T1 in clinical matrix, identify the lowest concentration for which all three replicates generate positive results. This is the target dilution for confirmation for each virus.
- For the next testing step (confirmatory testing) you should test the target dilution(s) identified in the previous step plus one 3-fold dilution above and below the identified target dilution. Additional dilutions need to be made as applicable until at least 1of the 20 samples generate a negative result. If in the confirmatory testing none of the levels reaches at least 95% positivity, you will need to go further up in the dilution scheme until you can show at least 95% with 20 replicates (19/20 positive results).
- Using the same extraction method used in the range finding study that has been authorized (or to be authorized) with the device:
- For the targeted dilutions for confirmation, if the confirmation is performed the same day of the range finding, 17 additional replicates should be tested from extraction to amplification/detection. Please add any triplicates from the range finding to the 17 replicates of the confirmatory study as applicable. If confirmation is performed on a following day, 20 replicates should be tested from extraction to amplification/detection for the targeted dilution to limit variability in Ct values.
- For the two dilutions bracketing the targeted level for confirmation, 20 replicates should be tested from extraction to amplification/detection.
- Test each individually extracted nucleic acid sample once by your assay.
### 4. Graphical Summary:
- Please provide a plot of Mean Ct (with error bars) versus log~10~ (RNA NAAT detectable units/ mL).
**Study Outline for Blinded Controls using T2-T5**:
- Prepare a 1:10 dilution and a 1:100 dilution of provided material T2 to T5 in NP matrix as shown in Figure 1 and test the dilutions in red.
Figure 1. Panel Dilution Scheme
_Diagram showing the panel dilution scheme: serial dilution of SARS-CoV-2 reference material into multiple tubes at decreasing concentrations for limit of detection determination and confirmation._
For 10mL final volume:
- Pipette 9 mL of normal human matrix into eight vials; designate two vials for each blinded control T2 (T2 and T2.1), T3 (T3 and T3.1), T4 (T4 and T4.1), and T5 (T5 and T5.1).
- From the FDA Verification Panels stored at -80°C, remove T2-T5 and thaw them at RT, vortex and briefly centrifuge.
- Transfer 1 mL of each of T2-T5 to its designated vial containing clinical matrix. Total volume should now be 10 mL in each vial.
- Place lid on vial and vortex to mix.
- Centrifuge briefly to prevent aerosol upon opening the tube.
- Use these final T3 and T4 (all 1:10 dilutions) dilution for testing.
- For T2, T3, T4 and T5 (all 1:10 dilutions), transfer 1 mL of T2 into the vial labeled T2.1., 1 mL of T3 into the vial labeled T3.1, 1 mL of T4 into the vial labeled T4.1, and 1 mL of T5 into the vial labeled T5.1 to generate the 1:100 dilution. Use these final T2.1, T3.1, T4.1 and T5.1 (all 1:100) dilutions for testing.
- Place lid on vial and vortex to mix.
- Centrifuge briefly this vial to prevent aerosol upon opening the tube.
- For each spiked matrix with T2.1 (1:100), T3 (1:10), T3.1(1:100), T4 (1:10), T4.1 (1:100) and T5.1 (1:100):
- Extract each control at least five times using the extraction method authorized (or to be authorized) with the new device. You will have half of the preparation unused in this case,
- Test the diluted specimens with your assay.
- For each Ct value obtained for the blinded controls (30 values in total), please provide an estimated value of RNA NAT detectable units/ mL by comparing the Ct values of the controls to the corresponding 10-fold dilution with known concentrations in units/ mL used to construct the graph above.
*Note*: Please do not include the dilution factor in your estimation; provide the NAAT detectable units as measured in the sample tested.
*Note* 2: For a more robust study, please extract and test 10 times T2.1, T3, T3.1, T4, T4.1, and T5.1. This will result in 60 blinded testing values in total. In this case, you will use all the volume prepared above.
*Note 3*: Please run all the unknowns on the same day.
*Note 4:* Please provide individual Ct values, average Ct values, error of the mean Ct values, and number of positive hits over total replicates in each step of the study.
*Summary of the vials provided:*
| Tube # | Volume (mL) | Number of tubes | Dilution to be tested |
| --- | --- | --- | --- |
| 1 | 0.6 | 2 | Serial dilution: one vial is for LoD determination and another one for LoD confirmation |
| 2 | 1.5 | 1 | 1:100 |
| 3 | 1.5 | 1 | 1:10 and 1:100 |
| 4 | 1.5 | 1 | 1:10 and 1:100 |
| 5 | 1.5 | 1 | 1:100 |
||
*Note: The material cannot be used for other purposes than the ones specified in this protocol.*
For additional questions, please contact Mayra Garcia, Ph.D., M.B.A., at (240) 402-7213 or at [Mayra.Garcia@fda.hhs.gov](mailto:Mayra.Garcia@fda.hhs.gov)
# 3,275 2020-08-24_FDA Policy IVD - Pooled Sample Testing and Screening Testing for COVID-19.md
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last updated: 2026-03-04 by BA
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summary_short: The FDA “Pooled Sample Testing and Screening Testing for COVID-19” policy summarizes federal recommendations and linked resources for validating and using SARS-CoV-2 IVDs in pooled-sample workflows and in screening of asymptomatic individuals. It defines pooled testing approaches (sample/media vs. swab pooling), highlights key validation expectations (including ≥85% PPA vs. individual testing) and reporting/CLIA considerations to mitigate dilution-driven false negatives. It also distinguishes screening from surveillance testing and provides practical guidance for providers on when highly sensitive tests, serial testing, and confirmatory testing may be appropriate.
CONTENT
[08-24 New FDA Webpage on Pooled Sample Testing and Screening Testing](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19?utm_campaign=2020-08-21%20Pooled%20Sample%20Testing%20and%20Screening%20Testing&utm_medium=email&utm_source=Eloqua)
The U.S. Food and Drug Administration (FDA) has taken steps to encourage the development of tests for screening asymptomatic individuals and for testing pooled samples. Today, the FDA posted a new webpage that provides an overview of available resources related to SARS-CoV-2 screening testing and testing using pooled samples.
***INTERNAL TITLE:*** Pooled Sample Testing and Screening Testing for COVID-19
The FDA has taken steps to encourage the development of tests for screening asymptomatic individuals and for testing pooled samples, as summarized in the June 16, 2020, FDA Statement [Facilitating Diagnostic Test Availability for Asymptomatic Testing and Sample Pooling](https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-facilitating-diagnostic-test-availability-asymptomatic-testing-and). The FDA has continued to work with developers to facilitate testing of pooled samples, including providing more detailed recommendations in the July 6, 2020, and July 28, 2020, updates to the EUA templates.
This page provides an overview of available resources related to SARS-CoV-2 screening testing and testing using pooled samples.
### On this page:
- [Overview](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19?utm_campaign=2020-08-21%20Pooled%20Sample%20Testing%20and%20Screening%20Testing&utm_medium=email&utm_source=Eloqua#overview)
- [Pooled Sample Testing](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19?utm_campaign=2020-08-21%20Pooled%20Sample%20Testing%20and%20Screening%20Testing&utm_medium=email&utm_source=Eloqua#pooled)
- [Screening of Asymptomatic Individuals](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19?utm_campaign=2020-08-21%20Pooled%20Sample%20Testing%20and%20Screening%20Testing&utm_medium=email&utm_source=Eloqua#screening)
- [Surveillance Testing](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19?utm_campaign=2020-08-21%20Pooled%20Sample%20Testing%20and%20Screening%20Testing&utm_medium=email&utm_source=Eloqua#surveillance)
- [Questions](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19?utm_campaign=2020-08-21%20Pooled%20Sample%20Testing%20and%20Screening%20Testing&utm_medium=email&utm_source=Eloqua#questions)
## Overview
The FDA encourages developers to consider validating their tests for the screening of asymptomatic individuals and for testing pooled samples.
### *Resources*
The FDA has provided these resources about testing using pooled samples and testing for asymptomatic screening:
- [Emergency Use Authorization (EUA) Templates](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas#covid19ivdTemplates): Include validation recommendations for tests, including for screening of asymptomatic individuals and pooled sample testing.
- [FAQs on Testing for SARS-CoV-2](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2): Includes Frequently Asked Questions, including about screening of asymptomatic individuals and pooled sample testing, and discusses the differences between surveillance, screening, and diagnostic testing.
## Pooled Sample Testing
The FDA is aware that there is a great interest in performing testing using pooled samples. Pooling samples involves mixing several samples together in a "batch" or pooled sample, then testing the pooled sample with a diagnostic test. This approach increases the number of individuals that can be tested using the same amount of resources. For example, four samples may be tested together, using only the resources needed for a single test. However, because samples are diluted, which could result in less viral genetic material available to detect, there is a **greater likelihood of false negative results**, particularly if not properly validated. This method of pooling samples works well when there is a low prevalence of cases, meaning more negative results are expected than positive results.
### *Validation*
The FDA believes that sample pooling can be authorized for use in certain SARS-CoV-2 tests with appropriate mitigations and validation. The FDA has provided validation recommendations for tests intended for use with pooled samples in the [EUA Templates](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas#covid19ivdTemplates).
Test developers seeking authorization for their test for use with pooled samples should validate their test for such use, considering the validation recommendations outlined in the EUA templates, and submit an EUA request to the FDA.
As discussed in the templates, there are currently two approaches to patient specimen pooling:
- Sample/media pooling: Pooling aliquots of transport media each containing a single patient sample or
- Swab pooling: Adding swabs from multiple patients into a single volume of transport media.
The templates include validation recommendations for both types of pooling approaches.
Generally, the FDA recommends validating the test with either pooling approach in a way that preserves the sensitivity of the test as much as possible. That is, it is preferable to use an approach where all specimens identified as positive when tested individually are also identified as positive when tested using the pooled testing approach. However, a decrease in performance is likely with pooling strategies, due to dilution of the primary clinical sample.
As discussed in the templates, since sample pooling will greatly increase the number of individuals that can be tested using existing resources, a small reduction in sensitivity may be acceptable depending on the pooling efficiency and other mitigations in place.
Therefore, the FDA generally recommends that, after pooling, test performance includes ≥85% percent positive agreement (PPA) when compared with the same test performed on individual samples. Additional limitations, such as considering negative results from pooled samples to be presumptive negatives, may be recommended based on the patient population included in the sponsor's clinical evaluation and the performance data submitted in the EUA request.
As discussed in the templates, a plan for ongoing monitoring of the positivity rate and of the performance of a test with a pooling strategy should be included in the test's procedures. As data become available and new approaches are identified, our recommendations in these templates may evolve.
### *Testing Considerations*
A [Clinical Laboratory Improvement Amendments](https://www.cdc.gov/clia/index.html) (CLIA) certified laboratory **using a test authorized for pooling** must follow the manufacturer's authorized Instructions for Use (IFU). Additionally, the Letter of Authorization issuing the EUA includes certain Conditions of Authorization, some of which apply to the authorized laboratories performing the test.
Generally, laboratories should report diagnostic or screening negative test results to the individuals in the pool according to the instructions for use or the EUA Summary of the FDA-authorized SARS-CoV-2 test that the laboratory used, including providing the associated Fact Sheet.
The test report given to the individuals in the pool should include any information specified in an EUA, such as indicating that the testing procedure involved specimen pooling and explaining the limitations of that type of testing.
As discussed in the CDC guidance, [Interim Guidance for Use of Pooling Procedures in SARS-CoV-2 Diagnostic, Screening, and Surveillance Testing](https://www.cdc.gov/coronavirus/2019-ncov/lab/pooling-procedures.html)
- The CLIA-certified laboratory **must also report** those diagnostic or screening negative test results to appropriate federal, state, and local public health agencies in accordance with applicable federal, state, and local laws.
- The CLIA-certified laboratory **should not report** positive or indeterminate results of a pooled test to either the individuals in the pool, or the local, state, tribal, or territory health department. All individual specimens that were in a pooled test with a positive or indeterminate result should be retested separately, and the subsequent individual diagnostic or screening results must be reported to the local, state, tribal, or territory health department as well as to the individuals tested.
## Screening of Asymptomatic Individuals
The FDA regulates screening tests as *in vitro* diagnostics (IVDs). Screening for COVID-19 systematically looks for individual infections in a group even if there is no reason to suspect those individuals are infected. Screening involves testing asymptomatic individuals who do not have known exposures with the intent of making individual decisions based on the test results. Screening tests are intended to identify infected individuals before they develop symptoms or to identify infected individuals who may not develop symptoms, so that measures can be taken to prevent further spread.
Examples of screening include testing, regardless of exposure or signs and symptoms, such as:
- An employer testing all employees returning to the workplace
- A school testing all students and faculty returning to the school.
In both examples, the intent of screening would be to use the results to determine who may return and what protective measures to take on an individual basis.
Laboratories may be interested in using pooling techniques when performing testing for screening of [asymptomatic](https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scenarios.html#:~:text=An%20asymptomatic%20case%20is%20an,to%20disease%20transmission%20include%3A) individuals, since this involves testing a large volume of patient samples. Additionally, pooling is most effective when there is a low prevalence of cases, which may be more likely in an asymptomatic population, particularly if the population is at low risk for contracting COVID-19.
### *Validation*
Screening using a highly sensitive test, especially given the asymptomatic testing population, leads to the most accurate results when rapid turnaround times are available. The FDA has provided validation recommendations designed to establish high sensitivity for tests intended for screening in the [EUA Templates](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas#covid19ivdTemplates). We encourage developers who want to offer a less sensitive test for screening to discuss validation approaches with us.
Developers seeking authorization for their test for screening asymptomatic individuals should validate their test for such use, considering the validation recommendations outlined in the EUA templates, and submit an EUA request to the FDA.
### *Testing Considerations for Providers*
Most currently authorized SARS-CoV-2 diagnostic tests are authorized for use on individuals suspected of COVID-19 by their healthcare provider. The FDA recognizes that the CDC has issued guidance related to screening—and that organizations may want to conduct screening—of asymptomatic individuals as part of a strategy to assure the safety of their employees, patients, students, and others. An asymptomatic individual may be suspected of COVID-19 by their healthcare provider for many reasons, including known exposure or working in a high-risk environment. Such use is within the authorized indications for use of tests for individuals suspected of COVID-19.
For healthcare providers who are ordering an authorized SARS-CoV-2 diagnostic test to be used off-label (outside the authorization) to screen asymptomatic individuals not suspected of having COVID-19, we recommend they consider the information below.
Although the current available literature suggests that symptomatic individuals with COVID-19 and asymptomatic individuals without known exposure may have similar levels of viral genetic material, there is limited data on the distribution of viral loads in individuals with and without symptoms across demographics, different settings, and specimen types. Therefore, when screening asymptomatic individuals, healthcare providers should consider using a highly sensitive test, especially if rapid turnaround times are available. If highly sensitive tests are not feasible, or if turnaround times are prolonged, health care providers may consider use of less sensitive point of care tests, even if they are not specifically authorized for this indication (commonly referred to as "off label"). For congregate care settings, like nursing homes or similar settings, repeated use of rapid point of care testing may be superior for overall infection control compared to less frequent, highly sensitive tests with prolonged turnaround times.
If less sensitive tests, such as some rapid point-of-care tests, are used, healthcare providers should be aware of the performance of the tests and may want to consider different testing approaches, such as serial testing.
As discussed in the [EUA Templates](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas#covid19ivdTemplates), use of tests in a general, asymptomatic screening population is generally intended to be used as part of an infection control plan, that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. "Negative" results should be considered as "presumptive negative" and healthcare providers should consider them in the context of clinical observations, patient history, and epidemiological information. Thus, if there is a significant new outbreak in a congregate care facility, or high clinical suspicion of an infection in an individual resident, a negative point of care test should be confirmed with a highly sensitive molecular test (refer to CDC guidelines). It is not necessary to perform confirmatory high sensitivity molecular tests on individuals with negative antigen test or other point-of-care test results if they are obtained during routine screening or surveillance.
## Surveillance Testing
The FDA generally does not regulate surveillance testing. Surveillance testing is primarily used to gain information about infection at a community or population level, rather than an individual level. Surveillance testing can involve testing a certain percentage of a specific population to monitor for increasing or decreasing prevalence or to determine the effect of community interventions such as social distancing.
Surveillance for SARS-CoV-2 includes ongoing systematic activities, including collection, analysis, and interpretation of health-related data that are essential to planning, implementing, and evaluating public health practice. Surveillance testing is generally used to monitor for a community- or population-level occurrence, such as an infectious disease outbreak, or to characterize the occurrence once detected, such as looking at the incidence and prevalence of the occurrence.
- *Example:* a testing plan developed by a state public health department to randomly select and sample 1 percent of all individuals in a city on a rolling basis to determine local infection rates and trends
Please refer to the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) for information on conducting surveillance testing and reporting results.
## Questions?
Contact the FDA at CDRH-EUA-Templates@fda.hhs.gov with specific proposals or questions about asymptomatic testing or pooled sample testing.
# 13,046 2020-10-26_FDA Template - Antigen Template for Test Developers.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2020-10-26_FDA Template - Antigen Template for Test Developers.md
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summary_short: The FDA “Antigen Template for Test Developers” is an interactive EUA review template that specifies the data, validation studies, and labeling information recommended for SARS-CoV-2 antigen test submissions. It details analytical, clinical, stability, manufacturing, software, and point-of-care performance expectations to support intended use claims, including screening and asymptomatic testing. It is used by test developers to structure pre-EUA/EUA submissions and align study design with FDA review expectations during the COVID-19 public health emergency.
CONTENT
***INTERNAL TITLE:*** Antigen Template for Test Developers
This template (the “template”) provides the Food and Drug Administration’s (FDA) current recommendations concerning what data and information should be submitted to FDA in support of a pre- Emergency Use Authorization (EUA)/EUA submission for a SARS-CoV-2 antigen test. As outlined in Section V.B. of the FDA guidance document: [*Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised),[2] FDA recommends that the following validation studies be conducted for a SARS-CoV-2 antigen assay: Limit of Detection/Analytical Sensitivity, Cross-reactivity/Analytical Specificity, Microbial Interference, and a Clinical Agreement Study. This template is intended to help test developers provide these validation data and other information to FDA, but alternative approaches can be used. It reflects FDA’s current thinking on the topic, and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should* mean that something is suggested or recommended, but not required. For more information about EUAs in general, please see the FDA guidance document: [*Emergency Use Authorization of Medical Products and Related Authorities*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities).[3]
## GENERAL INFORMATION ABOUT THIS TEMPLATE
- Text highlighted in yellow ***\[Text\]*** should be completed by the test developer (sponsor) as applicable to their specific test. Text in **bold** outlines the FDA’s additional recommendations for the sponsors’ consideration when completing the suggested information in each section.
- A test authorized under an EUA is only authorized for emergency use while the EUA is in effect.
- This is an EUA interactive review template for Pre-EUA/EUA submissions. We plan to update the template as appropriate as we learn more about the COVID-19 disease and gain experience with the EUA process for this test.
## EXAMPLE TEMPLATE:
### A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the ***\[test name\]*** to ***\[indicate labs, if applicable\]*** for the *in vitro* qualitative detection of antigen from the SARS-CoV-2 in ***\[add all claimed specimen types, e.g., nasopharyngeal/ oropharyngeal swabs, sputa, BAL, and serum, etc.\]*** from patients who are suspected of COVID-19 by a healthcare provider ***\[within the first \[insert number\] days of symptom onset, or for screening of individuals without symptoms or other reasons to suspect COVID-19 infection, if applicable\].*** Additional testing and confirmation procedures should be performed in consultation with public health and/or other authorities to whom reporting is required. Test results should be reported in accordance with local, state, and federal regulations.
***If you plan to request authorization to test specimens collected with a home specimen collection kit, please refer to the*** [Home Specimen Collection Molecular Diagnostic Template](https://www.fda.gov/media/138412/download)[4] ***and include any relevant information in this request.***
### B. MEASURAND
Specific antigen(s) from the SARS-CoV-2 **\[*please specify the targeted antigen(s)*\]**.
### C. APPLICANT
***\[Official name, address and contact information of applicant\]***
### D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name - ***\[test name\]***
Established Name - ***\[test name\]***
### E. REGULATORY INFORMATION
**Approval/Clearance Status:**
The ***\[test name\]*** test is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
**Product Code:** QKP
### F. PROPOSED INTENDED USE
#### 1. Intended Use:
Example text is provided below for a qualitative antigen test, but could be adapted according to the specific emergency situation addressed by the device, proposed intended use population, testing sites, or performance characteristics. Please note that if you seek authorization for testing at point of care (POC) sites or for asymptomatic screening, you should provide data from your clinical validation studies to support such use.
***\[Test name\]*** is a ***\[specify test technology, such as lateral flow immunoassay***\] intended for the qualitative detection of ***\[protein name\]*** antigen from SARS-CoV-2 in ***\[describe all the specimen types\] \[with specific brand of transport media, as applicable\]*** from individuals who are suspected of COVID-19 by their healthcare provider \[***within the first \[insert number\] days of symptom onset*** ***or for screening of individuals without symptoms or other reasons to suspect COVID-19 infection, if applicable******\]***. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, that meet the requirements to perform ***\[moderate complexity, high complexity, or waived tests. This test is authorized for use at the Point of Care (POC), i.e., in patient care settings operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation.\].***
Results are for the identification of SARS-CoV-2 ***\[protein name\]*** antigen. Antigen is generally detectable in ***\[specimen type\]*** during the acute phase of infection. Positive results indicate the presence of viral antigens, but clinical correlation with patient history and other diagnostic information is necessary to determine infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities.
Negative results should be treated as presumptive, and do not rule out SARS-CoV-2 infection and should not be used as the sole basis for treatment or patient management decisions, including infection control decisions. Negative results should be considered in the context of a patient’s recent exposures, history, and the presence of clinical signs and symptoms consistent with COVID-19, and confirmed with a molecular assay, if necessary, for patient management.
The ***\[test name\]*** is intended for use by ***\[include intended user, e.g., trained clinical laboratory personnel specifically instructed and trained in vitro diagnostic procedures\].*** The ***\[test name\]*** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
#### 2. Special Conditions for Use Statements:
For prescription use only
For in vitro diagnostic use only
For Emergency Use Authorization only
#### 3. Special Instrument Requirements:
The ***\[test name\]*** test is to be used with the ***\[list all instruments, software requirements, other applicable instrumentation, etc.\].***
### G. DEVICE DESCRIPTION AND TEST PRINCIPLE
***Example text has been added under each of the sub-headings. If a different test principle is used by the test for the detection of a specific analyte, please modify the description accordingly to capture the salient points in each of the sub-headings below. For new investigative technologies FDA may request additional detailed information so we can adequately assess the risks and benefits associated with the device.***
#### 1. Product Overview/Test Principle:
\[Describe the technology of the test and how this technology works to identify the measurand, the instruments employed/required to perform the test from sample collection to result, and the specimen types for which you claim to have specific performance characteristics, as described below. Please indicate if the test uses biotin-Streptavidin/avidin chemistry in any of the steps for coupling reagents. Please specifically state if your device is intended to be used with viral transport media and if so, provide the specific brands of transport media with which you have validated your device.\]
The ***\[test name\]*** is a ***\[description of technology (e.g., lateral flow, etc.)\]*** test. The ***\[test name\]*** is designed to detect antigen from the SARS-CoV-2 in ***\[list all the specimens\]*** from patients who are suspected of COVID-19 by their healthcare provider ***\[within the first \[number of days\] of symptom onset or for screening of individuals without symptoms or other reasons to suspect COVID-19 infection, if applicable\]***. The ***\[test name\]*** is validated for use from direct specimens testing without transport media and/or specimens with ***\[specific brand\]*** transport media.
#### 2. Description of Test Steps:
\[List and describe in detail all of the steps of the test sequentially, from specimen collection to assay report.\]
1. ***\[Step one\]***
2. ***\[Step two\]***
3. ***Etc.…\]***
#### 3. Control Material(s) to be Used with \[test name\]:
List all controls materials (provided with the test kit and/or required but not provided with the test kit) and describe what they are, how they are expected to work, where in the testing process they are used, and the frequency of use. If a control is commercially available, provide supplier’s name and catalog number or other identifier; if your device relies on external controls that are manufactured by a third party, please note that these controls should also be validated within your analytical and clinical studies, described below in Section J.
Controls that will be provided with the test kit include:
a. An external positive control is needed to ***\[describe need\]*** and is used ***\[describe use – please specify the concentration of the positive control relative to the Limit of Detection (LoD) of your test (note that ideally the positive control concentration should be such that it is close to the LoD of your test) and specify frequency of use\]***
b. An external negative control is needed to ***\[describe need\]*** and is used ***\[describe use – please specify the composition of the negative control and specify frequency of use\]***
c. A ***\[other (e.g., sample adequacy, internal, etc.)\]*** control is needed to ***\[describe need\]*** and is used ***\[describe use – please specify the composition of the control and specify frequency of use\]***
Controls that are required but not provided with the test kit include ***\[describe control – provide recommended sources of the control materials – either a separate control kit for purchase that you, the applicant, develops, or a control material that can be purchased from a third party\].*** This/these control(s) is/are needed to ***\[describe need\]*** and is/are used ***\[describe use – please also specify frequency of use\]***.
**Please note that any control recommended to be used with your device (provided with the kit or not) should be validated in the context of your analytical and clinical study (i.e., your studies should include use of these controls). In instances where control material is not readily available through 3^rd^ party vendors, FDA recommends that you include suitable control material with your device. Please note that external control materials are considered particularly important when good manufacturing practice (GMP) requirements are waived and reagent stability studies are limited.**
### H. INTERPRETATION OF RESULTS
All test controls should be examined prior to interpretation of patient results. If the controls are not valid, the patient results cannot be interpreted. ***\[If the test result involves the use of an algorithm/calculation when determining the final patient test result, please include a detailed description and any additional calibration materials that may be required.\]***
#### 1. \[Test name\] Controls – Positive, Negative, and Others:
\[Describe in detail the expected results generated, including the acceptance criteria, for all the controls described in detail in Section G above. Describe the measured values (if applicable) for valid and invalid controls and outline the recommended actions the laboratory should take in the event of an invalid control result.\]
#### 2. Examination and Interpretation of Patient Specimen Results:
\[Describe when clinical specimen test results should be assessed and outline the criteria for test validity.\]
Example text: Assessment of ***\[test name\]*** results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
***\[Clearly indicate how to interpret numeric test values (if applicable) as detected or not detected for presence of COVID-19 antigen. If applicable, indicate how to identify indeterminate/inconclusive/equivocal results. When applicable, we recommend providing a table clearly describing the possible combinations of test result values for each detected antigen, if applicable, and controls. Describe how they should be combined into a final interpretation of the result for your test. If the test produces an equivocal or indeterminate result, please indicate what follow-up testing/process should be conducted.\]***
### I. PRODUCT MANUFACTURING
The ***\[test name\]*** has been validated using only the components referenced in this submission and will not be changed without prior concurrence from the FDA.
#### 1. Overview of Manufacturing and Distribution:
The product will be manufactured at ***\[test developer’s name and FDA registration number\]*** by ***\[test developer name\]*** personnel consistent with practices for the production of ***\[types of devices\]*** based on ***\[type of quality system\].*** Material manufactured by ***\[test developer’s name\]*** may be bottled and kitted by ***\[packager name\]*** manufacturing facility.
The current manufacturing capabilities include the ability to manufacture approximately ***\[please insert the approximate number of units/products that can currently be manufactured per week at the manufacturing facility\]*** products per week, however in the event of a surge in demand this could be increased to ***\[please insert the approximate maximum number of units/products that could potentially be manufactured per week at the manufacturing facility if there was a surge in demand\]*** products per week within a ***\[please specify in weeks/months the expected timeframe to increase product production, if conditions warrant\]*** timeframe.
The product will be distributed by ***\[please describe the distribution plan for the product and list all current distributors\]**.*
#### 2. Components Included with the Test:
Components manufactured by ***\[test developer’s name and FDA registration number\]*** and supplied with the test include:
***\[List all components and reagents provided for your test, including a description of the reagents (including antibodies), volumes, concentrations, quantities, buffer components, etc.\]***
#### 3. Components Required But Not Included with the Test:
\[List all components and reagents not included with the test that must be supplied by the user to perform the test, with specific supplier names and catalog numbers or other identifiers for obtaining these components and reagents. Please include here all specific consumables that were validated for use with your device, that are not interchangeable with other products, and that are needed to guarantee device performance as established in the EUA validation studies listed in Section J below.\]
#### 4. Software Validation:
If you are introducing a system onto the market that has not been previously reviewed by FDA, we recommend providing evidence that the software has been validated to ensure that:
- **The inputs and outputs of the software are appropriate to fulfill the system and assay requirements;**
- **All expected inputs produce the expected outputs for all functions critical for system operation; and**
- **The system will be provided to the customer free of defects, or defects will be known and mitigated.**
**If this evidence is not available prior to authorization and the software and hardware have been designed and developed in a manner consistent with current GMPs (for additional information on the Quality System Regulation/Medical Device Good Manufacturing Practices, see **[5]**), additional software validation documentation may be incorporated into the conditions of authorization. If changes which impact assay performance or safety and effectiveness of the system are needed to address validation failures post-authorization, an EUA supplement may be required under the conditions of authorization.**
**If not available prior to authorization, FDA recommends the following evaluations be performed as soon as possible post-authorization and documentation kept on file and may be incorporated as a condition of authorization:**
- **Perform electromagnetic compatibility (EMC) testing to International Electrotechnical Commission (IEC) 60601-1-2 Edition 4.0:2014;**
- **Evaluate cybersecurity of your system to ensure user and patient safety in the intended use environment;**
- **Complete validation of all systems and software to ensure that all functions of the system perform as labeled. For more information on system validation please see the following FDA guidance documents and resources:**
a. **[Guidance for the Content of Premarket Submissions for Software Contained in Medical Devices](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-content-premarket-submissions-software-contained-medical-devices);**[6]
b. **[General Principles of Software Validation](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/general-principles-software-validation);**[7]
c. **[Device Software Functions Including Medical Applications](https://www.fda.gov/medical-devices/digital-health/device-software-functions-including-mobile-medical-applications);**[8]
d. **[Cybersecurity](https://www.fda.gov/medical-devices/digital-health/cybersecurity);**[9]
e. **[Off-The-Shelf Software Use in Medical Devices](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/shelf-software-use-medical-devices#:~:text=Off%2Dthe%2Dshelf%20(OTS,to%20run%20device%2Dspecific%20functions.);**[10] **and**
f. **[21 CFR 820.30](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=820.30).**
**Below are some examples of tables which could be populated with information sufficient to fulfill the three bullets above. Text in the tables is provided as an example only. In the example, the tables are completed with system-appropriate information and a thorough functional description of the system software and instrumentation needed to fulfill the intended use of the test.**
**System specifications and validation example**
| Critical specifications: Description of the specification | Evidence that the design of the system can fulfill the specification. This column should consist of system-level validation data. |
| --- | --- |
| Optical system of each instrument sent to a user has sufficient dynamic range to appropriately differentiate between positive and negative test results | |
| Software displays appropriate result during test run | |
| If reader stores test result, software accurately stores and retrieves test results | |
| System has a defined lifetime where the user can expect the system to maintain performance as stated in the label | |
| Etc… | |
||
**Hazard analysis example**
| ID | Hazard | Adverse Effect | Severity | Potential causes of hazard | Risk mitigation measure | Risk of experiencing the hazard after mitigation |
|--------|---------|----------|---------|--------------|--------------|----------|
| 1 | Invalid result | Delay in returning test result | Low | User inserts cartridge incorrectly | Labeling noting correct orientation | Low |
| 2 | False result | Wrong result returned to user | High | Incorrect alignment of test strip and optics; test strip inserted in the wrong orientation | Mechanical design of reader input slot | Moderate |
| 3 | False negative result | Wrong result returned to user | High | User reads test strip too early; incubation time not sufficient | Labeling noting correct incubation time | Moderate |
| 4 | False result | Wrong result returned to user | High | Incorrect alignment of test strip and optics; control line misinterpreted | Software interprets data from optical system identifying a valid/invalid control | Moderate |
| 5 | False result | Wrong result returned to user | High | Control reaction intensity is misinterpreted | Software interprets data from optical system identifying a valid/invalid control | Moderate |
| 6 | False result | Wrong result returned to user | High | Analyte reaction intensity is misinterpreted | Software interprets data from optical system identifying a valid/invalid control | Moderate |
||
#### 5. Testing Capabilities:
*\[Briefly describe current sample throughput capacity, total time to perform the test (from clinical specimen collection, specimen transport, to result), and number of tests that can be performed per instrument run and per day.\]*
#### 6. Reagent Stability:
*\[Briefly describe stability test plan for \[test name\] reagents and include any accelerated stability information, if available. Please note that reagent stability studies do not need to be completed at the time of EUA issuance, however the study design should be agreed upon during interactive review and the stability studies started immediately following authorization, if not before.\] *
**General recommendations for reagent stability study design:**
- For EUAs, you may follow the current FDA recognized “CLSI Standard EP25 – Evaluation of Stability of In Vitro Diagnostic Reagents; Approved Guideline” when evaluating the suitability of stability study designs. If you are planning to pursue clearance or approval for your device, we recommend discussing in more detail your stability design to facilitate potential use of the EUA data in your regular premarket submission.
- Please note that use of only the positive controls is not recommended for reagent stability evaluation because controls are usually formulated at a moderate positive level. For all the stability evaluations, in addition to your external positive and negative controls and the no-template control, you should include for the EUA evaluation at least one sample, which should be prepared by spiking negative clinical matrix at an analyte concentration of 3-5xLoD.
- If you are claiming multiple clinical specimen types in which similar LoDs are determined, you should use the most challenging clinical matrix for this study.
- Please note we typically recommend your stability study design include the evaluation of at least 5 replicates. You should also evaluate, if available, 3 different lots of reagents.
- You should design your study to provide data for a timeframe that is about 10% longer than the one to be claimed. For example; a claim of 18 months should be supported by stability data out to 20 months and a claim of 7 days should include stability data out to 8 days.
- FDA considers 15-30°C to represent room temperature conditions. Ideally, you should evaluate stability at both 15°C and 30°C; however, for the purposes of the EUA evaluation, we believe 30°C is acceptable as it represents the worse-case scenario.
- Unopened kit Shelf-Life Stability:
1. You should evaluate real-time kit stability studies with unopened kits stored at the claimed storage temperature for your test.
2. Accelerated stability evaluations for unopened kits can be included for EUA submissions while the real-time studies are on-going.
- Unopened kit Shipping Stability: Study should evaluate the anticipated handling and shipping times and temperatures expected for unopened kits.
- In-use/Opened Kit Stability: Depending on your device, your stability study design should also support in-use stability of the kit reagents once the kit has been opened, e.g., storage at 2-8°C for 7 days. This includes on board stability once reagents have been placed on the instrument (if applicable).
- Inverted stability (if applicable): Study should support inverted stability for kits.
- Freeze-thaw Stability: If you recommend aliquoting the reagents to meet the end-users needs following the initial thaw, this recommendation should be supported by a freeze-thaw stability study, including the specific number of allowed freeze-thaw cycles.
- FDA analysis recommendations for real time stability studies are as follows:
- Baseline of the study (t=0 of stability study) should not exceed a month from bottling;
- Clear baselines should be described (e.g., a month from bottling) for each stability claim under each study;
- Claims should be determined based on regression analysis. Any %change (%shift) from time zero (baseline) should be calculated between the target claim and the zero-time as (Ttest-Tbaseline)/ Tbaseline\*100 with 95% confidence interval (CI) using the regression equation obtained from plotting the mean values. When formulating your acceptance criteria for evaluating the shift from baseline, you should consider the reproducibility of your device. However, generally, the shift at the target claim due to storage cannot exceed 10-15%. The target stability is the next to last tested point that was within +/- 10% of time zero; and
- Acceptance criterion may be different, depending on the test samples analyte concentration distribution in the intended use population and the risk of false results to public health.
### J. PERFORMANCE EVALUATION
***The following validation studies should be performed during your assay development:***
1. **Limit of Detection (LoD) - Analytical Sensitivity: You should determine the LoD of the device utilizing the entire test system from sample preparation to detection. It is recommended to spike inactivated virus (e.g., irradiated virus) into real clinical matrix (e.g., nasal or nasopharyngeal (NP) swabs, bronchoalveolar lavage (BAL) fluid, sputum, etc.) for LoD determination. The use of recombinant antigen is not recommended for the LoD determination. It is recommended that test developers test a 2-3 fold dilution series of 3-5 replicates per concentration, and then confirm the final concentration with 20 replicates. FDA defines LoD as the lowest concentration at which 19 of 20 replicates are positive. If multiple matrices are intended for clinical testing, test developers should submit the results from one representative of each claimed clinical matrix to FDA. For example, if testing respiratory specimens (e.g., sputum, BAL, NP swabs, etc.), please submit results from one upper respiratory matrix and one lower respiratory matrix. The most challenging matrix of the claimed matrices should be tested. FDA considers NP swabs with and without your claimed viral transport media (VTM) to be the most challenging upper respiratory matrix and sputum to be the most challenging lower respiratory matrix, as applicable. If claiming other specimen types (saliva, blood, etc.), we recommend that you establish your LoD in each matrix, with and without transport media, as applicable. If needed, we recommend that you follow the most current version of the CLSI standard, “Evaluation of Detection Capability for Clinical Laboratory Measurement Procedures (CLSI EP17).”**
***\[Please describe your LoD study, the specific viral material used to assess the LoD (e.g., irradiated virus),*** ***and the LoD (with appropriate units) for your assay. Please provide the line data for the LoD study as part of your submission.\]***
LoD studies determine the lowest detectable concentration of SARS-CoV-2 at which approximately 95% of all (true positive) replicates test positive. The LoD was determined by limiting dilution studies using characterized ***\[please described samples used in the study, e.g. viral stocks\]***.
***\[List/describe the following in this section:***
- ***Titers and strains of the SARS-CoV-2 stocks used for the LoD study and how the organism stocks were prepared and how the titers were determined.***
- ***The dilution factor and number of serial dilutions of the characterized SARS-CoV-2 that were tested to determine the LoD.\]***
Serial dilutions of the characterized SARS-CoV-2 were then tested in ***\[number of replicates\]*** replicates. The lowest concentration at which all ***\[number of replicates\]*** replicates were positive was treated as the tentative LoD for each test. The LoD of each test was then confirmed by testing ***\[number of replicates (at least 20 recommended)\]*** with concentrations at the tentative limit of detection. The final LoD of each test was determined to be the lowest concentration resulting in positive detection of ***\[number of positive replicates (at least 19 out of 20 replicates)\]. \[Include analysis of LoD results, indicating the final LoD for each test.\]***
2. **Cross-reactivity (Analytical Specificity): Cross-reactivity studies are performed to demonstrate that the test does not react with related pathogens, high prevalence disease agents, and normal or pathogenic flora that are reasonably likely to be encountered in the clinical specimen. We recommend that the organisms in the table below are wet-tested in negative clinical matrix; please contact FDA if you are unable to obtain specific organisms to discuss potential options and labeling mitigations. If multiple matrices are claimed, the most challenging should be used for cross-reactivity testing. For wet testing, concentrations of 10^6^ CFU/ml or higher for bacteria and 10^5^ pfu/ml or higher for viruses is recommended.**
**Recommended List of Organisms for Respiratory Specimens**
| **Other high priority pathogens from the same genetic family** | **High priority organisms likely in the circulating area** |
|------------------------------------|------------------------------------|
| **Human coronavirus 229E (Wet-testing)** | **Adenovirus (e.g. C1 Ad. 71) (Wet-testing)** |
| **Human coronavirus OC43 (Wet-testing)** | **Human Metapneumovirus (hMPV) (Wet-testing)** |
| **Human coronavirus NL63 (Wet-testing)** | **Parainfluenza virus 1-4 (Wet-testing)** |
| **MERS-coronavirus (Wet-testing)** | **Influenza A & B (Wet-testing)** |
| **SARS-coronavirus (Wet-testing)** | **Enterovirus (Wet-testing)** |
| **Human coronavirus HKU1 (In-silico (protein blast))** | **Respiratory syncytial virus (Wet-testing)** |
| | **Rhinovirus (Wet-testing)** |
| | ***Haemophilus influenzae* (Wet-testing)** |
| | ***Streptococcus pneumoniae* (Wet-testing)** |
| | ***Streptococcus pyogenes* (Wet-testing)** |
| | ***Candida albicans* (Wet-testing)** |
| | **Pooled human nasal wash – *representative of normal respiratory microbial flora* (Wet-testing)** |
| | ***Bordetella pertussis* (Wet-testing)** |
| | ***Mycoplasma pneumoniae* (Wet-testing)** |
| | ***Chlamydia pneumoniae* (Wet-testing)** |
| | ***Legionella pneumophila* (Wet-testing)** |
| | ***Staphylococcus aureus* (Wet-testing)** |
| | ***Staphylococcus epidermidis* (Wet-testing)** |
| | ***Mycobacterium tuberculosis* (In-silico (protein blast))** |
| | ***Pneumocystis jirovecii* (PJP) (In-silico (protein blast))** |
||
**Recommended List of Organisms for Blood Specimens**
| **Other high priority pathogens from the same genetic family** | **High priority organisms likely in the circulating area** |
|------------------------------------|------------------------------------|
| **Human coronavirus 229E (Wet-testing)** | **Cytomegalovirus (CMV) (Wet-testing)** |
| **Human coronavirus OC43 (Wet-testing)** | **Epstein-Barr Virus (EBV) (Wet-testing)** |
| **Human coronavirus NL63 (Wet-testing)** | **Varicella Zoster Virus (VZV) (Wet-testing)** |
| **MERS-coronavirus (Wet-testing)** | **Parvovirus B19 (Wet-testing)** |
| **SARS-coronavirus (Wet-testing)** | **Human Immunodeficiency Virus – 1 (HIV-1) (Wet-testing)** |
| **Human coronavirus HKU1 (In-silico (protein blast))** | **Human Immunodeficiency Virus – 2 (HIV-2) (Wet-testing)** |
| | **Hepatitis C Virus (HCV) (Wet-testing)** |
| | **Hepatitis B Virus (HBV) (Wet-testing)** |
| | **Herpes Simplex Virus-1 (HSV-1) (Wet-testing)** |
| | **Herpes Simplex Virus-2 (HSV-2) (Wet-testing)** |
| | ***Escherichia coli* (Wet-testing)** |
| | ***Streptococcus pneumoniae* (Wet-testing)** |
| | ***Streptococcus pyogenes* (Wet-testing)** |
| | ***Staphylococcus aureus* (Wet-testing)** |
| | ***Staphylococcus epidermidis* (Wet-testing)** |
||
3. ***Microbial Interference Studies: If cross-reactivity is not observed between your assay and any of the microorganisms listed above, you should conduct a microbial interference study. A microbial interference study demonstrates that false negatives will not occur when SARS-CoV-2 is present in a specimen with other microorganisms. You should prepare contrived specimens in your most challenging claimed matrix with SARS-CoV-2 and common organisms found in that matrix. You should provide a list of common pathogens or commensal organisms for your most challenging matrix as part of your submission.***
***If applicable, microbial interference should be evaluated using samples spiked at a low (3x LoD) SARS-CoV-2 concentration and a high interferent level (preferably microorganisms), to represent the worst-case scenario, with a minimum of 3 replicates. The interferent microorganisms can be tested individually or as a pool (of 4-5); each microorganism should be tested individually if that pool shows interference. If you plan to claim both upper and lower respiratory matrices, the study should be performed in the most challenging respiratory matrix (i.e., sputum). If interference is observed at the level tested, an additional titration study should be performed to determine the highest microorganism interferent level your test can tolerate.***
4. ***Endogenous Interference Substances Studies***: ***The extent of testing for endogenous interference substances depends on the matrix that is claimed for the device, as well as on the technology of the device. For respiratory specimens, please test the following substances listed in the table below with inactivated virus at 3xLoD.***
| **Substance** | **Concentration** |
|-----------------------------------|-------------------|
| Whole Blood | 4% |
| Mucin | 0.5% |
| Chloraseptic (Menthol/Benzocaine) | 1.5 mg/mL |
| Naso GEL (NeilMed) | 5% v/v |
| CVS Nasal Drops (Phenylephrine) | 15% v/v |
| Afrin (Oxymetazoline) | 15% v/v |
| CVS Nasal Spray (Cromolyn) | 15% v/v |
| Zicam | 5% v/v |
| Homeopathic (Alkalol) | 1:10 dilution |
| Sore Throat Phenol Spray | 15% v/v |
| Tobramycin | 4 μg/mL |
| Mupirocin | 10 mg/mL |
| Fluticasone Propionate | 5% v/v |
| Tamiflu (Oseltamivir Phosphate) | 5 mg/mL |
||
5. ***High-dose Hook Effect*: *A high-dose hook effect refers to the false negative result which can be seen when very high levels of target are present in a tested sample. We recommend you conduct studies to evaluate if a hook effect occurs by testing increasing antigen concentrations and, if applicable, indicate the concentration which begins to affect assay performance.***
6. ***Specimen Stability: Testing should be conducted to demonstrate specimen stability throughout the real-world conditions in which they are collected and tested, according to your instructions for use. When the test is intended to be performed on the specimen immediately or shortly after obtaining the specimen, specimen stability testing could be relatively short (i.e., 2 hours at room temperature) and conducted with contrived specimens at 3xLoD using inactivated virus. If you intend to test retrospective clinical specimens that have been frozen, you should also conduct fresh versus frozen studies to support use of these specimens.***
7. ***Clinical Evaluation: Use of natural clinical specimens is needed for the clinical evaluation. You should not use contrived clinical specimens as FDA believes they are inadequate to support the clinical performance of a test of this type. You should confirm the performance of your assay by testing a minimum of 30 positive specimens and 30 negative specimens in a randomized blinded fashion. We recommend only using an EUA test with high sensitivity and reverse transcription polymerase chain reaction (RT-PCR), which uses a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction) as the comparator method. The comparator method should be one of the more sensitive RT-PCR assays authorized by FDA. We encourage you to review the results from the FDA SARS-CoV-2 Reference Panel available [here](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-reference-panel-comparative-data) when selecting your comparator method; we strongly recommend you contact us to discuss your choice of comparator assay.***
***Specimens may be prospectively or retrospectively collected. For prospective specimen collection, patients should be sequentially enrolled and tested blindly. Please contact us to discuss any proposed enrichment strategies. We believe it may be appropriate to use retrospective clinical specimens, but they should be randomized with negative specimens and tested blindly. Retrospective specimens should be reflective of the natural distribution of SARS-CoV-2 viral loads, and approximately 10-20% of the clinical specimens should be low positives (i.e., RT-PCR Ct counts >30), as has been observed in other sequentially enrolled clinical studies. Please note that FDA has observed erroneous results in association with clinical specimens stored in transport media. Therefore, if you validate your assay using 30 positive and 30 negative retrospective specimens in transport media, you should also present the results from at least five positive clinical specimens that are prospectively collected and processed directly without transport media. The remainder of the 30 positive clinical specimens tested directly could potentially be provided post-authorization and incorporated as a condition of authorization. When collecting specimens, the standard of care specimen should be collected first. Swabs taken from the same anatomical area for the comparator and subject device (e.g., nasal swabs, oropharyngeal (OP) swabs, etc.) should be randomized to ensure that bias is not introduced due to an unequal distribution of viral materials. When two distinct anatomical sites are being assessed, FDA does not believe it is necessary to randomize specimen collection order (e.g., saliva compared to NP swabs).***
***If you intend to seek a claim for saliva, oral fluid, blood, or other specimen types, you should test at least 30 positive specimens with paired polymerase chain reaction (PCR) results from an NP swab.***
***\[When you describe your clinical study please indicate/include:***
1. ***Clinical study protocol, including collection and testing sites, number of samples collected, and number of operators used to run your assay***
2. ***Enrollment criteria (inclusion/exclusion criteria)***
3. ***The name of the comparator assay***
4. ***How the samples were collected or sourced***
5. ***Please describe the total number of samples tested. If the study was not a prospective study, please also list the numbers of prospective, and/or retrospective tested by each category.***
6. ***The sample matrix(ces) tested***
7. ***The technique and collection device(s), including transport media, used to obtain clinical samples. All clinical specimens tested in your study should be evaluated in accordance with your proposed diagnostic algorithm, including retesting when appropriate.***
8. ***The conditions used to collect and store specimens***
***Please provide the study data in an Excel file as part of the EUA submission for each specimen. The study data should include the following:***
- ***Specimen type for the antigen test***
- ***Specimen collection date and time for the antigen test***
- ***Specimen testing date and time for the antigen test***
- ***VTM type, as applicable, for the antigen test and PCR***
- ***Antigen test result with the analyzer or reader value***
- ***Specimen type for RT-PCR***
- ***Specimen collection date and time for RT-PCR test***
- ***Specimen testing date and time for RT-PCR test***
- ***Name of RT-PCR used as the comparator***
- ***RT-PCR test results (+/-)***
- ***RT-PCR test value results (Ct values)***
- ***Number of days post-onset of patient symptoms***
- ***Patient age and gender, if available***
***For clinical specimens collected to support the EUA request, you must adhere to all applicable rules of human subject protection, including IRB approval consistent with 21 CFR part 50 and 21 CFR 56.103(a). Use of leftover de-identified samples may follow the policy outlined in the FDA Guidance on Informed Consent for In Vitro Diagnostic Device Studies Using Leftover Human Specimens that are Not Individually Identifiable ().***
**Tests should demonstrate a minimum sensitivity of ≥ 80% for all sample types submitted.**
***Strategies for serial testing with less sensitive tests, such as 70% sensitivity, could increase overall sensitivity and be considered cumulatively rather than based on one-time testing. If you are proposing serial testing as a mitigation for a less sensitive assay, you should provide supportive evidence documenting clinical performance ≥ 80% sensitivity with serial testing. You should provide detailed instructions for conducting serial testing in your package insert, including a recommended testing interval, that is supported by your clinical data. You should also discuss how you will ensure compliance with serial testing post-authorization, such as multi-test packs, software applications, or other mitigations. Additional post-authorization studies may be necessary to assess the success of your proposed mitigations.***
8. ***Studies to support a POC claim, as applicable: \[If the device is intended for near patient or POC testing, please provide data to demonstrate that non-laboratory personnel can perform the test accurately in the intended use environment (i.e. a non-laboratorian healthcare provider accuracy study). Please also provide data to demonstrate robust use of your device for POC patient testing (e.g., as applicable, studies to demonstrate the impact of adding different volumes of sample, different volumes of reagents, incorrect order of sample or reagent application, etc.).\] ***
1. ***POC Clinical Evaluation: A POC clinical evaluation should include 5-6 minimally trained operators at 1-2 non-laboratory (e.g., CLIA waived) sites in the United States. Each operator should test at least three positive and three negative specimens using only the test instructions and/or quick reference guide. As part of the EUA application, provide the detailed individual replicate result data and protocols for each of your studies, including:***
- ***The objective of the study***
- ***Detailed test procedure***
- ***Materials used***
- ***A list of samples tested***
- ***Results (presented in tabular format), including invalid results***
- ***Conclusions***
- ***Mitigation*** ***measures, if required (e.g., labeling changes, changes to test design, etc.)***
***You should also conduct testing with samples prepared with SARS-CoV-2 viral load near the LoD of your assay in clinical matrix. The testing should be conducted by minimally trained operators, and should consist of 10 low positives (<2xLoD) and 10 negative specimens per site. All contrived specimens should be blinded and randomized and each operator should test at least three low positive and three negative specimens. These specimens are intended to supplement, not replace, the clinical specimens in your study.***
***All testing should be conducted in a blinded fashion in which patients with an unknown SARS-CoV-2 status are presented to minimally trained operators. We recommend only using a high sensitivity EUA RT-PCR test that uses a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction) as the comparator method.*** ***The comparator method should be one of the more sensitive RT-PCR assays authorized by FDA. We encourage you to review the results from the FDA SARS-CoV-2 Reference Panel available [here](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-reference-panel-comparative-data) when selecting your comparator method; please contact us to discuss your choice of comparator assay. Ideally, patients should be prospectively enrolled and tested sequentially and blindly. It may be acceptable to use retrospective clinical specimens (e.g., leftover specimens in VTM), provided they are randomized with negative specimens and tested blindly. Retrospective specimens should be reflective of the natural distribution of SARS-CoV-2 viral loads, and approximately 10-20% of the clinical specimens should be low positives (i.e., RT-PCR Ct counts >30) as has been observed in other sequentially enrolled clinical studies. Please note that FDA has observed erroneous results in association with clinical specimens stored in transport media. Therefore, if you validate your assay using retrospective specimens in transport media, you should also present the results from at least five positive clinical specimens that are prospectively collected and processed directly without transport media. The remainder of the 30 positive clinical specimens tested directly can be provided post-authorization and incorporated as a condition of authorization.***
***When collecting specimens for the investigational device and the comparator method, the standard of care specimen should be collected first, so as not to compromise the medical care of the patient. After the standard of care specimen has been collected, swabs taken from the same area for the comparator and subject device (e.g., nasal swabs, OP swabs, etc.) should have their order of collection randomized to ensure that bias is not introduced due to an unequal distribution of viral materials. Randomizing order of collection when two distinct anatomical sites are being assessed may not be needed (e.g., saliva compared to NP swabs).***
***Your study data should be presented in an Excel file and include the same data elements outlined in item 7 above.***
2. ***POC Flex Studies: You should also conduct a thorough hazard analysis considering the main known sources of errors. Based upon your hazard analysis, you should conduct flex studies to evaluate the impact of errors, or out-of-specifications conditions, on the assay performance. Each sample should be prepared at 2xLoD in negative clinical matrix and should be evaluated in three replicates for each condition under evaluation. Flex studies can be conducted with trained operators at an internal testing site. Each study should be performed using a pre-defined study protocol that includes the following:***
- ***The objective of the study***
- ***Detailed test procedure***
- ***Materials used***
***Potential stress conditions include:***
- ***40°C and 95% room humidity (RH) (mimicking hot and humid climates)***
- ***Delay in sample testing or reading time***
- ***Delay and/or disturbance in operational steps***
- ***Sample volume variability***
- ***Buffer volume variability***
- ***Other, as appropriate***
***Please see Appendix A for more in-depth flex study designs. Alternative sources of information on flex studies that may be appropriate for your device can be found on the FDA CDRH website containing [CLIA Waiver by Application Decision Summaries](https://www.fda.gov/about-fda/cdrh-transparency/clia-waiver-application-decision-summaries).***[11]
9. ***Studies to support asymptomatic claim, as applicable: If you seek authorization for screening individuals without symptoms or other reasons to suspect COVID-19, FDA recommends that you conduct a clinical study in the intended population. In the clinical study, you should compare results from your assay and a comparator assay for each patient enrolled. In addition to the clinical study recommendations listed above, you should enroll at least 20 positive asymptomatic individuals to collect unique specimens. It may also be acceptable to present the results from 10 positive specimens from asymptomatic individuals to support EUA authorization, provided data from symptomatic individuals are also submitted and analysis of cycle threshold (Ct) values demonstrates reasonably similar distribution of viral loads. The remainder of the 20 positive clinical specimens collected from unique asymptomatic individuals can be provided post-authorization and incorporated as a condition of authorization. Ideally, the specimens should be sequentially collected in a blinded fashion, and therefore, the total sample size of your study will depend on the prevalence of SARS-CoV-2 in your study population. You can also consider use of an enrichment strategy, in which individuals with a known COVID-19 infection status are invited to participate in your clinical validation study. If using an enrichment strategy, you should carefully consider how you will randomize and blind operators to the participant’s infection status and minimize potential bias. As discussed previously, FDA anticipates that any data from an enriched study design will also represent the full range of viral loads, with both low and high positives specimens included in the study data. It may also be possible to use archived specimens. Please contact FDA to discuss any alternative study designs.***
10. ***Studies to support multi-analyte respiratory panels under EUA: To support an EUA for a multi-analyte respiratory panel, analytical and clinical evaluations for each target analyte should be provided. The validation needed to support an EUA may vary if the test platform was previously cleared by FDA, as noted below. The following analytical studies should be conducted, and data provided to the FDA for review:***
- ***Limit of Detection (Analytical Sensitivity)***
- ***Cross-Reactivity / Microbial Interference***
- ***Inclusivity / Analytical Reactivity, when different strains become available***
- ***Co-infection (Competitive Interference)***
- ***Interfering Substances Study (Endogenous and Exogenous)***
- ***Clinical Specimen Stability***
- ***Reagent Stability testing protocol***
- ***Carry over/Cross-Contamination\****
- ***Reproducibility and Repeatability\****
- ***Fresh vs. Frozen - If you intend to submit data collected from testing archived frozen specimens in support of your EUA, please conduct an analytical study to demonstrate that preservation of samples (e.g., by freezing at ≤-70°C) does not affect the accuracy of test results compared to freshly collected samples.***
***\* Recommended for new instruments not previously reviewed by the FDA. If the instrument was previously reviewed by FDA, please identify the submission number.***
***For multiplex devices that include Influenza A and/or Influenza B, you should establish the LoD on at least two strains of Influenza A and Influenza B. We recommend using the H12009 and H3N2 for Influenza A and the Yamagata and Victoria lineages for Influenza B.***
***Clinical Performance: To evaluate the clinical performance of your multi-analyte test, a prospective clinical study should be conducted. Considering the public health needs in the current emergency, a clinical performance study in support of the EUA submission may be conducted at one site testing positive and negative clinical samples with known specimen types. Retrospective clinical specimens can be used, however, your positive samples should include results from an EUA RT-PCR device for COVID-19, or an FDA cleared RT-PCR device in which 10-20% of the specimens are low positive samples (Ct value > 30).***
***If your device has not been previously FDA-cleared for influenza or other respiratory pathogens, FDA generally intends to include a condition of authorization that you will conduct a post EUA prospective clinical study. The prospective clinical study should include a minimum of three sample collection sites and three testing sites, prospectively enrolling patients with general respiratory symptoms. You may consider conducting a prospective clinical study in the Southern Hemisphere during their typical influenza/respiratory season to increase the likelihood of obtaining a sufficient number of positive samples (e.g., for influenza at least 50 positive Flu A and 30 positive Flu B samples) in a timely fashion.***
***If your device has been previously FDA-cleared for influenza or other respiratory pathogens, you should confirm that the LoD for the previously cleared pathogens is unchanged due to the modification by conducting side-by-side testing of 3-5 replicates of serially diluted viruses with the original and modified versions of your device. You should also test at least 10 retrospective positive clinical specimens of each previously cleared analyte. You should perform a competitive inhibition study with clinically relevant titers of each analyte in the panel (viruses 10^5^ PFU/mL, bacteria 10^6^ CFU/mL).***
***All multiplex devices that include Influenza A and B should also verify the analytical reactivity of the device against the Centers for Disease Control and Prevention (CDC) human influenza panel to ensure adequate performance against currently circulating strains of influenza. Information on how to request this panel can be found at CDC’s “[Request for CDC Influenza Virus Panel” website](https://www.cdc.gov/flu/dxfluviruspanel/index.htm).***[12]
### K. UNMET NEED ADDRESSED BY THE PRODUCT
**This section will be completed by FDA.**
### L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the detection of the SARS-CoV-2 have been approved/ cleared by FDA.
### M. BENEFITS AND RISKS:
**This section will be completed by FDA.**
### N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
***\[You should include proposed Fact Sheets for Patients and Healthcare Providers\]* S*ee examples for authorized EUA tests on our website. During review, FDA will make available Fact Sheet templates.***
### O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
***\[You should include Instructions for Use, Box Labels, Vial Labels, and any other proposed labeling.\]***
### P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
***\[Test Developer name\]*** will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report on adverse events, and this website is referenced in the Fact Sheet for Health Care providers as well as through the ***\[Test Developer name\]*** Product Support website: ***\[Include link to Test Developer’s Website\].*** Each report of an adverse event will be processed according to ***\[Test Developer name\]***’s Non-Conformance Reporting Requirements, and Medical Device Reports will be filed with the FDA as required. Through a process of inventory control, ***\[Test Developer name\]*** will also maintain records of device usage/purchase. ***\[Test Developer name\]*** will collect information on the performance of the test, and report to FDA any suspected occurrence of false positive or false negative results of which ***\[Test Developer name\]*** becomes aware. ***\[Test Developer name\]*** will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
### Appendix A: Sample Flex Study Design Details.
1. **Delay in Reading Time: We recommend evaluating test results at reading times four times below and three times above the recommended reading time. For example, for a test where the recommended read time is 20 minutes, reading time times would be performed to evaluate at least read times of 5, 10, 15, 20, 30, and 60 minutes.**
2. **Specimen Volume Variability: We recommend evaluating test results at specimen volumes two times below and two times above the recommended specimen volume, and the maximum possible added. For example, for a test where the recommended specimen volume is 10 µL, specimen volume testing should be performed to evaluate at least specimen volumes of 5, 10, 20 µL, and maximum volume. If incorrect results are observed at either 5 or 20 µL, additional testing at 7.5 and/or 15 uL may be needed. The diluent/buffer amount added should be that specified in the instructions for use.**
3. **Buffer Volume Variability: We recommend evaluating test results at diluent/buffer volumes at two times below and two times above the recommended diluent/buffer volume and the maximum volume. For example, for a test where the recommended buffer/diluent volume is 2 drops, sample diluent volume testing would be performed to evaluate at least sample diluent volumes of 1, 2, 3, 4 drops, and whole bottle. The sample volume added should be that specified in the instructions for use.**
4. **Temperature and Humidity: We recommend evaluating test results at temperature and humidity extremes that are likely to occur in the United States. For example, 40°C and 95% RH, mimicking hot and humid climates, and 5°C and 5% RH, mimicking cold and dry climates.**
5. **Disturbance during analysis: We recommend evaluating the effect on expected test results of moving the device while the test is running, such as dropping/moving the test, unplugging the test, receiving a phone call while the mobile app is running, etc.**
[1] This template is part of the “[Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised),” available at .
[2] Available at .
[3] Available at .
[4] All templates can be accessed at .
[5] Available at .
[6] Available at .
[7] Available at .
[8] Available at .
[9] Available at .
[10] Available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/shelf-software-use-medical-devices#:~:text=Off%2Dthe%2Dshelf%20(OTS,to%20run%20device%2Dspecific%20functions](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/shelf-software-use-medical-devices#:~:text=Off%2Dthe%2Dshelf%20(OTS,to%20run%20device%2Dspecific%20functions.).
[11] Available at *.*
[12] Available at *(last accessed on September 22, 20209). Note this website is not controlled by FDA.*
# 967 2021-03-13_FDA Fact Sheet - Screening for COVID-19 Deciding Which Test to Use When Establishing Testing Programs.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-03-13_FDA Fact Sheet - Screening for COVID-19 Deciding Which Test to Use When Establishing Testing Programs.md
file_date: 2021-03-13
title: FDA Fact Sheet - Screening for COVID-19 Deciding Which Test to Use When Establishing Testing Programs
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summary_short: The FDA fact sheet “Screening for COVID-19: Deciding Which Test to Use When Establishing Testing Programs” explains how screening of asymptomatic individuals differs from diagnostic testing and why tests have specific authorized use claims. It provides practical guidance for schools, workplaces, and communities on selecting tests, including considerations around sensitivity, turnaround time, pooling, serial testing, and interpreting presumptive negative results. It is useful for designing screening programs that align test performance with public health goals and mitigation strategies.
CONTENT
***INTERNAL TITLE:*** FDA FACT SHEET
## Screening for COVID-19: Deciding Which Test to Use When Establishing Testing Programs
### How is screening different from diagnostic testing?
- **Diagnostic testing:** Diagnostic testing identifies current infection at the individual level and is performed when a person has signs or symptoms of infection, or when a person is asymptomatic but has recent known or suspected exposure. Most tests the FDA has authorized are for diagnosing SARS-CoV-2 in people suspected of COVID-19 by their health care provider, whether or not they are symptomatic. Some diagnostic tests are authorized for use only in symptomatic individuals.
- **Screening testing:** Screening testing looks for individual infections in a group even if there is no reason to suspect those individuals are infected. Screening involves testing asymptomatic individuals who do not have known or suspected exposure to COVID-19 in order to make individual decisions based on the test results. The FDA has authorized some tests for screening.
### Why are there different claims for how a test is used?
Test developers decide the use they will seek to have authorized by the FDA. The FDA cannot compel developers to create tests, and the FDA does not decide the type of test, the use, or the price of tests that developers request to be authorized.
Test developers gather evidence to support their test's use and submit this evidence to the FDA. When the FDA issues an emergency use authorization (EUA) for a test, it means that the FDA reviewed scientific and clinical evidence to determine that the test may be effective when used as authorized, such as to diagnose individuals with SARS-CoV-2.
If the data provided for FDA review demonstrate that the test may be effective for testing certain individuals (e.g., individuals suspected of COVID-19) but is not effective for testing others (e.g., all individuals), the FDA generally includes an explicit limitation in the labeling regarding those other individuals. So, for tests authorized for use on a specific population (e.g., individuals suspected of COVID-19), the lack of a limitation in the labeling regarding use on other populations generally means that evidence to support a broader use (e.g., testing all individuals) was not provided to the FDA for review.
This should be considered by health care providers who choose to order authorized tests for individuals who fall outside the test authorization.
### How does one set up a screening program?
Schools, workplaces, communities, and others looking to establish testing programs to screen asymptomatic individuals without known or suspected exposure are using various options, including:
1. Using a test authorized for screening.
2. Health care providers on behalf of the program ordering an authorized diagnostic test for screening.
- When using a test that is not specifically authorized for screening, it is particularly important to understand what you know and don't know about the test's performance and combine it with other strategies, taking the following into consideration:
- Consider using a highly sensitive authorized test, especially if rapid turnaround times are available. If highly sensitive authorized tests are not feasible, or if turnaround times are prolonged, consider using a less sensitive authorized point-of-care test, such as an antigen test.
- Consider using a pooling strategy to conserve testing supplies. Several tests have been authorized for pooling.
- Consider frequent serial testing, such as the repeated use of rapid point-of-care or at-home tests for self-testing at a predetermined testing interval.
- Negative results should be considered as "presumptive negative," and health care providers should consider them in the context of clinical observations, patient history, and epidemiological information. If there is a concern that an individual with a negative antigen, other point-of-care or at-home test result may have COVID-19 (e.g., because of a new outbreak in a congregate setting), consider retesting the individual with a highly sensitive authorized molecular test.
Regardless of the test selected, it's important to monitor for updates from the FDA or the test developer for new information regarding the performance of the selected test with emerging mutations of the virus in your community. It is important to note that testing, even serial testing, is of limited value if it is not combined with appropriate mitigations for individuals who test positive (such as quarantine), good contact tracing, and effective behavioral protocols (such as mask wearing, hand washing and social distancing), even for individuals who test negative.
---
*The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation's food supply, cosmetics, dietary supplements, and products that give off electronic radiation, and for regulating tobacco products.*
# 1,998 2021-03-16_FDA Template - Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-03-16_FDA Template - Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing.md
file_date: 2021-03-16
title: FDA Template - Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing
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subcategory: fda-policy
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summary_short: The FDA “Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing” outlines recommended data and labeling elements to support EUA requests for screening claims that rely on serial testing rather than pre-authorization asymptomatic studies. It specifies expected serial testing intervals (typically twice over 2–3 days, 24–36 hours apart), clinical performance expectations (including PPA thresholds and confidence intervals for POC/at-home tests), and how these recommendations supplement the primary molecular/antigen EUA templates. It also describes likely post-authorization study conditions to establish asymptomatic performance and how results could affect continued authorization.
CONTENT
***INTERNAL TITLE:*** Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing
This template provides the Food and Drug Administration’s (FDA) current recommendations concerning what data and information should be submitted to FDA in support of a pre-Emergency Use Authorization (EUA) submission/EUA request for a molecular or antigen diagnostic test for SARS-CoV-2 used for screening with serial testing.
As outlined in Sections V.A. and V.B. of the FDA guidance document: [*Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised),[2] FDA recommends certain validation studies be conducted for a SARS-CoV-2 molecular or antigen diagnostic assay. The [EUA Templates](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas#covid19ivdTemplates)[3] are intended to help test developers provide validation data and other information to FDA, but alternative approaches can be used. Current templates for molecular and antigen diagnostic tests include recommendations that the developer provide validation data on asymptomatic individuals prior to authorization of a screening claim, including when using a serial testing approach. This template is intended to provide supplemental recommendations for developers of molecular and antigen tests seeking claims for screening with serial testing without studying asymptomatic individuals prior to authorization, including for point-of-care (POC) and at-home tests.
It reflects FDA’s current thinking on the topic, and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should* means that something is suggested or recommended, but not required. For more information about EUAs in general, please see the FDA guidance document: [*Emergency Use Authorization of Medical Products and Related Authorities*](https://www.fda.gov/media/97321/download).[4]
## GENERAL INFORMATION ABOUT THIS TEMPLATE
- Text highlighted in yellow ***\[Text\]*** should be completed by test developers (sponsor) as applicable to their specific test. Text in **bold** outlines the FDA’s additional recommendations for the sponsors’ consideration when completing the suggested information in each section.
- This template should be used by developers of molecular or antigen diagnostic tests, for use in serial testing programs as well as tests for serial at-home[5] use by individuals separate from a testing program, including to support authorization for over-the-counter use, intended to detect SARS-CoV-2 from individuals with or without symptoms or other epidemiological reasons to suspect COVID-19 infection.
- The information in this template does not reflect complete validation data or information that FDA recommends be included in a pre-EUA submission/EUA request; it supplements the recommendations in the Molecular Diagnostic Template for Commercial Manufacturers, Antigen Template for Test Developers, and Template for Manufacturers of Molecular and Antigen Diagnostic COVID-19 Tests for Non-Laboratory Use, all available for download from FDA’s website.[6] Test developers should use one of these referenced templates as their primary template and incorporate information from this supplemental template as applicable.
- A test authorized under an EUA is only authorized for emergency use while the EUA is in effect.
- This is an EUA interactive review template for Pre-EUA submissions/EUA requests. We plan to update the template as appropriate as we learn more about the COVID-19 disease and gain experience with the EUA process for these kinds of tests.
## EXAMPLE TEMPLATE:
**\[Note: This is intended to provide information to supplement completion of the EUA template most appropriate for your test type. This is not a complete template.\]**
**The supplemental information included in this template is for test developers of molecular or antigen tests interested in offering their test for screening (i.e., testing individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection) with serial testing prior to conducting the asymptomatic validation studies recommended in the corresponding EUA template(s). We note that these recommendations will generally not be applicable to developers with tests for which data has already demonstrated poor performance (e.g., less than 80% PPA) for testing asymptomatic individuals.**
### A. PROPOSED INTENDED USE
**FDA recommends including the following in the requested intended use:**
**\[…*****individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested twice over two (or three) days with at least 24 hours (and no more than 36 hours) between tests.\]***
**Alternative testing intervals, such as testing every 3 days or testing twice a week (such as Monday/Thursday or Tuesday/Friday), may be considered for molecular or antigen tests intended for use as part of a testing program.**
**A weekly testing interval may be considered for higher sensitivity molecular tests.**
### B. CLINICAL PERFORMANCE EVALUATION
**FDA recommends following the recommendations for clinical performance evaluation in the appropriate EUA template, except we are including information below for test developers seeking a screening claim (i.e., testing of individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection) with serial testing who have conducted the clinical evaluation with symptomatic patients suspected of COVID-19 infection by their healthcare providers. For a screening claim with serial testing, FDA would generally expect labeling to indicate that testing be done twice over two (or three) days with at least 24 hours (and no more than 36 hours) between tests. Alternative testing intervals may be considered for molecular or antigen tests intended for use as part of a testing program, as discussed above.**
**In such circumstances, the developer should generally follow the clinical performance evaluation recommendations in the corresponding molecular or antigen template for validation with symptomatic individuals or individuals otherwise suspected of COVID-19 infection by their healthcare providers. Additionally, for POC and at-home tests, including OTC tests, FDA would consider authorizing tests with a positive percent agreement (PPA) of at least 80% with 70% at the lower bound of the two-sided 95% confidence interval.**
**As discussed in the Antigen Template for Test Developers, strategies for serial testing with less sensitive tests (i.e., PPA <80%) may be able to be support authorization; however, clinical evaluation in an asymptomatic population would generally be expected prior to authorization of a screening claim, including for OTC use, for such tests.**
**When FDA authorizes a test for screening with serial testing, but the clinical validation does not include any or the recommended total number of asymptomatic individuals, FDA generally intends to include a condition of authorization in the letter of authorization that the developer conduct a study to establish performance with asymptomatic individuals within a pre-specified timeframe. A study protocol for the post-authorization study, generally including at least 20 positive asymptomatic individuals, should be agreed upon with FDA prior to study initiation. If the post-authorization study is not completed within the agreed upon timeframe or does not demonstrate adequate performance in asymptomatic individuals, FDA would consider taking additional actions as appropriate under section 564 of the FD&C Act, including revoking or revising the authorization to remove any intended use(s) that is not adequately supported.**
### C. INSTRUCTIONS FOR USE/PROPOSED LABELING/PACKAGE INSERT:
**Proposed labeling should clearly identify the population in which the test’s performance has been validated, and clearly identify any populations included in the intended use for which the test’s performance has not yet been established and will be established during the above referenced post-authorization study.**
[1] This template is part of the “[Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised)”, available at .
[2] Available at .
[3] All EUA templates can be found at .
[4] Available at https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities.
[5] At-home tests are tests labeled for self-testing in any environment outside a clinical laboratory setting, professional healthcare facility, or point-of-care patient care setting operating under a Clinical Laboratory Improvement Amendments (CLIA) certificate. This includes but is not limited to homes, outdoor environments, office environments, schools, vehicles, emergency shelters, and independent living retirement homes. If the test is intended to be used in a clinical laboratory setting, professional healthcare facility, or patient care setting operating under a CLIA certificate and also outside those facilities, it meets this definition.
[6] All EUA templates can be found at .
# 955 2021-03-16_FDA Website - FDA takes steps to streamline path for COVID-19 screening tools.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-03-16_FDA Website - FDA takes steps to streamline path for COVID-19 screening tools.md
file_date: 2021-03-16
title: FDA Website - FDA takes steps to streamline path for COVID-19 screening tools
category: regulatory
subcategory: fda-policy
tags:
source_file_type: website
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gfile_url: NA
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conversion_input_file_type: docx
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tokens: 955
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notes: date converted 2024-06-20
web_url: https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-takes-steps-streamline-path-covid-19-screening-tools-provides
summary_short: The FDA takes steps to streamline the path for COVID-19 screening tools announces a March 16, 2021 policy to accelerate EUAs for tests used in serial screening of asymptomatic individuals. It outlines a new supplemental EUA template allowing certain molecular, antigen, and at-home tests to be authorized for screening and OTC use based on strong symptomatic performance combined with serial testing. The update also provides guidance to schools, workplaces, and communities on selecting appropriate tests for screening programs.
CONTENT
Coronavirus (COVID-19) Update: FDA takes steps to streamline path for COVID-19 screening tools, provides information to help groups establishing testing programs
The following is attributed to Jeff Shuren, M.D., director of the FDA’s Center for Devices and Radiological Health, and Tim Stenzel, M.D., Ph.D., director of the Office of In Vitro Diagnostics in the Center for Devices and Radiological Health
For Immediate Release:
March 16, 2021
Statement From:
Jeff Shuren, M.D., J.D.
Director - CDRH Offices: Office of the Center Director
Testing remains an important cornerstone of our nation’s fight against COVID-19. This includes schools, workplaces, communities and other locations using testing to screen asymptomatic individuals who may still spread the virus. Screening involves testing asymptomatic individuals who do not have known or suspected exposure to COVID-19 in order to make individual decisions, such as whether an individual should participate in an activity, based on the test results.
Today, we are providing information for test developers about a streamlined path to emergency use authorization for these important screening tools as well as information to help these groups as they set up testing programs. Our actions complement those taken by the Centers for Disease Control and Prevention (CDC) and are not intended to replace CDC’s testing or other public health guidance.
First, the FDA issued a [new supplemental template](https://www.fda.gov/media/146695/download) for test developers seeking emergency use authorization (EUA) of certain tests for screening with serial testing. Serial testing involves testing the same individual multiple times within a few days, and can increase chances of detecting asymptomatic infection that might not always show up with a single test. CDC recommends serial testing at least once per week, along with other mitigation measures, such as masking and social distancing, to reduce disease transmission. This template applies to developers of molecular and antigen tests, for use in serial testing programs, as well as at-home tests for use in a serial manner outside of a testing program, intended to detect SARS-CoV-2 from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection. This includes tests conducted in any location, including in a laboratory, at the point-of-care (POC), or even places such as a person’s home or certain non-traditional sites such as offices, sporting venues, airports, schools, etc.
We believe this effort will pave the way for further expanding the availability of tests authorized for screening asymptomatic individuals, help bolster existing and new testing programs and increase consumer access to testing.
As part of this new template for test developers, the agency provided recommendations aimed to streamline the authorization of screening tests with serial testing. The recommendations apply to test developers who seek an EUA from the FDA for certain screening tests prior to conducting certain performance evaluations with asymptomatic individuals. For example, in certain circumstances, a POC test or an at-home test could be authorized for over-the-counter (OTC) use without the need for validating its use in asymptomatic individuals prior to authorization. The FDA believes that evidence of a test’s strong performance in symptomatic patients combined with serial testing can mitigate the risk of false results when testing asymptomatic individuals.
Additionally, today the FDA issued a fact sheet that outlines considerations for selecting a test for use in a screening testing program. The fact sheet will help schools, workplaces, communities and other locations as they are selecting a test for screening and help them understand the difference between tests used for diagnosis of suspected COVID-19 compared to those used for screening asymptomatic individuals.
This information we’re providing will be helpful to groups as they set up testing programs. We believe these combined efforts will further expand the availability of tests authorized for screening asymptomatic individuals, including OTC use, help bolster existing and new testing programs and increase consumer access to testing.
The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation and for regulating tobacco products.
Related Information
[Emergency Use Authorization Supplemental Template](https://www.fda.gov/media/146695/download)
[Fact Sheet](https://www.fda.gov/about-fda/page-not-found)
[FAQs on Testing for SARS-CoV-2](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2)
# 2,458 2021-04-20_FDA Fact Sheet - Sample Updated Fact Sheet for Health Care Providers.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-04-20_FDA Fact Sheet - Sample Updated Fact Sheet for Health Care Providers.md
file_date: 2021-04-20
title: FDA Fact Sheet - Sample Updated Fact Sheet for Health Care Providers
category: regulatory
subcategory: fda-policy
tags:
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xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
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tokens: 2458
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notes:
summary_short: The FDA “Sample Updated Fact Sheet for Health Care Providers” is a fill-in template that EUA test sponsors use to communicate authorized use, specimen types, and key interpretation guidance for a COVID-19 diagnostic test. It provides standardized language on what positive and negative results mean (including limitations for asymptomatic and pooled testing), biosafety and specimen handling considerations, EUA status, and reporting requirements. It helps ensure consistent, compliant provider-facing instructions and risk/benefit disclosures across EUA-authorized tests.
CONTENT
***INTERNAL TITLE:*** FACT SHEET FOR HEALTHCARE PROVIDERS
**COMPANY/LAB NAME**
**Month DD, YYYY**
**DEVICE/TEST NAME**
**Coronavirus Disease 2019 (COVID-19)**
This Fact Sheet informs you of the significant known and potential risks and benefits of the emergency use of the DEVICE/TEST NAME.
The DEVICE/TEST NAME is authorized for use with specific respiratory (and/or salvia) specimens collected from individuals consistent with the Emergency Use Authorization (EUA).
All patients whose specimens are tested with this assay will receive the Fact Sheet for Patients: COMPANY/LAB NAME - DEVICE/TEST NAME.
This test is to be performed only using specific respiratory (and/or salvia) specimens collected from individuals consistent with the Emergency Use Authorization (EUA).
## What are the symptoms of COVID-19?
Many patients with COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, dyspnea), although some individuals experience only mild symptoms or no symptoms at all. The current information available to characterize the spectrum of clinical illness associated with COVID-19 suggests that, when present, symptoms include cough, shortness of breath or dyspnea, fever, chills, myalgias, headache, sore throat, new loss of taste or smell, nausea or vomiting or diarrhea. Signs and symptoms may appear any time from 2 to 14 days after exposure to the virus, and the median time to symptom onset is approximately 5 days. For further information on the symptoms of COVID-19 please see the link provided in "Where can I go for updates and more information?" section.
Public health officials have identified cases of COVID-19 infection throughout the world, including the United States. Please check the CDC COVID-19 webpage (see link provided in "Where can I go for updates and more information?" section at the end of this document) or your local jurisdictions website for the most up to date information.
## What do I need to know about COVID-19 testing?
Current information on COVID-19 for healthcare providers is available at CDC's webpage, Information for Healthcare Professionals (see links provided in "Where can I go for updates and more information?" section).
- The DEVICE/TEST NAME can be used to test LIST ALL SPECIMEN TYPES CLAIMED.
- The DEVICE/TEST NAME should be ordered for the detection of COVID-19 in individuals who INDICATION STATEMENT.
- THIS IS EXAMPLE BULLET FOR TESTS THAT ARE AUTHORIZED WITH HOME COLLECTION KITS: The DEVICE/TEST NAME can be used to test individual nasal swab specimens that are self-collected at home or in a healthcare setting by individuals using an authorized home-collection kit when determined to be appropriate by a healthcare provider.
- INCLUDE YOUR SAMPLE POOLING INDICATION HERE: The DEVICE/TEST NAME can also be used to test up to [INCLUDE INDICATION BASED ON THE EXHIBIT YOU ARE CLAIMING].
- The DEVICE/TEST NAME is authorized for use in laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, that meet requirements to perform [high / high or moderate / high, moderate or waived] complexity tests.
Specimens should be collected with appropriate infection control precautions. Current guidance is available at the CDC's website (see links provided in "Where can I go for updates and more information?" section).
When collecting and handling specimens from individuals suspected of being infected with COVID-19, appropriate personal protective equipment should be used as outlined in the CDC Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with Coronavirus Disease 2019 (COVID-19). For additional information, refer to CDC Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons Under Investigation (PUIs) for Coronavirus Disease 2019 (COVID-19) (see links provided in "Where can I go for updates and more information?" section).
## What does it mean if the specimen tests positive for the virus that causes COVID-19?
A positive test result for COVID-19 indicates that RNA from SARS-CoV-2 was detected, and therefore the patient is infected with the virus and presumed to be contagious. Laboratory test results should always be considered in the context of clinical observations and epidemiological data (such as local prevalence rates and current outbreak/epicenter locations) in making a final diagnosis and patient management decisions. Patient management should be made by a healthcare provider and follow current CDC guidelines.
The DEVICE/TEST NAME has been designed to minimize the likelihood of false positive test results. However, it is still possible that this test can give a false positive result, even when used in locations where the prevalence is below 5%. In the event of a false positive result, risks to patients could include the following: a recommendation for isolation of the patient, monitoring of household or other close contacts for symptoms, patient isolation that might limit contact with family or friends and may increase contact with other potentially COVID-19 patients, limits in the ability to work, delayed diagnosis and treatment for the true infection causing the symptoms, unnecessary prescription of a treatment or therapy, or other unintended adverse effects.
Individuals included in a pool that returns a positive or invalid result should be treated as a presumptive positive unless or until they receive a negative result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, they should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result.
All laboratories using this test must follow the standard testing and reporting guidelines according to their appropriate public health authorities.
## What does it mean if the specimen tests negative for the virus that causes COVID-19?
A negative test result for this test means that SARS-CoV-2 RNA was not present in the specimen above the limit of detection. However, a negative result does not rule out COVID-19 and should not be used as the sole basis for treatment or patient management decisions. It is possible to test a person too early or too late during COVID-19 infection to make an accurate diagnosis via DEVICE/TEST NAME.
In addition, asymptomatic people infected with COVID-19 may not shed enough virus to reach the limit of detection of the test, giving a false negative result. In the absence of symptoms, it is difficult to determine if asymptomatic people have been tested too late or too early. Therefore, negative results in asymptomatic individuals may include individuals who were tested too early and may become positive later, individuals who were tested too late and may have serological evidence of infection, or individuals who were never infected.
Specimens with low viral loads may not be detected in sample pools due to the decreased sensitivity or increased interference of pooled testing. Your interpretation of negative results should take into account clinical and epidemiological risk factors.
When diagnostic testing is negative, the possibility of a false negative result should be considered in the context of a patient's recent exposures and the presence of clinical signs and symptoms consistent with COVID-19. The possibility of a false negative result should especially be considered if the patient's recent exposures or clinical presentation indicate that COVID-19 is likely, and diagnostic tests for other causes of illness (e.g., other respiratory illness) are negative.
If COVID-19 is suspected based on exposure history together with other clinical findings, re-testing using a new sample with a sensitive method or without pooling should be considered by healthcare providers in consultation with public health authorities. Additional testing may be helpful to ensure testing was not conducted too early.
Risks to a patient of a false negative test result include: delayed or lack of supportive treatment, lack of monitoring of infected individuals and their household or other close contacts for symptoms resulting in increased risk of spread of COVID-19 within the community, or other unintended adverse events.
The performance of this test was established based on the evaluation of a limited number of clinical specimens. The clinical performance has not been established in all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation. Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2 and their prevalence, which change over time.
## What is an EUA?
The United States FDA has made this test available under an emergency access mechanism called an Emergency Use Authorization (EUA). The EUA is supported by the Secretary of Health and Human Service's (HHS's) declaration that circumstances exist to justify the emergency use of in vitro diagnostics (IVDs) for the detection and/or diagnosis of the virus that causes COVID-19.
An IVD made available under an EUA has not undergone the same type of review as an FDA-approved or cleared IVD. FDA may issue an EUA when certain criteria are met, which includes that there are no adequate, approved, available alternatives, and based on the totality of scientific evidence available, it is reasonable to believe that this IVD may be effective in diagnosing COVID-19.
The EUA for this test is in effect for the duration of the COVID-19 declaration justifying emergency use of IVDs, unless terminated or revoked (after which the test may no longer be used).
## What are the approved available alternatives?
Any tests that have received full marketing status (e.g., cleared, approved), as opposed to an EUA, by FDA can be found by searching the medical device databases here: https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases. A cleared or approved test should be used instead of a test made available under an EUA, when appropriate and available. FDA has issued EUAs for other tests that can be found at: https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization.
## Where can I go for updates and more information?
### CDC webpages:
- General: https://www.cdc.gov/COVID19
- Symptoms: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
- Healthcare Professionals: https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html
- Information for Laboratories: https://www.cdc.gov/coronavirus/2019-nCoV/guidance-laboratories.html
- Laboratory Biosafety: https://www.cdc.gov/coronavirus/2019-nCoV/lab-biosafety-guidelines.html
- Isolation Precautions in Healthcare Settings: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
- Specimen Collection: https://www.cdc.gov/coronavirus/2019-nCoV/guidelines-clinical-specimens.html
- Infection Control: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/index.html
### FDA webpages:
- General: www.fda.gov/novelcoronavirus
- EUAs: (includes links to patient fact sheet and manufacturer's instructions) https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas
### COMPANY/LAB NAME:
COMPANY/LAB NAME
ADDRESS LINE 1
ADDRESS LINE 2
**Customer Support:**
+1 800 XXX-XXXX
customersupportemail@company.com
**Technical Support:**
+1 800 XXX-XXXX
techsupportemail@company.com
---
*Report Adverse events, including problems with test performance or results, to MedWatch by submitting the online FDA Form 3500 (https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.home) or by calling 1-800-FDA-1088*
# 1,652 2021-04-20_FDA Fact Sheet - Sample Updated Fact Sheet for Patients.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-04-20_FDA Fact Sheet - Sample Updated Fact Sheet for Patients.md
file_date: 2021-04-20
title: FDA Fact Sheet - Sample Updated Fact Sheet for Patients
category: regulatory
subcategory: fda-policy
tags:
source_file_type: pdf
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: https://drive.google.com/file/d/1PLLYvCrnxebmuK4V06Fd6f_VjwnbZobM
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2021-04-20_FDA%20Fact%20Sheet%20-%20Sample%20Updated%20Fact%20Sheet%20for%20Patients.pdf
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conversion: claude
license: Public Domain
tokens: 1652
words: 1273
notes:
summary_short: The FDA “Sample Updated Fact Sheet for Patients” is a standardized, fill-in template that EUA test sponsors provide to individuals whose samples were tested for COVID-19 with an authorized device. It explains what the test is, why someone may be tested (including serial and pooled testing), and what positive or negative results mean, including the risks of false positives/negatives and recommended follow-up actions. It supports clear patient-facing communication of EUA status, benefits/limitations, and where to find additional public health guidance.
CONTENT
***INTERNAL TITLE:*** FACT SHEET FOR PATIENTS
**COMPANY/LAB NAME**
**Month, DD, YYYY**
**DEVICE/TEST NAME**
**Coronavirus Disease 2019 (COVID-19)**
You are being given this Fact Sheet because your sample(s) was tested for the Coronavirus Disease 2019 (COVID-19) using the DEVICE/TEST NAME.
This Fact Sheet contains information to help you understand the risks and benefits of using this test for the diagnosis of COVID-19. After reading this Fact Sheet, if you have questions or would like to discuss the information provided, please talk to your healthcare provider.
For the most up to date information on COVID-19 please visit the CDC Coronavirus Disease 2019 (COVID-19) webpage: https://www.cdc.gov/COVID19
## What is COVID-19?
COVID-19 is caused by the SARS-CoV-2 virus which is a new virus in humans causing a contagious respiratory illness. COVID-19 can present with a mild to severe illness, although some people infected with COVID-19 may have no symptoms at all. Older adults and people of any age who have underlying medical conditions have a higher risk of severe illness from COVID-19. Serious outcomes of COVID-19 include hospitalization and death. The SARS-CoV-2 virus can be spread to others not just while one is sick, but even before a person shows signs or symptoms of being sick (e.g., fever, coughing, difficulty breathing, etc.). A full list of symptoms of COVID-19 can be found at the following link: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.
## What is the DEVICE/TEST NAME?
The test is designed to detect the virus that causes COVID-19 in respiratory specimens, for example nasal or oral swabs – depending on device.
## Why was my sample tested?
You were tested because your healthcare provider believes you may have been exposed to the virus that causes COVID-19 based on your signs and symptoms (e.g., fever, cough, difficulty breathing), and/or because:
- You are being tested at regular intervals (serial testing) even though you do not have symptoms or risk factors for COVID-19; or
- You live in or have recently traveled to a place where transmission of COVID-19 is known to occur, and/or
- You have been in close contact with an individual suspected of or confirmed to have COVID-19.
- You and your healthcare provider believe there is another reason to investigate your COVID-19 infection status.
Testing of the samples will help find out if you may have COVID-19.
Laboratories may use pooling when testing your specimen, which means they combine your sample with other individuals samples prior to testing and test them as a "pool". The laboratory may return a result for the entire pool together or may return individual results.
## What are the known and potential risks and benefits of the test?
Potential risks include:
- Possible discomfort or other complications that can happen during sample collection.
- Possible incorrect test result (see below for more information).
Potential benefits include:
- The results, along with other information, can help your healthcare provider make informed recommendations about your care.
- The results of this test may help limit the spread of COVID-19 to your family and those you come in contact with.
## What does it mean if I have a positive test result?
If you have a positive test result, it is very likely that you have COVID-19. Therefore, it is also likely that you may be placed in isolation to avoid spreading the virus to others. You should follow CDC guidance to reduce the potential transmission of disease.
If you were tested as part of a pool that returned a positive or invalid test result, you may have COVID-19 and should consider yourself to have a positive test result unless or until you receive a negative test result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, you should isolate until receiving a negative result when re-tested individually and should not be grouped with other individuals who have received a positive or presumptive positive result.
There is a smaller possibility that this test can give a positive result that is wrong (a false positive result) particularly when used in a population without many cases of COVID-19 infection. Your healthcare provider will work with you to determine how best to care for you based on the test results along with medical history, and your symptoms
## What does it mean if I have a negative test result?
A negative test result means that the virus that causes COVID-19 was not found in your sample.
However, it is possible for this test to give a negative result that is incorrect (false negative) in some people with COVID-19. You might test negative if the sample was collected early during your infection. You could also be exposed to COVID-19 after your sample was collected and then have become infected.
In particular, people infected with COVID-19 but who have no symptoms may not shed enough virus to trigger a positive test. This means that you could possibly still have COVID-19 even though the test result is negative. If your test is negative, your healthcare provider will consider the test result together with all other aspects of your medical history (such as symptoms, possible exposures, and geographical location of places you have recently traveled) in deciding how to care for you.
If your test result indicates your specimen was pooled and you have a negative test result there a small chance that your result is incorrect. You should talk with your healthcare provider if you are concerned.
If you have no symptoms but have been tested because your doctor thought you may have been exposed to COVID-19, you should continue to monitor your health and let your healthcare provider know if you develop any symptoms of COVID-19. If you develop symptoms you may need another test to determine if you have contracted the virus causing COVID-19.
If you develop symptoms or your symptoms get worse you should seek medical care. If you have the following symptoms you should seek immediate medical care at the closest emergency room:
- Trouble breathing
- Persistent pain or pressure in the chest
- New confusion
- Inability to wake up or stay awake
- Bluish lips or face
It is important that you work with your healthcare provider to help you understand the next steps you should take.
## Is this test FDA-approved or cleared?
No. This test is not yet approved or cleared by the United States FDA. FDA may issue an Emergency Use Authorization (EUA) when certain criteria are met, which includes that there are no adequate, approved, available alternatives. The EUA for this test is supported by the Secretary of Health and Human Service's (HHS's) declaration that circumstances exist to justify the emergency use of in vitro diagnostics for the detection and/or diagnosis of the virus that causes COVID-19. This EUA will remain in effect (meaning this test can be used) for the duration of the COVID-19 declaration justifying emergency of IVDs, unless it is terminated or revoked by FDA (after which the test may no longer be used).
## What are the approved alternatives?
Any tests that have received full marketing status (e.g., cleared, approved), as opposed to an EUA, by FDA can be found by searching the medical device databases here: https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases. A cleared or approved test should be used instead of a test made available under an EUA, when appropriate and available. FDA has issued EUAs for other tests that can be found at: https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization
---
Where can I go for updates and more information? The most up-to-date information on COVID-19 is available at the CDC General webpage: https://www.cdc.gov/COVID19. In addition, please also contact your healthcare provider with any questions/concerns.
# 10,719 2021-04-20_FDA Letter - Amendment Letter.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-04-20_FDA Letter - Amendment Letter.md
file_date: 2021-04-20
title: FDA Letter - Amendment Letter
category: regulatory
subcategory: fda-policy
tags:
source_file_type: pdf
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: https://drive.google.com/file/d/1j5PHj5Ukp0M4RfIlJL03CkOGzitr2_gY
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2021-04-20_FDA%20Letter%20-%20Amendment%20Letter.pdf
conversion_input_file_type: pdf
conversion: megaparse-v
license: Public Domain
tokens: 10719
words: 8628
notes:
summary_short: The FDA “Amendment Letter” (April 20, 2021) authorizes certain EUA RT-PCR molecular tests to add screening indications using pooled anterior nasal specimens when deployed in serial testing programs (typically at least weekly), with appendices specifying pooling type (swab vs. media) and maximum pool sizes (e.g., up to 3, 5, or 10). It defines eligibility criteria for which EUAs can be amended, the required validation/notification package for inclusion on FDA’s Exhibit 1 list, and detailed conditions for developers and CLIA high-complexity laboratories (including follow-up for positive/invalid pools, reporting language, and positivity-rate monitoring). It also prescribes required updates to provider and patient fact sheets to address presumptive positives from pools and the limitations of negative results in asymptomatic and pooled testing.
CONTENT
April 20, 2021
To: Developers of Molecular-Based Diagnostic Tests Authorized for Emergency Use for Coronavirus Disease 2019 (COVID-19) as of Today’s Date
Re: Amending Certain EUAs for RT-PCR Molecular-Based Diagnostic Tests to Authorize the Detection of Nucleic Acid from SARS-CoV-2 from Pooled Anterior Nasal Respiratory Specimens for Screening When Used as Part of a Serial Testing Program
On February 4, 2020, pursuant to Section 564(b)(1)(C) of the Federal Food, Drug, and Cosmetic Act (the Act) (21 U.S.C. § 360bbb-3(c)), the Secretary of the Department of Health and Human Services (HHS) determined that there is a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad, and that involves the virus that causes COVID-19. Pursuant to Section 564 of the Act, and on the basis of such determination, the Secretary of HHS then declared that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the virus that causes COVID-19 subject to the terms of any authorization issued under Section 564(a) of the Act.¹
On April 20, 2021, pursuant to Section 564 of the Act, in response to public health needs to expand the nation’s testing capacity,² FDA is issuing this letter to authorize additional indications for EUAs that are within the Scope of this Amendment (Section II). For such indications, use is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meet requirements to perform high complexity tests, except that tests authorized for use in specific named or designated high complexity laboratories can only be used in such laboratories.
As set forth throughout, this authorization amends certain EUAs to authorize the tests for additional indications for use. There are multiple indications for use in the appendices but they all contain these essential elements: tests with EUAs that are amended by this letter are authorized for use with pooled anterior nasal specimens for screening (i.e., testing individuals without symptoms or other epidemiological reasons to suspect COVID-19) when used as part of a serial testing program. This means that tests with EUAs that are amended by this authorization may be used with pooled anterior nasal respiratory specimens from individuals without known or suspected COVID-19 when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week, such as those implemented by schools, workplaces and community groups. The indications in each appendix (A-H) differ in the number of specimens that can be pooled (i.e., up to 3, up to 5, or up to 10) and the type of pooling that can be done (i.e., media or swab pooling). Tests with EUAs that are amended by this authorization will be added to Exhibit 1, annotated with the authorized indication(s) for each test, which will be maintained on FDA’s webpage.³ FDA’s determination that the indications added by this amendment meet the criteria for issuance under section 564(c) of Act is based on the available scientific evidence, including recent studies involving antigen tests used in a serial manner, knowledge of recently authorized antigen and molecular tests, as well as our experience with SARS-CoV-2 tests over the past year.
Having concluded, based on the available scientific evidence, that the criteria for issuance of this authorization under Section 564(c) of the Act are met, I am authorizing the emergency use of the tests identified in the Scope of this Amendment (Section II) and subject to the Conditions of Authorization (Section IV), for use in laboratories certified under the CLIA, 42 U.S.C. § 263a, that meet the requirements to perform high complexity tests to detect SARS-CoV-2 in anterior nasal respiratory specimens from individuals, except that tests authorized for use in specific named or designated high complexity laboratories can only be used in such laboratories.⁴
## I. Criteria for Issuance of Authorization
I have concluded that the emergency use of the authorized tests meets the criteria for issuance of an authorization under Section 564(c) of the Act, because I have concluded that:
1. The SARS-CoV-2 can cause a serious or life-threatening disease or condition, including severe respiratory illness, to humans infected by this virus;
2. Based on the totality of scientific evidence available to FDA, it is reasonable to believe that the authorized tests may be effective in diagnosing COVID-19 for the indications set forth in the appendices, and that the known and potential benefits of the authorized tests when used for such use, outweigh the known and potential risks of the authorized tests; and
3. There are no adequate, approved, and available alternatives to the emergency use of the authorized tests.⁵
## II. Scope of this Amendment
I have concluded, pursuant to Section 564(d)(1) of the Act, that the scope of this amendment is limited to authorized tests identified below for the additional indications for use⁶ given in the applicable appendix(es) for use in laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meet requirements to perform high complexity tests, except that tests authorized for use in specific named or designated high complexity laboratories can only be used in such laboratories.
### Authorized Tests
The emergency use authorization (EUA) of a molecular diagnostic SARS-CoV-2 test is amended consistent with this letter where:
1. The test is an RT-PCR test authorized under an EUA specific to that test as of today’s date for the qualitative detection of SARS-CoV-2 in respiratory specimens collected by anterior nasal swabs, with a PPA ≥ 95% based on validation with positive patient specimens as stated in the test’s authorized labeling;
2. The test as authorized is designed to detect two or more viral targets on the SARS-CoV-2 genome;
3. The test as authorized includes a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction);
4. The test is authorized for detecting only SARS-CoV-2;
5. Prior to notification pursuant to Condition of Authorization C of this letter, either validation data has not been submitted to FDA for testing pooled specimens, or such validation data has been submitted to FDA and FDA authorized the test for testing pooled specimens⁷; and
6. Prior to notification pursuant to Condition of Authorization C of this letter, either validation data has not been submitted to FDA for testing specimens from asymptomatic individuals, or such validation data has been submitted to FDA and FDA authorized the test for screening (i.e., testing individuals without symptoms or other reasons to suspect COVID-19).⁸
As set forth in Condition of Authorization A of this letter, and notwithstanding other statements and conditions concerning authorized labeling in the EUAs being amended, developers must make the following changes to the test’s authorized labeling before distributing or using the test for any indication added by this authorization:
- Update your Instructions for Use and/or laboratory procedure to add the following language:
- The following indication is authorized under the Pooling and Serial Testing Amendment [include link to this letter] for use in [laboratories certified under CLIA to perform high complexity tests] OR [for tests authorized for use in specific named or designated high complexity laboratories, insert the language included under “Authorized Laboratories” in your EUA]: [insert indication from applicable appendix]
- This indication is authorized with the following validated protocol: [insert the relevant validated protocol for testing with pooled specimens that meets Condition of Authorization D]; and
- Update your Fact Sheet for Health Care Providers and Fact Sheet for Patients with the relevant additional information set forth in Appendix I.
This labeling will be added to FDA’s webpage and posted with the EUA being amended after it is submitted to FDA per the process outlined below.
A test may not be distributed or used for any additional indications authorized by this letter until the pooling protocol for that indication is validated in accordance with the applicable appendix and the required notification is submitted and confirmed to be complete by FDA in accordance with Condition of Authorization C of this letter.
Tests limited for use at specific named or designated laboratories that are not authorized to be distributed per the EUA being amended continue to be authorized for use only in those laboratories and not for distribution even if the EUAs are amended as set forth in this authorization.
### Addition to Exhibit 1
An EUA that meets the above will be added to Exhibit 1 after FDA confirms that the required documentation set forth below has been submitted to FDA. At that time, FDA will notify the developer of the inclusion of its test(s) in Exhibit 1 by replying to the email. Please note that being added to Exhibit 1 does not necessarily mean that FDA has reviewed the underlying validation data submitted or confirmed that the test is appropriately validated. Instead, being added to Exhibit 1 only means that the developer has submitted complete documentation. FDA may revise or revoke an EUA under certain circumstances, such as when there are concerns with the test’s performance.
As set forth in Condition of Authorization C of this letter, developers must notify FDA by sending a message to FDA with the subject line “Addition to Exhibit 1 of the Pooling and Serial Testing Amendment” to CDRH-EUA-Templates@fda.hhs.gov with the information below before the test can be distributed (if authorized to be distributed per the EUA being amended) and used for the additional indication(s):
- Developer (company) name
- Contact individual’s name, address, phone number, email address
- Test name
- EUA# and link to the EUA being amended
- The specific new indication(s), referenced by noting the applicable appendix
- The required validation data as set forth in the applicable appendices
- Revised (redline and final) labeling as set forth above and required by Condition of Authorization A
- The following information on testing capacity:
1. The number of individual tests that can be run with normal operation in a 24-hour period;
2. The number of patient samples that can be tested in a 24-hour period if all samples are pooled at the maximum ratio permitted by the additional indication(s) added by this amendment; and
3. For distributed test kits, the number of laboratories in the United States with the required platforms installed.
- Statement certifying that the six criteria above are met, no changes have been made to the authorized test other than to add the indication(s) for use set forth in the applicable appendix, no changes have been made to the authorized labeling other than those required by this amendment, and that all information submitted is truthful and accurate, for example:
- I certify that, in my capacity as [the position held in company] of [company name], I believe to the best of my knowledge that all six criteria described in this amendment have been met, no changes have been made to the authorized test other than to add the indication(s) for use set forth in the applicable appendix(ces), no changes have been made to the authorized labeling other than those required by this amendment, and that all data and information I am submitting are truthful and accurate and no material fact has been omitted.
Authorized tests are qualitative tests for the detection of nucleic acid from SARS-CoV-2 in anterior nasal respiratory specimens from individuals without symptoms or other reasons to suspect COVID-19, when tested with pooled testing at least once per week as part of a serial testing program, as set forth in the applicable appendix.
Negative results from pooled testing should not be treated as definitive. If a patient’s clinical signs and symptoms are inconsistent with a negative result or results are necessary for patient management, then the patient should be considered for individual testing. Specimens included in pools with a positive or invalid result must be reported as presumptive positive or tested individually prior to reporting a result. Individuals included in a pool that returns a positive or invalid result should be treated as a presumptive positive unless or until they receive a negative result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, they should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result. Specimens with low viral loads may not be detected with pooled testing due to decreased sensitivity or increased interference from pooled testing.
For serial testing programs, additional confirmatory testing for negative results may be necessary, if there is a high likelihood of COVID-19, such as an individual with a close contact with COVID-19 or with suspected exposure to COVID-19 or in communities with high prevalence of infection. Additional confirmatory testing for positive results may also be necessary, if there is a low likelihood of COVID-19, such as in individuals without known exposure to COVID-19 or residing in communities with low prevalence of infection.
The above described tests, with the authorized labeling provided as set forth in the Scope of this Amendment (Section II) and subject to the Conditions of Authorization (Section IV) of this letter, are authorized to be distributed (if previously authorized to be distributed per the underlying EUA) and used in accordance with the Scope of this Amendment (Section II) and the Conditions of Authorization (Section IV), despite the fact that such tests do not meet certain requirements otherwise required by applicable federal law.
I have concluded, pursuant to Section 564(d)(2) of the Act, that it is reasonable to believe that the known and potential benefits of the authorized tests, when used consistent with the Scope of this Amendment (Section II), outweigh the known and potential risks of such authorized tests.
I have concluded, pursuant to Section 564(d)(3) of the Act, based on the totality of scientific evidence available to FDA, that it is reasonable to believe that the authorized tests may be effective in diagnosing COVID-19 as set forth in Section I of this letter, when used consistent with the Scope of this Amendment (Section II), pursuant to Section 564(c)(2)(A) of the Act.
FDA has reviewed the scientific information available to FDA, including the information supporting the conclusions described in Section I above, and concludes that the authorized tests (as described in the Scope of this Amendment (Section II)) meet the criteria set forth in Section 564(c) of the Act concerning safety and potential effectiveness.
The emergency use of the authorized tests under this amendment must be consistent with, and may not exceed the terms of this letter, including the Scope of this Amendment (Section II) and the Conditions of Authorization (Section IV). Subject to the terms of this amendment and under the circumstances set forth in the Secretary of HHS’s determination under Section 564(b)(1)(C) described above and the Secretary of HHS’s corresponding declaration under Section 564(b)(1), the authorized tests are authorized for the additional indications set forth in the applicable appendix.
## III. Waiver of Certain Requirements
This amendment does not change the waiver of any requirements included in the EUAs being amended.
## IV. Conditions of Authorization
Pursuant to Section 564(e) of the Act, I am establishing the conditions below, which are specific to the indications added by this amendment for which developers intend to distribute or use their test. The conditions in the EUAs being amended continue to apply to all authorized indications for use, including any indications added by this amendment for which developers intend to distribute or use their test.
### Developer (You)
A. You must update your labeling in accordance with Section II of this letter.
B. You must provide any authorized distributor(s) with a copy of this amendment and its authorized accompanying materials (e.g., Fact Sheets).
C. In order for your test to be distributed (if authorized to be distributed per the underlying EUA) and used for any of the indications authorized by this letter, you must first validate your test in accordance with the requirements in the applicable appendix and notify FDA by submitting the information set forth in Section II to FDA at [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov) using the subject line “Addition to Exhibit 1 of the Pooling and Serial Testing Amendment”.
D. You must have a pooling protocol that includes instructions for follow-up for positive and invalid pools, including follow-up instructions to be provided to the organizer of the testing program. For media pooling, the instructions for follow up for positive and invalid pools must include deconvoluting to retest individual samples. For swab pooling, the instructions for follow up for positive and invalid pools must include reporting as “presumed positive” unless or until the individual is re-tested individually and must include instructions to collect a new specimen to be tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, the instructions must indicate that such individuals should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result.
E. You must immediately cease distribution and use of your test for an indication added by this amendment upon written notification by FDA that the test has not been validated for that indication in accordance with the applicable requirements, and must notify authorized laboratories to which your test has been distributed that they must immediately cease use of your test for that indication. You must also relabel any tests that have been distributed for that indication to no longer include such indication.
F. If, prior to the date of this letter, your test was not authorized for screening (i.e., testing individuals without symptoms or other reasons to suspect COVID-19), you must further evaluate the clinical performance of your test to support the serial testing claim in an FDA agreed upon post authorization clinical evaluation study within 6 months of submitting the notification pursuant to Condition C of this letter (unless otherwise agreed to with DMD/OHT7-OIR/OPEQ/CDRH). Results from this study must be submitted to FDA at [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov). After FDA concurs with the data, you must update your authorized labeling to reflect the additional testing. Such labeling updates must be made only after concurrence by DMD/OHT7-OIR/OPEQ/CDRH. If FDA does not concur with the results from the study, then you must cease distributing or using the test for screening and relabel such tests that have already been distributed to reflect this change.
### Authorized Laboratories
G. Authorized laboratories that use a test that has been amended by this letter must notify the relevant public health authorities of their intent to run the authorized test for the new indication(s) set forth in this amendment prior to initiating testing.
H. Authorized laboratories testing pooled specimens with your test must include with test result reports for specific individuals whose specimen(s) were the subject of pooling, a notice that pooling was used during testing and that “Individual specimens with low viral loads may not be detected due to the decreased sensitivity or increased interference when tested with pooled testing.”
I. Authorized laboratories must follow your pooling protocol that includes instructions for follow up for positive and invalid pools, including follow-up instructions to be provided to the organizer of the testing program. For media pooling, the instructions for follow up for positive and invalid pools must include deconvoluting to retest individual samples. For swab pooling, the instructions for follow up for positive and invalid pools must include reporting as “presumed positive” unless or until the individual is re-tested individually and must include instructions to collect a new specimen to be tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, the instructions must indicate that such individuals should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result.
J. Authorized laboratories testing pooled specimens with your test must include with test result reports for specific individuals whose specimen(s) were the subject of pooling, a notice that their test result is “presumed positive” unless or until they are re-tested individually if the pool in which they were included returns a positive or invalid result. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, the report must include instructions to collect a new specimen to be tested individually and must indicate that such individuals should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result.
K. Authorized laboratories testing specimens using pooled testing with your test must monitor the positivity rate of the specimens tested using pooled testing by calculating the percent positive results using a moving average (such as a rolling average updated daily using data from the previous 7-10 days).
L. Authorized laboratories must keep records of specimen pooling test result data, daily testing totals including number of pooled test results, number of individuals tested and daily running average of percent positive results. For the first 12 months from the date of their creation, such records must be made available to FDA upon request within 48 business hours for inspection. After 12 months from the date of their creation, upon FDA request, such records must be made available for inspection within a reasonable time.
Sincerely,
RADM Denise M. Hinton
Chief Scientist
Food and Drug Administration
Enclosures
## Appendix A
### Swab pooling up to n=3
Subject to the terms of this EUA, a test that is within the Scope of this Amendment (Section II) is authorized for the following additional indication without needing additional validation and may be distributed (if previously authorized for distribution per the EUA being amended) and used for this indication after a notification has been submitted to FDA and confirmed by FDA to be complete in accordance with Condition of Authorization C of this letter:
Qualitative detection of RNA from SARS-CoV-2 in pooled samples containing up to 3 individual human anterior nasal swabs placed in a single vial containing transport media after being collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week as part of a serial testing program.
This indication is authorized for use in laboratories certified under CLIA to perform high complexity tests, except that tests authorized for use in specific named or designated laboratories can only be used in such high complexity laboratories.
Tests will be added to Exhibit 1 after FDA determines it has received a complete notification.
## Appendix B
### Swab pooling up to n=5
Subject to the terms of this EUA, a test that is within the Scope of this Amendment (Section II) is authorized for the following additional indication and may be distributed (if previously authorized for distribution per the EUA being amended) and used for this indication after validation is completed as set forth in this Appendix and a notification has been submitted to FDA and confirmed by FDA to be complete in accordance with Condition of Authorization C of this letter:
Qualitative detection of RNA from SARS-CoV-2 in pooled samples containing up to 5 individual human anterior nasal swabs placed in a single vial containing transport media after being collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals without symptoms or other reasons to suspect COVID-19, when tested as part of a serial testing program including testing at least once per week.
This indication is authorized for use in laboratories certified under CLIA to perform high complexity tests, except that tests authorized for use in specific named or designated laboratories can only be used in such high complexity laboratories.
Tests will be added to Exhibit 1 after FDA determines it has received a complete notification.
Validation for this indication includes both validation protocols outlined below, “Validation of Expected Limit of Detection (LoD)” and “Validation of High Viral Concentrations”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. **Validation of Expected Limit of Detection (LoD)**
Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your IFU or procedure for testing 5-swab pools.
To generate a 5-swab pool positive for SARS-CoV-2, prepare a single positive swab by spiking a known amount of inactivated virus or quantified positive patient sample onto the swab prior to immersion in the volume of transport media you intend to include in your IFU or procedure for 5-swab pooling. The remaining four swabs added to transport media should only contain negative patient clinical matrix. The final concentration of the transport media must be approximately 3x the LoD of your previously authorized assay. To ensure this concentration is achieved, factor in how much volume the swab absorbs, and the SARS-CoV-2 concentration needed on the single positive swab to achieve a final concentration of approximately 3x the LoD in the transport media. This is the concentration you should use to prepare the positive swabs for your validation study.
Test at least 20 independent extraction replicates of individual swabs in the same volume of buffer used in the LoD study as described in your authorized test’s IFU or procedure, using the testing protocol in your authorized test’s IFU or procedure. Test 20 paired 5-swab pools in parallel, each containing a single positive swab and 4 individual negative swabs in the volume of transport media you intend to include in your IFU or procedure for testing 5-swab pools, using the testing protocol you intend to include in your IFU or procedure for testing 5-swab pools.
Your validation must demonstrate that:
- ≥95% of pooled replicates are detected as positive using the swab pooling protocol;
- The Ct score difference between the pooled and single swab protocols does not exceed 1.7 Ct; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
2. **Validation of High Viral Concentrations**
Prepare three swabs simulating high viral concentrations by spiking 10^6 copies/mL of inactivated virus or quantified positive patient sample. Test 10 replicates of viral transport material containing the three spiked positive swabs and 2 individual negative swabs in the volume of transport media you intend to include in your IFU or procedure for testing 5-swab pools, using the testing protocol you intend to include in your IFU or procedure for testing 5-swab pools.
Your validation must demonstrate that:
- All 10 replicates are detected as positive; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
## Appendix C
### Swab pooling up to n=10
Subject to the terms of this EUA, a test that is within the Scope of this Amendment (Section II) is authorized for the following additional indication and may be distributed (if previously authorized for distribution per the underlying EUA) and used for this indication after validation is completed as set forth in this Appendix and a notification has been submitted to FDA and confirmed by FDA to be complete in accordance with Condition of Authorization C of this letter:
Qualitative detection of RNA from SARS-CoV-2 in pooled samples containing up to 10 individual human anterior nasal swabs placed in a single vial containing transport media after being collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals without symptoms or other reasons to suspect COVID-19, when tested as part of a serial testing program including testing at least once per week.
This indication is authorized for use in laboratories certified under CLIA to perform high complexity tests, except that tests authorized for use in specific named or designated laboratories can only be used in such high complexity laboratories.
Tests will be added to Exhibit 1 after FDA determines it has received a complete notification.
Validation for this indication includes both validation protocols outlined below, “Validation of Expected Limit of Detection (LoD)” and “Validation of High Viral Concentrations”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. **Validation of Expected Limit of Detection (LoD)**
Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your IFU or procedure for testing 10-swab pools.
To generate a 10-swab pool positive for SARS-CoV-2, prepare a single positive swab by spiking a known amount of inactivated virus or quantified positive patient sample onto the swab prior to immersion in the volume of transport media you intend to include in your IFU or procedure for 10-swab pooling. The remaining four swabs added to transport media should only contain negative patient clinical matrix. The final concentration of the transport media must be approximately 3x the LoD of your previously authorized assay. To ensure this concentration is achieved, factor in how much volume the swab absorbs, and the SARS-CoV-2 concentration needed on the single positive swab to achieve a final concentration of approximately 3x the LoD in the transport media. This is the concentration you should use to prepare the positive swabs for your validation study.
Test at least 20 independent extraction replicates of individual swabs in the same volume of buffer used in the LoD study as described in your authorized test’s IFU or procedure, using the testing protocol in your authorized test’s IFU or procedure. Test 20 paired 10-swab pools in parallel, each containing a single positive swab and 9 individual negative swabs in the volume of transport media you intend to include in your IFU or procedure for testing 10-swab pools, using the testing procedure you intend to include in your IFU or procedure for testing 10-swab pools.
Your validation must demonstrate that:
- ≥95% of pooled replicates are detected as positive using the swab pooling protocol;
- The Ct score difference between the pooled and single swab protocols does not exceed 1.7 Ct; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
2. **Validation of High Viral Concentrations**
Prepare three swabs simulating high viral concentrations by spiking 10^6 copies/mL of inactivated virus or quantified positive patient sample. Test 10 replicates of viral transport material containing the three spiked positive swabs and 7 individual negative swabs in the volume of transport media you intend to include in your IFU or procedure for testing 10-swab pools, using the testing protocol you intend to include in your IFU or procedure for testing 10-swab pools.
Your validation must demonstrate that:
- All 10 replicates are detected as positive; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
## Appendix D
### Media pooling up to n=3
Subject to the terms of this EUA, a test that is within the Scope of this Amendment (Section II) is authorized for the following additional indication without needing additional validation and may be distributed (if previously authorized for distribution per the underlying EUA) and used for this indication after a notification has been submitted to FDA and confirmed by FDA to be complete in accordance with Condition of Authorization C of this letter:
Qualitative detection of RNA from SARS-CoV-2 in pooled samples containing aliquots of transport media from up to 3 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials containing transport media when tested as part of a serial testing program including testing at least once per week.
This indication is authorized for use in laboratories certified under CLIA to perform high complexity tests, except that tests authorized for use in specific named or designated laboratories can only be used in such high complexity laboratories.
Tests will be added to Exhibit 1 after FDA determines it has received a complete notification.
## Appendix E
### Media pooling up to n=5 – validation option 1
Subject to the terms of this EUA, a test that is within the Scope of this Amendment (Section II) is authorized for the following additional indication and may be distributed (if previously authorized for distribution per the underlying EUA) and used for this indication after validation is completed as set forth in this Appendix and a notification has been submitted to FDA and confirmed by FDA to be complete in accordance with Condition of Authorization C of this letter:
Qualitative detection of RNA from SARS-CoV-2 in pooled samples containing aliquots of transport media from up to 5 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials containing transport media, when tested as part of a serial testing program including testing at least once per week.
This indication is authorized for use in laboratories certified under CLIA to perform high complexity tests, except that tests authorized for use in specific named or designated laboratories can only be used in such high complexity laboratories.
Tests will be added to Exhibit 1 after FDA determines it has received a complete notification.
Validation for this indication includes the validation protocol outlined below, “Validation of Expected Limit of Detection (LoD)”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. **Validation of Expected Limit of Detection (LoD)**
Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your IFU or procedure for testing 5-sample pools.
Prepare positive samples for your validation study at 5x the LoD of your previously authorized assay.
Test at least 20 independent extraction replicates of individual samples using the testing protocol in your authorized test’s IFU or procedure. Test 20 paired 5-sample pools in parallel, each containing aliquots from a single positive sample and 4 individual negative samples, using the volumes and testing protocol you intend to include in your IFU or procedure for testing 5-sample pools.
Your validation must demonstrate that:
- ≥95% of pooled replicates are detected as positive using the sample pooling protocol;
- The Ct score difference between the pooled and single swab protocols does not exceed 1.7 Ct; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
## Appendix F
### Media pooling up to n=10 – validation option 1
Subject to the terms of this EUA, a test that is within the Scope of this Amendment (Section II) is authorized for the following additional indication and may be distributed (if previously authorized for distribution per the underlying EUA) and used for this indication after validation is completed as set forth in this Appendix and a notification has been submitted to FDA and confirmed by FDA to be complete in accordance with Condition of Authorization C of this letter:
Qualitative detection of RNA from SARS-CoV-2 in pooled samples containing aliquots of transport media from up to 10 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials containing transport media, when tested as part of a serial testing program including testing at least once per week.
This indication is authorized for use in laboratories certified under CLIA to perform high complexity tests, except that tests authorized for use in specific named or designated laboratories can only be used in such high complexity laboratories.
Tests will be added to Exhibit 1 after FDA determines it has received a complete notification.
Validation for this indication includes the validation protocol outlined below, “Validation of Expected Limit of Detection (LoD)”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. **Validation of Expected Limit of Detection (LoD)**
Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your IFU or procedure for testing 10-sample pools.
Prepare positive samples for your validation study at 10x the LoD of your previously authorized assay.
Test at least 20 independent extraction replicates of individual samples using the testing protocol in your authorized test’s IFU or procedure. Test 20 paired 10-sample pools in parallel, each containing aliquots from a single positive sample and 9 individual negative samples, using the volumes and testing protocol you intend to include in your IFU or procedure for testing 10-sample pools.
Your validation must demonstrate that:
- ≥95% of pooled replicates are detected as positive using the sample pooling protocol;
- The Ct score difference between the pooled and single swab protocols does not exceed 1.7 Ct; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
## Appendix G
### Media pooling up to n=5 – validation option 2
Subject to the terms of this EUA, a test that is within the Scope of this Amendment (Section II) is authorized for the following additional indication and may be distributed (if previously authorized for distribution per the underlying EUA) and used for this indication after validation is completed as set forth in this Appendix and a notification has been submitted to FDA and confirmed by FDA to be complete in accordance with Condition of Authorization C of this letter:
Qualitative detection of RNA from SARS-CoV-2 in pooled samples containing aliquots of transport media from up to 5 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials containing transport media, when tested as part of a serial testing program including testing at least once per week.
This indication is authorized for use in laboratories certified under CLIA to perform high complexity tests, except that tests authorized for use in specific named or designated laboratories can only be used in such high complexity laboratories.
Tests will be added to Exhibit 1 after FDA determines it has received a complete notification.
Validation for this indication includes the validation protocol outlined below, “Validation of the Effect on the Percent Agreement”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. **Validation of the Effect on the Percent Agreement**
Test at least 20 individual positive clinical specimens using the testing protocol in your authorized test’s IFU or procedure. Test 20 paired 5-sample pools in parallel, each containing aliquots from a single positive specimen and 4 randomly selected individual negative clinical specimens (collection of negative anterior nasal specimens from healthy individuals is acceptable), using the testing protocol you intend to include in your IFU or procedure for testing 5-sample pools.
20 unique positive specimens and 80 unique negative specimens are needed to comprise twenty 5-sample pools. At least 20% of positive clinical specimens used for this validation study should be low positives, where, for 5-sample pooling, a low positive is within 2.32 Ct of the mean Ct at LoD for your previously authorized test.
Archived individual clinical anterior nasal specimens are acceptable for this validation study, if available, given they contain enough volume for both individual and 5-sample pool testing. If archived specimens are used, the original diagnostic results are acceptable in lieu of repeating the individual specimen testing, if the original diagnostic results were acquired according to your previously authorized test’s IFU or procedure for individual testing.
If you cannot acquire at least 20% low positive samples as natural clinical specimens, you may dilute positive clinical specimens into pooled negative anterior nasal clinical matrix prepared as described here. Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your IFU or procedure for testing 5-sample pools.
Your validation must demonstrate that:
- ≥85% agreement between pooled testing and individual testing; and
- The invalid rate in the pooling protocol does not exceed 5%.
## Appendix H
### Media pooling up to n=10 – validation option 2
Subject to the terms of this EUA, a test that is within the Scope of this Amendment (Section II) is authorized for the following additional indication and may be distributed (if previously authorized for distribution per the underlying EUA) and used for this indication after validation is completed as set forth in this Appendix and a notification has been submitted to FDA and confirmed by FDA to be complete in accordance with Condition of Authorization C of this letter:
Qualitative detection of RNA from SARS-CoV-2 in pooled samples containing aliquots of transport media from up to 10 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials containing transport media, when tested as part of a serial testing program including testing at least once per week.
This indication is authorized for use in laboratories certified under CLIA to perform high complexity tests, except that tests authorized for use in specific named or designated laboratories can only be used in such high complexity laboratories.
Tests will be added to Exhibit 1 after FDA determines it has received a complete notification.
Validation for this indication includes the validation protocol outlined below, “Validation of the Effect on the Percent Agreement”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. **Validation of the Effect on the Percent Agreement**
Test at least 20 individual positive clinical specimens using the testing protocol in your authorized test’s IFU or procedure. Test 20 paired 10-sample pools in parallel, each containing aliquots from a single positive specimen and 9 randomly selected individual negative clinical specimens (collection of negative anterior nasal specimens from healthy individuals is acceptable), using the testing protocol you intend to include in your IFU or procedure for testing 10-sample pools.
20 unique positive specimens and 180 unique negative specimens are needed to comprise twenty 10-sample pools. At least 20% of positive clinical specimens used for this validation study should be low positives, where, for 10-sample pooling, a low positive is within 3.32 Ct of the mean Ct at LoD for your previously authorized test.
Archived individual clinical anterior nasal specimens are acceptable for this validation study, if available, given they contain enough volume for both individual and 10-sample pool testing. If archived specimens are used, the original diagnostic results are acceptable in lieu of repeating the individual specimen testing, if the original diagnostic results were acquired according to your previously authorized test’s IFU or procedure for individual testing.
If you cannot acquire at least 20% low positive samples as natural clinical specimens, you may dilute positive clinical specimens into pooled negative anterior nasal clinical matrix prepared as described here. Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your IFU or procedure for testing 10-sample pools.
Your validation must demonstrate that:
- ≥85% agreement between pooled testing and individual testing; and
- The invalid rate in the pooling protocol does not exceed 5%.
## Appendix I
### Required Changes to Authorized Labeling – Fact Sheets
Per Condition of Authorization A and as set forth in the Scope of this Amendment (Section II), your labeling must be updated in the following ways:
A) Fact Sheet for Healthcare Providers (a sample updated Fact Sheet for Healthcare Providers is included in Appendix J):
1) Include the additional authorized indication(s) from the applicable appendix in all places where the Fact Sheet includes the indications.
2) In the section titled “What does it mean if the specimen tests positive for the virus that causes COVID-19?” add the following paragraph immediately following the first paragraph:
_Individuals included in a pool that returns a positive or invalid result should be treated as a presumptive positive unless or until they receive a negative result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, they should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result._
3) In the section titled “What does it mean if the specimen tests negative for the virus that causes COVID-19?” add the following three paragraphs immediately following the first paragraph:
_In addition, asymptomatic people infected with COVID-19 may not shed enough virus to reach the limit of detection of the test, giving a false negative result. In the absence of symptoms, it is difficult to determine if asymptomatic people have been tested too late or too early. Therefore, negative results in asymptomatic individuals may include individuals who were tested too early and may become positive later, individuals who were tested too late and may have serological evidence of infection, or individuals who were never infected._
_Specimens with low viral loads may not be detected in sample pools due to the decreased sensitivity or increased interference of pooled testing. Your interpretation of negative results should take into account clinical and epidemiological risk factors._
_If COVID-19 is suspected based on exposure history together with other clinical findings, re-testing using a new sample with a sensitive method or without pooling should be considered by healthcare providers in consultation with public health authorities. Additional testing may be helpful to ensure testing was not conducted too early._
B) Fact Sheet for Patients (a sample updated Fact Sheet for Healthcare Providers is included in Appendix K):
1. In the section titled “Why was my sample tested?” add the following to the beginning of the section:
*You are being tested at regular intervals (serial testing) even though you do not have symptoms or risk factors for COVID-19; or*
And add the following to the end of the section:
*Laboratories may use pooling when testing your specimen, which means they combine your sample with other individuals samples prior to testing and test them as a “pool”. The laboratory may return a result for the entire pool together or may return individual results.*
2. In the section titled “What does it mean if I have a positive test result?” add the following to the beginning of the section:
*If you were tested as part of a pool that returned a positive or invalid test result, you may have COVID-19 and should consider yourself to have a positive test result unless and until you receive a negative test result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, you should isolate until receiving a negative result when re-tested individually and should not be grouped with other individuals who have received a positive or presumptive positive result.*
3. In the section titled “What does it mean if I have a negative test result?” add the following after the second paragraph of the section:
*In particular, people infected with COVID-19 but who have no symptoms may not shed enough virus to trigger a positive test.*
*If your test result indicates your specimen was pooled and you have a negative test result there a small chance that your result is incorrect. You should talk with your healthcare provider if you are concerned.*
And add the following paragraph and text box to the end of the section:
*If you have no symptoms but have been tested because your doctor thought you may have been exposed to COVID-19, you should continue to monitor your health and let your healthcare provider know if you develop any symptoms of COVID-19. If you develop symptoms you may need another test to determine if you have contracted the virus causing COVID-19.*
**If you develop symptoms or your symptoms get worse you should seek medical care. If you have the following symptoms you should seek immediate medical care at the closest emergency room:**
- Trouble breathing
- Persistent pain or pressure in the chest
- New confusion
- Inability to wake up or stay awake
- Bluish lips or face
## Appendix J
### Sample Updated Fact Sheet for Health Care Providers
## Appendix K
### Sample Updated Fact Sheet for Patients
¹ U.S. Department of Health and Human Services, *Determination of a Public Health Emergency and Declaration that Circumstances Exist Justifying Authorizations Pursuant to Section 564(b) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3*. 85 FR 7316 (February 7, 2020)
² Based on the production and testing capacity estimates provided by test developers and the anticipated demand by schools, workplaces and other groups setting up testing programs, the need for testing remains greater than available resources. If such testing programs are scaled up using individual tests, it would likely overwhelm the supply chain for many of the consumables used for diagnostic testing. Pooled testing strategies are intended to address public health needs by mitigating potential shortages.
³ CDRH IVD EUA webpage [FDA EUA](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas).
⁴ For ease of reference, this letter uses the phrase “authorized tests” to refer to molecular-based tests authorized by this amendment to detect nucleic acid from SARS-CoV-2 with pooled anterior nasal respiratory specimens for screening when used as part of a serial testing program.
⁵ No other criteria of issuance have been prescribed by regulation under Section 564(e)(4) of the Act.
⁶ The additional indications for use authorized by this amendment are limited to anterior nasal swab specimens and do not include any additional indications for other specimen types, such as saliva.
⁷ In other words, this amendment does not amend EUAs for tests for which validation data for pooling was submitted, reviewed, and not authorized for pooling.
⁸ In other words, this amendment does not amend EUAs for tests for which validation data from asymptomatic individuals was submitted, reviewed, and not authorized for screening.
# 404 2021-04-20_FDA Website - Pooling and Serial Testing Amendment.md
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notes: date converted 2024-03-27
web_url: https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2#amendment
summary_short: The Pooling and Serial Testing Amendment explains FDA’s April 20, 2021 amendment that allowed certain authorized molecular SARS-CoV-2 tests to use pooled anterior nasal specimens from asymptomatic individuals within serial testing programs after developers submit a complete notification and validation documentation. It specifies CLIA high-complexity laboratory limitations and describes how authorized pooling parameters vary by appendix (pool sizes up to 3, 5, or 10 and media vs. swab pooling). It also clarifies that FDA adding a test to the exhibit/list reflects receipt of required documentation and does not necessarily indicate FDA review of the underlying validation data.
CONTENT
On April 20, 2021, the FDA issued an amendment allowing certain authorized molecular diagnostic SARS-CoV-2 tests to be distributed and used to pool anterior nasal respiratory specimens from asymptomatic individuals as part of a serial testing program after developers submit a complete notification, including meeting required validation data, as set forth in the letter. Use of tests for these indications is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, except that tests authorized for use in specific named or designated high complexity laboratories can only be used in such laboratories.
This means that tests with EUAs that are amended by this authorization may be used with pooled anterior nasal specimens from individuals without known or suspected COVID-19 when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week. The indications in each appendix (A-H) differ in the number of specimens that can be pooled (up to 3, up to 5, or up to 10) and the type of pooling that can be done (media pooling or swab pooling).
Prior to a test being distributed or used for any new indication, the developer must submit a notification to the FDA with the information required by the amendment, including self-certifying that the applicable validation has been completed. Tests will be added to Exhibit 1 once FDA confirms that the required documentation has been submitted. Please note that being added to Exhibit 1 does not necessarily mean that the FDA has reviewed the underlying validation data submitted or confirmed that the test is appropriately validated.
[Amendment Letter](https://www.fda.gov/media/147737/download?attachment)
[Appendix J - Sample Updated Fact Sheet for Health Care Providers](https://www.fda.gov/media/147735/download?attachment)
[Appendix K - Sample Updated Fact Sheet for Patients](https://www.fda.gov/media/147736/download?attachment)
# 2,666 2021-09-23_FDA Letter - Viral Mutation Revision Letter.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-09-23_FDA Letter - Viral Mutation Revision Letter.md
file_date: 2021-09-23
title: FDA Letter - Viral Mutation Revision Letter
category: regulatory
subcategory: fda-policy
tags:
source_file_type: pdf
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: https://drive.google.com/file/d/1gZNI6dqEWCLUV53lH6YIuPVIjQ9K8hxZ
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2021-09-23_FDA%20Letter%20-%20Viral%20Mutation%20Revision%20Letter.pdf
conversion_input_file_type: pdf
conversion: megaparse-v
license: Public Domain
tokens: 2666
words: 1664
notes:
summary_short: The FDA “Viral Mutation Revision Letter” (September 23, 2021) adds new EUA Conditions of Authorization for certain molecular, antigen, and serology COVID-19 IVDs to address potential performance impacts from emerging SARS-CoV-2 variants. It requires developers to update authorized labeling within a defined timeframe to include variant-related limitations, conduct ongoing evaluations of mutation impacts (including multi-analyte targets), and rapidly notify FDA and implement additional risk-mitigation labeling if concerns arise. It is used to standardize post-authorization surveillance and communication about variant-driven performance changes across EUA-authorized tests.
CONTENT
September 23, 2021
To: Developers of Certain Molecular, Antigen and Serology In Vitro Diagnostics (IVDs) Authorized for Emergency Use for Coronavirus Disease 2019 (COVID-19) as of Today’s Date
Re: Establishing additional Conditions of Authorization for the EUAs of Certain Molecular, Antigen and Serology IVDs related to viral mutations.
On February 4, 2020, pursuant to Section 564(b)(1)(C) of the Federal Food, Drug, and Cosmetic Act (the Act) (21 U.S.C. § 360bbb-3(b)(1)(C)), the Secretary of the Department of Health and Human Services (HHS) determined that there is a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad, and that involves the virus that causes COVID-19. Pursuant to Section 564 of the Act, and on the basis of such determination, the Secretary of HHS then declared that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the virus that causes COVID-19 subject to the terms of any authorization issued under Section 564(a) of the Act.^1^ FDA subsequently authorized the emergency use of numerous in vitro diagnostics (IVDs) for detection and/or diagnosis SARS-CoV-2, the virus that causes COVID-19.^2^
Pursuant to Section 564 of the Act, and in response to the continued emergence of new genetic viral variants of SARS-CoV-2,^3^ FDA is issuing this letter to establish additional Conditions of Authorization on EUAs that are within the Scope of this Revision (Section I).
As set forth throughout, this letter revises the EUAs that are within the scope of this letter to require the additional Conditions of Authorization included in Section III of this letter. These conditions generally concern labeling updates and performance evaluations related to SARS-CoV-2 viral mutations for authorized tests that are within the scope of this revision.^4^ FDA’s determination that the Conditions of Authorization established by this revision are necessary or appropriate to protect the public health is based on the available scientific evidence and FDA’s continuing efforts to monitor the performance of authorized molecular, antigen, and serology IVDs with respect to emerging SARS-CoV-2 mutations.
Having concluded that establishing these additional conditions on the EUAs that are within the scope of this letter (section I) is appropriate to protect the public health or safety, I am hereby revising all such EUAs pursuant to Section 564(g)(2)(C) to establish the additional conditions set forth in this letter as permitted by Section 564(e) of the Act. This action is based on the available scientific evidence,^5^ including widespread detection of variants of the SARS-CoV-2 virus.
## I. Scope of this Revision
Except as provided in the next paragraph, this letter revises the EUAs of the following SARS-CoV-2 IVD devices that have been issued as of today’s date by establishing the additional conditions of authorization set forth in Section IV of this letter on such authorizations:
- [Molecular IVD devices](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas/molecular-diagnostic-tests-sars-cov-2).
- [Antigen IVD devices](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas/antigen-diagnostic-tests-sars-cov-2).
- [Serology IVD devices](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-serology-and-other-adaptive-immune-response-tests-sars-cov-2).
This revision does not apply to EUAs for authorized IL-6 assays, EUAs for standalone specimen collection devices, or EUAs for standalone home collection kits. Nor does this revision apply to EUAs that include substantially equivalent viral mutation conditions of authorization.
All updated labeling will be added to FDA’s webpage and posted with the EUA after it is submitted to FDA as required by Condition of Authorization (1) of this letter.
## II. Waiver of Certain Requirements
This revision does not change the waiver of any requirements included in the EUAs being amended.
## III. Conditions of Authorization
Pursuant to Section 564(e) of the Act, I am establishing the additional conditions below with respect to SARS-CoV-2 viral mutations.
**Developer (You)**
1. You must update your authorized labeling as set forth in Appendix A and B of this letter within 3 months of today’s date by submitting the updated labeling to FDA as a supplement to your EUA, unless otherwise agreed to by the Division of Microbiology (DMD)/Office of Health Technology 7 (OHT7)-Office of In Vitro Diagnostics and Radiological Health (OIR)/Office of Product Evaluation and Quality (OPEQ)/Center for Devices and Radiological Health (CDRH).^9^
2. You must evaluate the impact of SARS-CoV-2 viral mutations on your product’s performance. For multi-analyte tests, you must evaluate the impact of SARS-CoV-2 viral mutations and all other target analytes. Such evaluations must occur on an ongoing basis and must include any additional data analysis that is requested by FDA in response to any performance concerns you or FDA identify during routine evaluation. Additionally, if requested by FDA, you must submit records of these evaluations for FDA review within 48 hours of the request. If your evaluation identifies viral mutations that affect the stated expected performance of your device, you must notify FDA immediately (via email: CDRH-EUA-Reporting@fda.hhs.gov).
3. If requested by FDA, you must update your labeling within 7 calendar days to include any additional labeling risk mitigations identified by FDA regarding the impact of viral mutations on test performance. Such updates will be made in consultation with, and require concurrence of, DMD/OHT7-OIR/OPEQ/CDRH.
Sincerely,
/S/
RADM Denise M. Hinton
Chief Scientist
Food and Drug Administration
Enclosure
## Appendix A
**Required Changes to Authorized Labeling – IFU/Laboratory SOP and/or EUA Summary**
As required by Condition of Authorization (1), you must update your authorized labeling (e.g., IFU, Laboratory SOPs and/or EUA Summary) to include the limitation below:
*The performance of this test was established based on the evaluation of a limited number of clinical specimens. Clinical performance has not been established with all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation. Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2 and their prevalence, which change over time.*
## Appendix B
**Required Changes to Authorized Labeling – Fact Sheet for Healthcare Providers**
As required by Condition of Authorization (1), you must update the Fact Sheet for Healthcare Providers as follows:
1. For molecular and antigen IVDs at the end of the section titled “What does it mean if the specimen tests negative for the virus that causes COVID-19?” add the following paragraph:
*The performance of this test was established based on the evaluation of a limited number of clinical specimens. The clinical performance has not been established in all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation. Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2 and their prevalence, which change over time.*
2. For serology IVDs at the end of the section titled “What does it mean if the specimen tests negative for antibodies against virus that causes COVID-19?” add the following paragraph:
*The performance of this test was established based on the evaluation of a limited number of clinical specimens. The clinical performance has not been established in all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation. Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2 and their prevalence, which change over time.*
^1^: U.S. Department of Health and Human Services, *Determination of a Public Health Emergency and Declaration that Circumstances Exist Justifying Authorizations Pursuant to Section 564(b) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3, 85 FR 7316 (February 7, 2020)*
^2^: In Vitro Diagnostics EUAs: [FDA Website](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas), includes links to tables of currently authorized IVD EUAs for SARS-CoV-2.
^3^: Like all viruses, the SARS-CoV-2 genome has changed over the course of the COVID-19 pandemic through mutation, with new genetic viral variants of the virus documented in the United States and globally. Sometimes new mutations emerge and disappear, and other times they persist and the resulting new viral variants grow in prevalence. CDRH has been monitoring SARS-CoV-2 genetic viral mutations because of their potential to affect authorized SARS-CoV-2 IVDs. CDRH’s monitoring of SARS-CoV-2 genetic viral mutations resulted in FDA releasing a January 8, 2021 [safety alert](https://www.fda.gov/news-events/press-announcements/fda-issues-alert-regarding-sars-cov-2-viral-mutation-health-care-providers-and-clinical-laboratory) to healthcare providers and clinical laboratory staff about the potential impact of viral mutations on the performance of authorized molecular SARS-CoV-2 IVDs. This was subsequently followed by an FDA [guidance document](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-evaluating-impact-viral-mutations-covid-19-tests), issued in February 2021 - *“Policy for Evaluating Impact of Viral Mutations on COVID-19 Tests: Guidance for Test Developers and Food and Drug Administration Staff, February 2021,”* outlining the FDA’s concerns about the impact of viral mutations and recommendations for evaluating molecular, antigen and serology IVDs accordingly. In addition, a webpage was developed to provide information regarding the impact of viral mutations on SARS-CoV-2 tests, including the recommendations for clinical laboratory staff and health care providers from the safety alert, and information about certain tests for which the FDA has identified potential impacts on performance due to SARS-CoV-2 genetic mutations. This website was first posted in March 2021 and updated in June 2021: [SARS-CoV-2 Viral Mutations: Impact on COVID-19 Tests | FDA](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-viral-mutations-impact-covid-19-tests).
^4^: Authorized labeling potentially impacted by the additional conditions established by this letter include some combination of the following documents: Instructions for Use (IFU), laboratory Standard Operating procedures (SOPs), EUA Summary and/or Fact Sheet for Healthcare Providers. Note that the EUA Summary is generated by FDA who will update the document after it receives the supplement request to update the test’s other labeling consistent with this revision.
^5^: *SARS-CoV-2 Viral Mutations: Impact on COVID-19 Tests | FDA*: [FDA Website](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-viral-mutations-impact-covid-19-tests).
^9^: FDA will update the Healthcare Provider Fact Sheet for the “Umbrella EUA for Molecular Diagnostic Tests for SARS-CoV-2 Developed and Performed By Laboratories Certified Under CLIA To Perform High Complexity Tests.” Test developers that use this Fact Sheet for their tests should begin using the updated version no later than 3 months from today’s date.
^10^: The Fact Sheet for Patients/Individuals/Recipients does not include language specific to viral mutations and therefore does not need to be updated as part of this revision.
# 435 2021-09-23_FDA Website - Revision Concerning Viral Mutations.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-09-23_FDA Website - Revision Concerning Viral Mutations.md
file_date: 2021-09-23
title: FDA Website - Revision Concerning Viral Mutations
category: regulatory
subcategory: fda-policy
tags:
source_file_type: website
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: NA
pdf_github_url: NA
conversion_input_file_type: docx
conversion: manual cut and paste
license: Public Domain
tokens: 435
words: 284
notes: date converted 2024-03-27
web_url: https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2#Revision
summary_short: The Revision Concerning Viral Mutations summarizes FDA’s September 23, 2021 update to certain molecular, antigen, and serology COVID-19 test EUAs adding new Conditions of Authorization to address emerging SARS-CoV-2 variants. It requires EUA holders to monitor viral mutations for potential performance impacts, communicate identified risks to FDA and end users, and update and submit revised labeling within three months. The change was intended to reduce false negatives linked to decreased sensitivity or non-reactivity from new mutations, with specific exclusions for some EUA categories.
CONTENT
On September 23, 2021, the FDA revised the EUAs of certain molecular, antigen, and serology tests to establish additional Conditions of Authorization in response to the continued emergence of new variants of SARS-CoV-2. The revision requires test developers to update their authorized labeling and evaluate the impact of SARS-CoV-2 viral mutations on their test's performance as outlined in the letter. This revision is effective as of September 23, 2021 for all EUAs that are within the scope of the revision. This revision does not apply to EUAs for authorized IL-6 assays or standalone specimen collection devices and does not apply to EUAs that include substantially equivalent viral mutation conditions of authorization.
The FDA has determined that establishing additional conditions is necessary to mitigate the potential risk of false negative results due to either decreased sensitivity or non-reactivity associated with SARS-CoV-2 viral mutations. As set forth in the September 23, 2021 letter, developers of authorized tests that are within the scope of the revision are now required to routinely monitor emerging viral mutations and their potential impact on the performance of the authorized SARS-CoV-2 test(s). If potential impacts are identified, the EUA holder must communicate with the FDA and end users about the potential risk that presence of the mutations may have on test performance. The EUA holder must also update their authorized labeling consistent with the revision letter and submit the labeling to the FDA within 3 months of September 23, 2021. By taking these steps, the FDA and the test developer can quickly act in response to the potential risks identified and, when applicable, share the findings on [SARS-CoV-2 Viral Mutations: Impact on COVID-19 Tests](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-viral-mutations-impact-covid-19-tests?utm_medium=email&utm_source=govdelivery).
[Viral Mutation Revision Letter - September 23, 2021](https://www.fda.gov/media/152406/download?attachment)
# 31,076 2021-10-06_FDA Template - For Developers of Molecular Diagnostic Tests.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-10-06_FDA Template - For Developers of Molecular Diagnostic Tests.md
file_date: 2021-10-06
title: FDA Template - For Developers of Molecular Diagnostic Tests
category: regulatory
subcategory: fda-policy
tags:
source_file_type: docx
xfile_type: docx
gfile_url: https://docs.google.com/document/d/1APPBLs59clpaOt2qBMzYbHVXvFpqkJas
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pdf_gdrive_url: https://drive.google.com/file/d/1xQ8iaicJm2rzOVlw351yDv5gKlFahDqc
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2021-10-06_FDA%20Template%20-%20For%20Developers%20of%20Molecular%20Diagnostic%20Tests.pdf
conversion_input_file_type: docx
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license: Public Domain
tokens: 31076
words: 20940
notes:
summary_short: The FDA “Template for Developers of Molecular Diagnostic Tests” is a detailed pre-EUA/EUA submission template outlining recommended validation, clinical study design, and labeling content for SARS-CoV-2 molecular diagnostics. It covers core analytical studies (LoD, inclusivity/variant monitoring, cross-reactivity, interference, stability), clinical performance expectations for symptomatic and asymptomatic screening populations, and requirements for pooled testing, including validation approaches and ongoing pooling monitoring/re-assessment. It is used by developers to structure submissions and align evidence packages with FDA review criteria, including manufacturing, software, reporting, and post-authorization obligations.
CONTENT
***INTERNAL TITLE:*** Template for Developers of Molecular Diagnostic Tests
This template provides the Food and Drug Administration’s (FDA) current recommendations concerning what data and information should be submitted to FDA in support of a pre-Emergency Use Authorization (EUA)/EUA request for a SARS-CoV-2 molecular diagnostic test. FDA generally recommends that the following validation studies be conducted for SARS-CoV-2 molecular diagnostic tests: limit of detection (LOD), inclusivity, cross-reactivity, sample stability, and clinical evaluation.
As described in the FDA guidance document [*Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised), [2] FDA is providing recommendations in this and other EUA templates regarding testing that should be performed to ensure appropriate analytical and clinical validity, including descriptions of appropriate comparators, for different types of tests. The EUA templates[3] are intended to help test developers provide recommended validation data and other information to FDA, but alternative approaches can be used. This template reflects FDA’s current thinking on the topic, and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should,* means that something is suggested or recommended, but not required. For more information about EUAs in general, please see the FDA guidance document: [*Emergency Use Authorization of Medical Products and Related Authorities*](https://www.fda.gov/media/97321/download).[4]
Test developers interested in pursuing an EUA may submit a pre-EUA to begin discussions with the FDA or may submit an EUA request to .
FDA recommends that all developers of molecular SARS-CoV-2 tests include the [Molecular EUA Template Cover Sheet](https://www.fda.gov/media/152768/download)[5] when submitting their EUA request to to help streamline the routing, triage, and review of EUA requests.
## GENERAL INFORMATION ABOUT THIS TEMPLATE
- Text highlighted in yellow ***\[Text\]*** should be completed by the test developer as applicable to their specific test. Text in **bold** outlines the FDA’s additional recommendations for the developers’ consideration when completing the suggested information in each section.
- Not all portions of this template may be relevant for all developers/tests. FDA recommends developers complete all portions that are relevant to facilitate a streamlined review.
- This template addresses tests intended for use with respiratory samples and saliva; if you are considering other sample types, please contact FDA at CDRH-EUA-Templates () to discuss your validation strategy.
- A test authorized under an EUA is only authorized for emergency use while the EUA is in effect.
- We may update the template as appropriate as we learn more about COVID-19 and gain experience with the EUA process for these kinds of tests.
- A developer that has provided data to the FDA may grant a right of reference to other developers, either broadly or to individual developers, to leverage that data. A right of reference provides a developer the ability to rely upon, and otherwise use, existing information in one regulatory submission for the purpose of supporting a different regulatory submission. In these cases, if the data is applicable to the new developer's test, the new developer may not have to repeat that validation for its submission to the FDA or FDA may recommend only a bridging study. Any developer seeking to leverage data regarding another developer’s EUA-authorized assay must obtain a right of reference from that developer. [6]
## EXAMPLE TEMPLATE:
### A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the ***\[test name\]*** for the *in vitro* qualitative detection of RNA from the SARS-CoV-2 in ***\[add all claimed sample types, e.g., nasopharyngeal/ oropharyngeal swabs, sputa, bronchoalveolar lavage (BAL), etc.\]*** ***\[select appropriate testing population, e.g.,*** ***from patients suspected of COVID-19 by a healthcare provider or for screening of individuals without symptoms or other reasons to suspect COVID-19.\]******.*** Test results should be reported in accordance with local, state, and federal regulations.
***\[If you plan to include a sample pooling protocol in your instructions for use, please include a brief description of the pooling strategy.\]***
***\[If you plan to request authorization for screening with serial testing, please refer to the*** *[Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing](https://www.fda.gov/media/146695/download) **and include any relevant information.****\]***
***\[If you plan to request authorization to test samples collected with a home specimen collection kit, please refer to the** [Home Specimen Collection Molecular Diagnostic Template](https://www.fda.gov/media/138412/download) **and include any relevant information.****\]***
### B. MEASURAND
Specific nucleic acid sequences from the genome of the SARS-CoV-2 ***\[please specify the targeted gene(s) of the pathogen\]***.
### C. APPLICANT
***\[Official name, address, and contact information (including phone number and email address) of applicant and primary correspondent.\]***
### D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name - ***\[test name\]***
Established Name - ***\[test name\]***
### E. REGULATORY INFORMATION
***Approval/Clearance Status:***
The ***\[test name\]*** test is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
***\[If the test has been previously reviewed in an EUA request or pre-EUA submission, please provide the submission number.\]***
Panel Code: MI for Microbiology tests
Review Group: Division of Microbiology Devices/VIR1
***Product Code:***
QJR (for SARS-CoV-2 only tests)
**OR**
QLP (for multi-analyte tests that include SARS-CoV-2)
### F. PROPOSED INTENDED USE
#### 1) Intended Use (IU):
**The proposed IU will be finalized based on, among other things, the data provided and recommendations from Public Health authorities at the time of authorization – example text is provided below for a qualitative molecular test that detects organism RNA but may be adapted according to the specific emergency situation addressed by the device, proposed intended use population, testing sites, or performance characteristics.**
The ***\[test name\]*** is a ***\[specify test technology such as, real-time RT-PCR test\]*** intended for the ***\[presumptive\]*** qualitative detection of RNA from SARS-CoV-2 in ***\[describe all the sample types that were evaluated, e.g., nasopharyngeal, nasal, and oropharyngeal swab samples and lower respiratory tract, BAL, sputum\]*** ***\[If your test is intended for testing multiple respiratory pathogens, please list the specific analytes detected by your test.\] \[describe intended use population, e.g., from individuals suspected of COVID-19 by their healthcare provider or for screening of individuals without symptoms or other reasons to suspect COVID19 infection.\].*** Testing is limited to ***\[laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, that meet the requirements to \[insert testing complexity, e.g., moderate complexity, high complexity, or waived tests. This test is authorized for use at the Point of Care (POC), i.e., in patient care settings operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation.\].***
***\[Describe the sample pooling approach, as appropriate\].*** This test is also for the qualitative detection of nucleic acid from SARS-CoV-2 in pooled samples containing up to ***\[maximum number\]*** individual ***\[type of sample and collection method\],*** where each specimen is collected using ***\[type of sample and collection method\]***. Negative results from pooled testing should not be treated as definitive. If a patient’s clinical signs and symptoms are inconsistent with a negative result or if results are necessary for patient management, then the patient should be considered for individual testing. Specimens included in pools with a positive or invalid result must be tested individually prior to reporting a result. Specimens with low viral loads may not be detected in sample pools due to the decreased sensitivity of pooled testing. For specific patients whose specimen(s) were the subject of pooling, a notice that pooling was used during testing must be included when reporting the result to the clinician or healthcare provider.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in ***\[name sample type, e.g., upper respiratory\]*** during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease.
Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
The ***\[test name\]*** is intended for use by ***\[include intended user, e.g., qualified, and trained clinical laboratory personnel specifically instructed and trained in the techniques of RT-PCR and in vitro diagnostic procedures\]***.
The ***\[test name\]*** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
**Depending on the performance and the populations studied in the clinical evaluation, additional limitations may be recommended.**
#### 2) Special Conditions for Use Statements:
For prescription use only
For *in vitro* diagnostic use
For Emergency Use Authorization only
#### 3) Special Instruments
The ***\[test name\]*** test is to be used with the ***\[list all RT-PCR instruments, software, and automated extraction instruments, other applicable instrumentation, etc.\]***.
**If your test system includes an instrument, the instrumentation manual should be submitted as part of the EUA request. If your test system includes an instrument that was not previously cleared, approved, or authorized by FDA, please see additional discussion in the Product Manufacturing section and note that additional labeling information may be discussed during the EUA review.**
### G. DEVICE DESCRIPTION AND TEST PRINCIPLE
**Please provide a device description. The example provided below applies to fluorescence based real-time reverse-transcriptase-polymerase chain reaction (RT-PCR) tests for detection of organism RNA. Please modify the example text as appropriate for tests that use a different test principle. For new technologies, FDA may request additional information so we can adequately assess the known and potential risks and benefits associated with the device*.***
#### 1) Product Overview/Test Principle:
***\[Describe the technology of the test and how this technology works to identify the measurand (i.e., the test principle), the instruments/reader employed/required to perform the test from sample collection to result (include all claimed extraction and PCR detection instruments), and the sample types for which the performance of the test has been established**. **If applicable, list all primer and probe sets, briefly describe what they detect, and include the nucleic acid sequences. Please indicate if the test uses biotin-Streptavidin/avidin chemistry in any of the steps for coupling reagents.\]***
The ***\[test name\]*** is a real-time reverse transcription polymerase chain reaction (RT-PCR) test. The SARS-CoV-2 primer and probe set(s) is designed to detect RNA from the SARS-CoV-2 in ***\[list all the sample types\]*** from patients suspected of COVID-19 by their healthcare provider.
#### 2) Description of Test Steps:
***\[List and describe in detail all the steps of the test sequentially from sample collection to assay report.\]***
1. ***\[Step one\]***
2. ***\[Step two\]***
3. ***Etc.…\]***
Nucleic acids are isolated and purified from ***\[samples\]*** using ***\[please describe the method(s) of extraction (please specify the*** ***sample input volume for extraction and/or test, the nucleic acid elution volume and whether isolation/purification is manual and/or automated)\]******.*** The purified nucleic acid is reverse transcribed using ***\[enzyme mix/kits – please specify the input volume of purified nucleic acid added to the RT-PCR reaction mix\]*** into cDNA which is then subsequently amplified in ***\[please describe the instrument(s) and enzyme mix\]***. In the process, the probe anneals to a specific target sequence located between the forward and reverse primers. During the extension phase of the PCR cycle, the 5’ nuclease activity of Taq polymerase degrades the probe, causing the reporter dye to separate from the quencher dye, generating a fluorescent signal. With each cycle, additional reporter dye molecules are cleaved from their respective probes, increasing the fluorescence intensity. Fluorescence intensity is monitored at each PCR cycle by ***\[please describe the detection instrument(s)\]***.
#### 3) Control Material(s):
***\[List all control materials (provided with the test kit and/or required but not provided with the test kit, e.g., sold as a separate kit) and describe what they are, how they are expected to work, where in the testing process they are used, and the frequency of use. If a control is commercially available, provide supplier’s name and catalog number or other identifier; if your device relies on external controls that are manufactured by a third party please note that these controls should also be validated within your analytical and clinical studies described below in Section J.\]***
Controls that will be provided with the test kit include:
a. An external positive template control is needed to ***\[describe need\]*** and is used ***\[describe use – please specify the concentration of the positive control relative to the LoD of your test (note that ideally the positive control concentration should be such that it is close to the LoD of your test) and specify frequency of use.\]***
b. An external negative control is needed to ***\[describe need\]*** and is used ***\[describe use – please specify the composition of the negative control and specify frequency of use.\]***
c. An extraction control ***\[describe control\]*** is needed to ***\[describe need\]*** and is used ***\[describe use – please also specify frequency of use\].*** **Please note that if the positive control is taken through the entire sample processing procedure, including the extraction, then a separate extraction control is not required**.
d. A ***\[other (e.g., sample adequacy, internal, etc.)\]*** control is needed to ***\[describe need\]*** and is used ***\[describe use – please specify the composition of the control and specify frequency of use\]***
Controls that are required but not provided with the test kit include ***\[describe control – provide recommended sources of the control materials – either a separate control kit for purchase that you the applicant develops or a control material that can be purchased from a third party\].*** This/these control(s) is/are needed to ***\[describe need\]*** and is used ***\[describe use – please also specify frequency of use\]***.
**Please note that any control used with your device (provided with the kit or not) should be validated in the context of your analytical and clinical studies (i.e., your studies should include use of these controls). In instances where control material is not readily available through 3^rd^ party vendors, FDA recommends that you include suitable control material with your device. External control materials are considered particularly important when good manufacturing practice (GMP) requirements are waived, and reagent stability studies are limited.**
#### 4) Test Result Reporting:
All test results are to be reported to healthcare providers and relevant public health authorities in accordance with local, state, and federal requirements, using appropriate LOINC and SNOMED codes, as defined by the [*Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests*](https://www.cdc.gov/csels/dls/sars-cov-2-livd-codes.html)[7] provided by the Centers for Disease Control and Prevention (CDC). Core diagnostic data elements[8] are to be collected for all tests, which have been defined by the Department of Health and Human Services (HHS), along with technical specifications for implementation for lab-based[9] and non-lab-based[10] tests.
### H. INTERPRETATION OF RESULTS
All test controls should be examined prior to interpretation of patient results. If the controls are not valid, the patient results cannot be interpreted. ***\[Appropriate control interpretation criteria should appear in your product labeling.*** ***Please describe if a Ct (cycle threshold) cutoff is used as part of your testing algorithm and/or if the end user is required to review curves before final result interpretation. Although not typical for molecular-based tests, if the test result involves the use of an algorithm/calculation, for example a ratio value, when determining the final patient test result, please include a detailed description and any additional calibration materials that may be required.\]***
#### 1) *\[Test name\] Controls – Positive, Negative, and Others:*
\[Describe in detail the expected results generated, including acceptance criteria, for all the controls described in Section G above. Describe the measured values (if applicable) for valid and invalid controls and outline the recommended actions the laboratory should take in the event of an invalid control result.\]
#### 2) *Examination and Interpretation of Patient Sample Results:*
\[Describe when clinical sample test results should be assessed and outline the criteria for test validity.\]
**Example text:** Assessment of \[test name\] results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
***\[Clearly indicate how to interpret numeric test values (if applicable) as positive or negative for presence of SARS-CoV-2. Indicate if the end user is required to review curves before final result interpretation and, if applicable, how to identify indeterminate/inconclusive/equivocal results. When applicable, we recommend providing a table clearly describing the possible combinations of test result values for each primer/probe set. Describe how they should be combined into a final interpretation of the result for your test. If the test produces an equivocal or indeterminate result, please indicate what follow-up testing/process should be conducted, if applicable.\]***
### I. PRODUCT MANUFACTURING
The \[test name\] has been validated using only the components referenced in this request and will not be changed after authorization without prior concurrence from the FDA.
#### 1) Overview of Manufacturing and Distribution:
The product will be manufactured at ***\[test developer’s name and FDA registration number (if applicable)\]*** by ***\[test developer’s name\]*** personnel consistent with practices for the production of ***\[types of devices\]*** based on ***\[type of quality system (e.g., 21 CFR 820 or ISO13485)\]*.** Material manufactured by ***\[test developer’s name\]*** may be bottled and kitted by ***\[packager name\]*** manufacturing facility.
The current manufacturing capabilities include the ability to manufacture approximately ***\[please insert the approximate number of tests/kits that can currently be manufactured per week at the manufacturing facility\]*** products per week for distribution in the United States, however, in the event of a surge in demand this could be increased to ***\[please insert the approximate maximum number of tests/kits that could potentially be manufactured per week at the manufacturing facility if there was a surge in demand\]*** product per week within a ***\[please specify in weeks/months the expected timeframe required to increase product production if conditions warrant\]*** timeframe.
**Under an EUA, certain sections of the 21 CFR Part 820 Quality System Regulation (QSR) requirements may be waived for an authorized produced during the duration of the EUA, but FDA recommends that test developers follow comparable practices as much as possible, even if such requirements are waived. Please see recent letters of authorization for examples of which QSR requirements have been required.**
***\[Please specify any instruments or other components of your test which are labeled as research use only (RUO) or are otherwise not labeled with the statement “For In Vitro Diagnostic Use” or a symbol found in a standard to the same effect.\]***
**For distributed tests (i.e., tests intended to be performed in more than one laboratory location), that use an RUO instrument, please provide the following information, as applicable:**
***FOR AN RUO INSTRUMENT WHERE THE EUA REQUESTER IS NOT THE MANUFACTURER OF THE INSTRUMENT:***
**Please include in the instructions for use found in your test’s labeling, appropriate procedures, including acceptance criteria, that laboratory customers should follow to qualify the performance of the RUO instrument prior to use with your test.**
**These procedures could include wet testing of quantitated test material with your test, or confirmation that key specifications of the instruments that are applicable to your test are within an acceptable range. The quantitated virus material could either be positive control material included with your kit or commercially available positive virus control material. If commercially available material is not labeled with the statement “For *In Vitro* Diagnostic Use” or a symbol found in a standard to the same effect, then you should qualify lots of this material in-house and have a mechanism to notify laboratory customers which lots are appropriate to use for qualification (i.e., posting on a website). For the qualification protocol, you should include a recommendation to test multiple dilutions of virus material with your test, with, at minimum, 3 replicates per dilution. There should be at least one dilution near the LoD (i.e., within 3x LoD) of your test. The protocol should outline the acceptance criteria for each dilution tested.**
***\[Please also provide the following** **labeling documentation with your request:***
1. ***A "For Emergency Use Authorization only" label that users can affix to the instrument after it has been qualified. This can be provided as an Appendix in the assay instructions for use.***
2. ***Please ensure that your test’s labeling either reproduces the parts of the instrument operating manual that are relevant to run your test or references the relevant sections of the manual.\]***
***FOR AN RUO INSTRUMENT WHERE THE EUA REQUESTER IS THE MANUFACTURER OF THE INSTRUMENT:***
***\[Please either provide the qualification protocol as described above or the following information to demonstrate your instrument meets the minimum quality system requirements for authorization:***
1. ***The ISO 13485 certificate for the site where your instrument is manufactured.***
2. ***A document mapping out the parts of your quality system that fulfill each of the following 21 CFR part 820 requirements:***
- ***Subpart H (Acceptance Activities, 21 CFR 820.80 and 21 CFR 820.86),***
- ***Subpart I (Nonconforming Product, 21 CFR 820.90), and***
- ***Subpart O (Statistical Techniques, 21CFR 820.250).***
***Please provide the following labeling documentation with your request:***
1. ***A “For Emergency Use Authorization only” label that the users can affix to the instrument after it has been qualified. This can be provided as an Appendix in the assay instructions for use.***
2. ***The instrument operating manual. Please note that the manual should not include any unapproved, uncleared, or unauthorized uses.***
3. ***An instrument manual addendum that will be distributed along with your EUA test kit. The addendum may have the following format:\]***
***Instrument Operation Manual Addendum:***
For emergency use authorization only with the ***\[test name\]***.
The ***\[test name\]*** is authorized for use under the US Food and Drug Administration (FDA) Emergency Use Authorization (EUA) with the ***\[name of instruments\]*** for the ***\[presumptive\]*** qualitative detection of RNA from SARS-CoV-2 ***\[intended use of test\].*** Refer to the ***\[test name\]*** instructions for use for additional information ***\[provide hyperlink\].***
This instrument operation manual addendum applies to the instruments listed in Table below that are authorized for use with the ***\[test name\].***
**Table: Instruments Authorized for Emergency Use Only with the *\[test name\] ***
| **Catalog Number** | **Product Name** |
|--------------------|------------------|
| | |
| | |
| | |
| | |
||
Warnings:
- This product has not been FDA cleared or approved; the product has been authorized by FDA as part of ***\[test name\]*** under an EUA for emergency use only by authorized laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C § 263a.
- This product has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens.
- The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of *in vitro* diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated, or authorization is revoked sooner.
#### 2) Components & Other Materials/Information Included with the Test:
Components manufactured by ***\[test developer’s name and FDA registration number (if applicable)\]*** and supplied with the test include:
***\[List all components and other materials/information included with your test, including a description of the primers and probes, volumes, concentrations, quantities, buffer components, etc.\]***
**Table: Example: Kit Components & Other Materials/Information**
| Kit Components & Other Materials/Information | Main Reagents Composition/ Matrix | Concentration/ Quantity/Volume | Manufacturer |
| --- | --- | --- | --- |
| Test Cassette with test strip | | | |
| Negative control | | | |
| Positive control | | | |
| Calibrators | | | |
| Sample buffer (bottle) | | | |
| Transfer pipette | | | |
| Instructions for Use leaflet | | | |
| Packing materials | | | |
| Others, as applicable | | | |
||
#### 3) Components and Other Materials/Information Required but Not Included with the Test:
***\[List all components and other materials/information (e.g., instruments, reagents) not included with the test that must be supplied by the user to perform the test, with specific supplier names and catalog numbers or other identifiers for obtaining the components. Please include here all specific consumables that were validated for use with your device, that are not interchangeable with other products and that are needed to guarantee device performance as established in the EUA validation studies listed in Section J below.\]***
#### 4) Software Validation:
**If you are introducing a system onto the market that has not been previously reviewed by FDA, we recommend providing evidence that the software has been validated to ensure that:**
- **The inputs and outputs of the software are appropriate to fulfill the system and assay requirements;**
- **All expected inputs produce the expected outputs for all functions critical for system operation; and**
- **The system will be provided to the customer free of defects, or defects will be known and mitigated.**
**If this evidence is not available prior to authorization and the software and hardware have been designed and developed in a manner consistent with current GMPs (for additional information, please see the discussion of “*Quality System Regulation/Medical Device Good Manufacturing Practices*,” on the FDA website**[11]**), additional software validation documentation may be incorporated into the conditions of authorization. If changes which impact assay performance or safety and effectiveness of the system are needed to address validation failures post-authorization, an EUA supplement may be required under the conditions of authorization.**
**Below are examples of tables for providing system specific information and your evidence that specifications have been met (e.g., hazard analysis). Text in the tables is provided as an example only. *\[Please provide thorough functional descriptions of system software and instrumentation specifications needed to support the intended use of the test and provide evidence that specifications have been fulfilled.\]***
** System specifications and validation example**
| Critical specifications: Description of the specification | Evidence that the design of the system can fulfill the specification. This column should consist of system-level validation data. |
| --- | --- |
| Optical system of each instrument sent to a user has sufficient dynamic range to appropriately differentiate between positive and negative test results | |
| Software displays appropriate result during test run | |
| If reader stores test result, software accurately stores and retrieves test results | |
| System has a defined lifetime where the user can expect the system to maintain performance as stated in the label | |
| Etc. | |
||
**Hazard analysis examples**
_Diagram showing a sample hazard analysis workflow: identifying hazards, assessing severity and probability, determining risk mitigation measures, and evaluating residual risk._
| **ID** | **Hazard** | **Adverse Effect** | **Severity** | **Potential causes of hazard** | **Risk mitigation measure** | **Risk of experiencing the hazard after mitigation** |
|-------|---------|----------|--------|--------------|-------------|-------------|
| 1 | Invalid result | Delay in returning test result | Low | User inserts cartridge incorrectly | Labeling noting correct orientation | Low |
| 2 | False result | Wrong result returned to user | High | Incorrect alignment of test strip and optics; test strip inserted in the wrong orientation | Mechanical design of reader input slot | Moderate |
| 3 | False negative result | Wrong result returned to user | High | User reads test strip too early; incubation time not sufficient | Labeling noting correct incubation time | Moderate |
| 4 | False result | Wrong result returned to user | High | Incorrect alignment of test strip and optics; control line misinterpreted | Software interprets data from optical system identifying a valid/invalid control | Moderate |
| 5 | False result | Wrong result returned to user | High | Control reaction intensity is misinterpreted | Software interprets data from optical system identifying a valid/invalid control | Moderate |
| 6 | False result | Wrong result returned to user | High | Analyte reaction intensity is misinterpreted | Software interprets data from optical system identifying a valid/invalid control | Moderate |
||
**If applicable to your test, FDA recommends the following evaluations be performed and documentation kept on file. If not completed by the time of authorization, these evaluations may be required in a condition of authorization.**
- **You should evaluate the cybersecurity of your system to ensure user and patient safety in the intended use environment;**[12]
- **You should complete validation of all systems and software to ensure that all functions of the system perform as labeled. For more information on system validation please see the following FDA guidance documents and resources:**
- ***[Guidance for the Content of Premarket Submissions for Software Contained in Medical Devices](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-content-premarket-submissions-software-contained-medical-devices);***[13]
- ***[General Principles of Software Validation](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/general-principles-software-validation);***[14]
- ***[Device Software Functions Including Mobile Medical Applications](https://www.fda.gov/medical-devices/digital-health/device-software-functions-including-mobile-medical-applications);***[15]
- **[*Off-The-Shelf Software Use in Medical Devices*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/shelf-software-use-medical-devices#:~:text=Off%2Dthe%2Dshelf%20(OTS,to%20run%20device%2Dspecific%20functions.);**[16] **and**
- **[21 CFR 820.30](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=820.30).**
#### 5) Basic Safety and Essential Performance:
***\[If you are introducing a system onto the market which has not been previously reviewed by the FDA, please describe how you addressed basic safety hazards such as electrical hazards (e.g., electrical shock to the operator and/or patient), fire hazards, and mechanical hazards.\]* We recommend that you consult the general requirements for basic safety, as indicated in International Electrotechnical Commission (IEC) 60601-1 (Medical electrical equipment – Part 1: General requirements for basic safety and essential performance). IEC 60601-1 is a standard that specifies the general requirements for basic safety and essential performance. IEC 60601-1 defines basic safety as freedom from unacceptable risk directly caused by physical hazards when medical electrical equipment is used under normal condition and single fault condition.**
#### 6) Electromagnetic Compatibility (EMC) Testing (if applicable)
**We recommend that EMC testing be conducted on any assay that uses a battery or power source. *\[Please provide FDA with any standards that were followed for EMC testing.\]* We recommend that you perform EMC testing according to the International Electrotechnical Commission (IEC) 60601-1-2 Edition 4.0:2014. *\[If you perform EMC testing to a different standard or use alternate methodologies to evaluate EMC, please provide a test plan, test report, acceptance criteria, and risk analysis to support your approach.\]***
#### 7) Manufacturing and Testing Capabilities
***\[Briefly describe current sample throughput testing capacity, the total time required to perform the test (from clinical sample collection to result), and the number of tests that can be performed per day (8-hour shift), excluding controls and calibrators, as applicable. Please provide the number of kits you can manufacture per day/week for distribution in the United States.\]***
#### 8) Distribution Plan
The product will be distributed by ***\[please describe the distribution plan for the product and list all current US distributors*\]**.
#### 9) Reagent Stability
***\[Briefly describe the stability test plan for \[test name\] reagents and include any accelerated stability information, if available.\]* Reagent stability studies generally do not need to be completed at the time of EUA issuance; however, the study design should be agreed upon during interactive review and the stability studies started immediately following authorization, if not before. You should consider the following recommendations when designing your stability study:**
- **For EUAs you may follow the current FDA recognized “Clinical Laboratory Standards Institute (CLSI) Standard EP25 – *Evaluation of Stability of In Vitro Diagnostic Reagents; Approved Guideline*” when evaluating the suitability of stability study designs. If you are planning to pursue a clearance or approval for your device, we recommend discussing with FDA in more detail your stability design to facilitate potential use of the EUA data in your regular premarket submission.**
- **For all the stability evaluations, you should include your external positive and negative controls and at least one sample, which should be prepared by spiking negative clinical matrix at an analyte concentration of 3-5x LoD of inactivated SARS-CoV-2, not recombinant protein. Please note that use of the positive controls alone is not recommended for reagent stability evaluation because controls are usually formulated at a moderate positive level.**
- **If you are using multiple clinical sample types in which similar LoDs are determined, you should use the most challenging clinical matrix for this study.**
- **You should evaluate at least 5 replicates and, if available, 3 different lots of reagents.**
- **You should design your study to provide data for a timeframe that is about 10% longer than the one to be authorized. For example, 18 months should be supported by stability data out to 20 months and 7 days should include stability data out to 8 days.**
- **FDA considers 15-30°C to represent room temperature conditions. Ideally you should evaluate stability at both 15°C and 30°C; however, for the purposes of the EUA evaluation, 30°C is generally appropriate as the worst-case scenario.**
- **Unopened Kit Shelf-Life Stability:**
- **You should evaluate real-time kit stability studies with unopened kits stored at the claimed storage temperature for your test.**
- **Accelerated stability evaluations for unopened kits can be included for EUA requests to support shelf-life claims up to six months while the real-time studies are on-going. However, please note real-time stability data is generally needed to support regular pre-market submissions.**
- **Unopened Kit Shipping Stability: You should evaluate the anticipated handling and shipping times and temperatures expected for unopened kits under different temperature conditions (e.g., summer, winter). The recommended summer profile is storage at 40℃ for 8 hours and then 22℃ for 4 hours and the recommended winter profile is -10℃ for 8 hours and then 18℃ for 4 hours.**
- **In-use/Opened Kit Stability: Depending on your device, your stability study design should also support in-use stability of the kit reagents once the kit has been opened, e.g., storage at 2-8°C for 7 days. This includes on board stability once reagents have been placed on the instrument (if applicable).**
- **Inverted stability (if applicable): Study should support stability for kits if stored inverted or in the wrong orientation.**
- **Freeze-thaw Stability: If you recommend aliquoting the reagents to meet the end-users needs following the initial thaw this recommendation should be supported by a freeze-thaw stability study, including the specific number of allowed freeze-thaw cycles.**
- **FDA recommendations for analysis of real time stability studies are as follows:**
- **Baseline of the study (t=0 of stability study) should not exceed one month from production;**
- **Clear baselines should be described (e.g., one month from production) for each stability claim under each study;**
- **Claims should be determined based on regression analysis. Any %change (%shift) from time zero (baseline) should be calculated between the target claim and the zero-time as (Ttest-Tbaseline)/ Tbaseline\*100 with 95% confidence interval (CI) using the regression equation obtained from plotting the mean values. When formulating your acceptance criteria for evaluating the shift from baseline you should consider the reproducibility of your device. Generally, the shift at the target claim due to storage cannot exceed 10-15%. The target stability is the next to last tested point that was within +/- 10% of time zero; and**
- **Acceptance criteria may differ depending on the reproducibility of your device, the distribution of analyte concentration expected in samples from the intended use population, and the risk of false results to public health.**
### J. PERFORMANCE EVALUATION
**The following validation studies should be performed to support your EUA request. Please note that, particularly for new technologies, FDA may request additional studies so we can adequately assess the known and potential risks and benefits associated with the candidate test. *\[For each validation study, you should provide a study protocol that includes a detailed, step-by-step description of how samples were prepared and how testing was conducted. You should also include complete study line data in an Excel-compatible format for all validation studies. Such line data should include the following information in individual columns:***
- ***coded identifiers for all samples and replicates;***
- ***the clinical matrix tested;***
- ***the SARS-CoV-2 concentration (applicable to studies using contrived samples);***
- ***raw signal output (i.e., cycle threshold (Ct) values) and final results for each distinguishable target for both the candidate test and the comparator test (as applicable); and***
- ***for both the candidate test and the comparator test, a final result for each sample/replicate based on the result interpretation algorithm of the test.\]***
#### 1) Limit of Detection (LoD) - Analytical Sensitivity:
**You should determine the LoD of the candidate test utilizing the entire test system from sample preparation and extraction to detection. We recommend spiking quantified inactivated virus (e.g., heat treated, chemically modified, or irradiated virus) into real clinical matrix (e.g., nasal or nasopharyngeal (NP) swabs, bronchoalveolar lavage (BAL) fluid, sputum, etc.).** **As positive natural clinical samples are generally available, a quantified known positive clinical sample as determined by an EUA**- **authorized test can be used to create dilutions in clinical matrix for LoD determination. Synthetic RNA is not an appropriate test material for the LoD studies. Respiratory samples collected from SARS-CoV-2 negative individuals can be used as clinical matrix. Collection media without clinical matrix or collection kits that were not used to collect a clinical sample are generally not considered real clinical matrix.**
**FDA recommends that preliminary LoD be determined by testing a 2-3-fold dilution series of 3 replicates per concentration, and then confirmed with 20 replicates of the concentration determined to be the preliminary LoD. For purposes of this document, the preliminary LoD is the lowest concentration that gives positive results 100% of the time and the final LoD is the lowest concentration at which at least 19 of 20 replicates are positive. The preliminary LoD studies should include at least one concentration that does not yield 100% positive results. If multiple clinical matrices are intended for clinical testing, you should include the results from one representative matrix of each indicated clinical matrix to FDA. The most challenging matrix of the claimed matrices should be tested. For example:**
- **If the candidate test is indicated for testing common upper respiratory tract samples (e.g., nasopharyngeal (NP) swabs, oropharyngeal (OP), swabs, nasal swabs, anterior nasal swabs, mid-turbinate nasal swabs, nasal aspirates, and nasal washes etc.), please submit results from NP swabs as FDA considers this to be the most challenging upper respiratory matrix.**
- **If the candidate test is indicated for testing common lower respiratory tract samples (e.g., tracheal aspirates, sputum, etc.), please submit results from sputum as FDA considers this to be the most challenging lower respiratory matrix.**
- **If the candidate test is indicated for testing both, upper and lower respiratory matrixes, submitting results from sputum samples may suffice to support both upper and lower respiratory matrices.**
- **If the candidate test is indicated for testing alternative samples, such as saliva, oral fluid, buccal swab, etc., please submit results from testing each of the claimed uncommon sample types.**
- **If relevant, FDA recommends that you follow the most current version of the CLSI EP17 “*Evaluation of Detection Capability for Clinical Laboratory Measurement Procedures*.”**
***\[Please provide your complete LoD study protocol that includes a step-by-step description of how samples were prepared and tested with your device, the specific viral material used to assess the LoD (e.g., irradiated virus),** **and the LoD (with appropriate units) for your assay. Please provide the line data for the LoD study in an Excel-compatible format. If the assay includes use of an analyzer or application to generate test results, please include the analyzer value for each test replicate.\]***
LoD studies determine the lowest detectable concentration of SARS-CoV-2 at which approximately 95% of all (true positive) replicates test positive. The LoD was determined by limiting dilution studies using characterized ***\[please describe samples used in the study, e.g., viral stocks\]***.
***\[List/describe the following in this section:***
- ***Titers and strains of the SARS-CoV-2 stocks used for the LoD study and how the organism stocks were prepared and how the titers were determined.***
- ***The dilution factor and number of serial dilutions of the characterized SARS-CoV-2 that were tested to determine the LoD.***
- ***The starting concentration, dilution factor used to reach target concentration, the volume of negative matrix with inactivated SARS-CoV-2 spiked onto each swab in your LoD study, and the type of dilutant used (e.g., Phosphate Buffered Saline (PBS), saline, etc.) to prepare each replicate in your LoD study. Please note that it is generally not appropriate to prepare samples with your assay reagents (e.g., extraction buffer) nor is it generally appropriate to dilute clinical matrix in VTM if the test is not indicated for use with VTM.\]***
Serial dilutions of the characterized SARS-CoV-2 made in clinical matrix obtained from individuals who tested negative for SARS-CoV-2 were then tested in ***\[number of replicates\]*** replicates. The lowest concentration at which all ***\[number of replicates\]*** replicates were positive was treated as the tentative LoD for each test. The LoD of each test was then confirmed by testing ***\[number of replicates (at least 20 recommended)\]*** with concentrations at the tentative limit of detection. The final LoD of each test was determined to be the lowest concentration resulting in positive detection of ***\[number of positive replicates (at least 19 out of 20 replicates)\]. \[Include analysis of LoD results, indicating the final LoD for each test.\]***
**Note: The LoD range finding study should include at least one concentration that achieves 95% detectability of replicates and at least one concentration that achieves less than 95% detectability. Replicates should be interpreted per the result interpretation of your test.**
#### 2) Inclusivity (analytical reactivity):
**Mutations in the SARS-CoV-2 genome have been identified as the virus has spread. A mutation is an individual genetic change in a SARS-CoV-2 virus sequence when compared with a reference sequence such as Wuhan-Hu1 or USA-WA1/2020. A new virus variant of SARS-CoV-2 has one or more mutations that differentiate it from the wild type or predominant virus variants already circulating in the general population. Variants of SARS-CoV-2 are identified by genomic sequences that contain mutation(s) in the RNA genome, which could result in amino acid substitutions, insertions, and/or deletions in viral proteins. Different variants can result in different phenotypes (e.g., a difference in antigenicity, transmissibility, or virulence). Viral mutations and viral variants could result in altered immunogenicity relative to the originally isolated virus, which could impact the performance of in vitro tests.**
**Test developers should monitor new and emerging viral mutations and variants that could impact molecular test performance on an ongoing basis. This includes assessing the prevalence of viral mutations in sequence databases (e.g., the GISAID**[17] **database), as mutations observed in these databases at a significant frequency may signify that the mutation is present in an increasing proportion of infected individuals in the U.S. FDA currently considers a significant frequency to be greater than 5% (when considering at least 2000 sequences over a recent period of time, such as the past week, month, or quarter). Monitoring should also include identifying if there are multiple credible reports indicating that a given viral variant (which may have one or more mutations) has the potential to increase virulence, increase transmission, or otherwise increase the public health risk. FDA recommends monitoring on at least a monthly basis in light of the rate of occurrence of mutations and variants and the importance of assessing their impact.**
**For any viral mutations and variants that are identified as prevalent and/or clinically significant as described above, you should assess whether the resulting predicted amino acid change(s) in the viral proteins are critical to your test design. This may be accomplished via *in silico* analysis of published SARS-CoV-2 sequences compared to the assay’s primers and probes. If the mutations are found to be critical to your test design, such mutations and variants should be evaluated using clinical (or contrived, as available and as appropriate) samples to assess the impact of the mutation or variant on your test’s performance. The aggregate impact of the mutations should not reduce the clinical performance of the test by 5% or more or decrease the clinical performance point estimates for the test below the clinical performance recommendations described in Section J(10). Please see the FDA guidance document “[*Policy for Evaluating Impact of Viral Mutations on COVID-19 Tests*](https://www.fda.gov/media/146171/download)” for additional discussion regarding monitoring the impact of genetic variants on molecular diagnostic tests.**[18]** **
**FDA also has ongoing monitoring efforts and may identify a viral mutation or variant as clinically significant for which testing with clinical (or contrived, as available and as appropriate) samples would be recommended to assess the impact of the mutation or variant on the performance of your test.**
**We recommend providing a summary of the strategy used to choose targeted amplification regions and the specific primer and probe regions, as applicable. Developers should document the methodology and results of an *in silico* inclusivity analysis that establishes the extent to which variation in the SARS-CoV-2 genome may impact sensitivity of test performance.**
***\[Please provide your plan for monitoring for new and emerging SARS-CoV-2 viral mutations and variants on an ongoing basis and for assessing the impact of mutations and variants that have been identified as prevalent and/or clinically significant on the performance of your assay over time.\] ***
***\[For mutations and variants that have been identified as prevalent and/or clinically significant as part of ongoing monitoring at the time of your EUA request, please provide information on the potential impact of the mutation(s) and variants on your test’s performance or explain how the risk associated with the unknown performance of your device in samples from individuals with the variant(s) can be adequately mitigated.\]***
#### 3) Cross-reactivity (Analytical Specificity):
**Cross-reactivity studies are performed to demonstrate that the test does not react with related pathogens, high prevalence disease agents, and normal or pathogenic flora that are reasonably likely to be encountered in a clinical sample. It is appropriate to conduct an in silico analysis of published genome sequences using the assay’s primers and probes. If in silico analyses of the target primers and probes reveal ≥ 80% homology between the cross-reactivity microorganism(s) and your test primers/ probe(s), we recommend that you conduct wet testing with that organism(s). We recommend using concentrations of 10^6^ CFU/ml or higher for bacteria and 10^5^ pfu/ml or higher for viruses. In silico analyses alone may be appropriate for organisms that are difficult to obtain. We recommend assessing potential cross-reactivity of the organisms listed in the table below, as applicable to the claimed sample type. If you are claiming an alternative matrix not listed below, please contact FDA to discuss the list of microorganisms recommended for testing.**
***\[Please provide your complete cross-reactivity protocol, including a step-by-step description of how samples were prepared (e.g., starting concentration, dilution factor used to reach target concentration, volume of organism suspension, volume of clinical matrix, etc.) and tested with your device, the specific materials used to assess cross-reactivity and where these materials were obtained. Please include the Certificates of Analysis for each microorganism that is tested, or equivalent information (e.g., the culture protocol, lot number, manufacturing date, viral strain, a description of viral inactivation, pre-inactivation titer, and pre-inactivation sterility for viral isolates, etc.). For bacterial isolates, information may also include the isolate source, method for identification, number of passages, microbiological features, or other information. Please provide the line data for the cross-reactivity study as part of your request, in an Excel-compatible format. If the assay includes use of an analyzer or application to generate test results, please include the analyzer value with each test replicate.\]* **
**Recommended List of Organisms to be Analyzed *in silico*
and by Wet Testing for All Respiratory Samples**
| **High priority pathogens from the same genetic family** | **High priority organisms likely present in respiratory samples** |
|---------------------------|---------------------------------------------|
| **Human coronavirus 229E** | **Adenovirus (e.g., C1 Ad. 71)** |
| **Human coronavirus OC43** | **Human Metapneumovirus (hMPV)** |
| **Human coronavirus HKU1** | **Parainfluenza virus 1-4** |
| **Human coronavirus NL63** | **Influenza A & B** |
| **SARS-CoV-1** | **Enterovirus (e.g., EV68)** |
| **MERS-coronavirus** | **Respiratory syncytial virus** |
| | **Rhinovirus** |
| | ***Chlamydia pneumoniae*** |
| | ***Haemophilus influenzae*** |
| | ***Legionella pneumophila*** |
| | ***Mycobacterium tuberculosis\**** |
| | ***Streptococcus pneumoniae*** |
| | ***Streptococcus pyogenes*** |
| | ***Bordetella pertussis*** |
| | ***Mycoplasma pneumoniae*** |
| | ***Pneumocystis jirovecii* (PJP)\*** |
| | **Pooled human nasal wash - *to represent diverse microbial flora in the human respiratory tract*** |
| | ***Candida albicans*** |
| | ***Pseudomonas aeruginosa*** |
| | ***Staphylococcus epidermis*** |
| | ***Streptococcus salivarius*** |
||
*\*M. tuberculosis* and *P. jirovecii* are applicable to lower respiratory matrices only (e.g., BAL, sputum, etc.).
**High Priority Organisms Likely Present in Saliva Samples Recommended List of Organisms to be Analyzed *in silico* and by Wet Testing for Saliva Samples\*\***
| **High priority pathogens from the same genetic family** | **High priority organisms likely in the circulating area** |
|---------------------------|---------------------------------------------|
| **Human coronavirus 229E** | **Adenovirus (e.g., C1 Ad. 71)** |
| **Human coronavirus OC43** | **Human Metapneumovirus (hMPV)** |
| **Human coronavirus HKU1** | **Parainfluenza virus 1-4** |
| **Human coronavirus NL63** | **Influenza A & B** |
| **SARS-coronavirus** | **Rhinovirus** |
| **MERS-coronavirus** | **Respiratory syncytial virus** |
| | **Herpes simplex virus type 1 (HSV-1)** |
| | **Epstein-Barr virus (EBV)** |
| | **Cytomegalovirus (CMV)** |
| | ***Moraxella catarrhalis*** |
| | ***Porphyromonas gingivalis*** |
| | ***Bacteroides oralis*** |
| | ***Nocardia sp.*** |
| | ***Streptococcus mutans*** |
| | ***Streptococcus mitis or other Strep viridans*** |
| | ***Eikenella sp.*** |
| | ***Neisseria sp.*** |
| | ***Candida albicans*** |
| | ***Pseudomonas aeruginosa*** |
| | ***Staphylococcus epidermis*** |
| | ***Streptococcus salivarius*** |
| | ***Lactobacillus sp.*** |
||
*\*\*These organisms should be analyzed/tested in addition to the ones included in the immediately preceding table.*
#### 4) Microbial Interference Studies:
**If *in silico* analysis reveals ≥ 80% homology between the cross-reactivity microorganisms and your test primers/ probe(s) set(s), we recommend that you either perform (1) a microbial interference study with SARS-CoV-2 and the microorganisms that your test primers/ probe(s) have homology to, or, as an alternative to the microbial interference study, (2) you may provide justification as to why (e.g., amount of primer(s)/ probe(s) included in your master mix) the performance of your test would not be impacted by the presence of a causative agent of a clinically significant co-infection, or (3) explain why the *in silico* results are clinically irrelevant (e.g., low prevalence of MERS-CoV, etc.).**
**Competitive microbial interference testing should be conducted for multiplex panels. The study should assess the effects of clinically relevant co-infections by testing selected microorganisms commonly found in the claimed sample matrix in the presence of SARS-CoV-2 at low concentration. The interference should be evaluated by testing with a minimum of 3 sample replicates spiked at a low (≤3x LoD) SARS-CoV-2 concentration and a high interferent level (preferably microorganisms), to represent the worst-case scenario. The interferent microorganisms can be tested individually or as a pool (of four or five) in the presence of low concentration of SARS-CoV-2. Each microorganism of a pool should be tested individually if that pool shows interference. If you plan to claim both upper and lower respiratory clinical samples, the study should be performed in the most challenging sample matrix, i.e., sputum. If interference is observed at the level tested, an additional titration study should be performed to determine the highest microorganism interferent level your test can achieve the stated performance.**
***\[Please provide your complete microbial interference study protocol, including a step-by-step description of how samples were prepared (e.g., starting concentration, dilution factor used to reach target concentration, and volume of organism suspension for both inactivated SARS-CoV-2 and microbial interferent, volume of clinical matrix, etc.) and tested with your device, the specific materials used to assess microbial interference and where these materials were obtained. Please provide the line data for the microbial interference study in an Excel-compatible format. If the assay includes use of an analyzer or application to generate test results, please include the analyzer value with each test replicate.\]***
#### 5) Endogenous/Exogenous Interference Substances Studies:
**The extent of testing for studies of interference substances depends on the matrix that is indicated for the candidate test as well as on the technology of the candidate test. If the candidate test uses extraction methods not previously reviewed by FDA as part of premarket submission or the candidate test does not use an extraction procedure (as for example, many point-of-care tests), we recommend testing for potential interferents. The following Table includes suggested potential interferents that might be appropriate to test for a test indicated for upper respiratory samples and/or oral fluid or saliva.** **We recommend testing the following substances listed in the table below, as applicable based on the indicated matrices, with and without inactivated virus at 2-3x LoD in three replicates for each substance. Please contact FDA if you have questions about appropriate study designs.**
**List of Potential Interfering Substances Recommended for Testing When the Candidate Test is Indicated for Respiratory Samples**
| Potential Interfering Substances | Concentration |
| --- | --- |
| Afrin Original nasal spray | 15% v/v |
| Sore throat and cough lozenges such as Cepacol Lozenges (benzocaine/menthol) | 3 mg/mL |
| Chloroseptic Sore Throat spray | 5% v/v |
| Mouth Wash (Saliva) | 5% v/v |
| Cough syrup (e.g., Robitussin) | 5% |
| Mucin: bovine submaxillary gland, type I-S | 2.5 mg/ml |
| Nicotine or Tobacco | 0.03 mg/ml |
| Toothpaste (Saliva) | 0.5% v/v |
||
***\[If a concentration is not listed in the table above, please determine an appropriate concentration and provide the scientific justification supporting your proposed concentration as part of your EUA request.\]***
#### 6) Sample Stability:
**Testing should be conducted to demonstrate sample stability throughout the real-world conditions in which they are collected and tested, according to your instructions for use. When the test is intended to be performed on the sample immediately or shortly after obtaining the sample, sample stability testing could be relatively short (i.e., 2 hours at room temperature) and conducted with contrived samples at 3x LoD using inactivated virus spiked into negative clinical matrix. If you intend to test retrospective clinical samples that have been frozen, you should also conduct fresh versus frozen studies to support use of these samples.**
| LoD Target Level | Number of Samples |
| --- | --- |
| 3-5 times LoD | 10 |
| 1-2 times LoD | 30 |
| Negative | 10 |
| Total | 50 |
||
***\[Please provide a complete sample stability protocol, including a detailed, step-by-step description of how you prepared and tested each replicate, and provide all study data in an Excel-compatible format, with analyzer values, if applicable. The protocol should also include sample stability information, including the study design and results if the sample is shipped to a testing site from another location (e.g., samples collected at home or physician’s office).\]***
#### 7. *Clinical Evaluation for Patients Suspected of COVID-19:*
**FDA recommends conducting prospective, blinded, randomized clinical agreement trials with at least 30 positive samples and 30 negative natural clinical samples (prospective, retrospective, or leftover) from patients suspected of COVID-19 by their healthcare provider. The number of negative samples may vary according to the disease prevalence at the time of your study. Evaluations with contrived clinical samples are inadequate to support the clinical performance of molecular diagnostic tests at this time.**
**If you seek authorization for multiple sample types, each sample type should be evaluated. This may be done by collecting samples from different anatomical sites from the same patient. To minimize the occurrence of discordant results due to biological variability, both samples should be collected within a short time period (e.g., within the same healthcare visit). Types of upper and lower respiratory samples are noted by the CDC at the following website: .**[19] **Please note that specimens with and without VTM are considered two distinct types of specimens. If you are seeking indications for testing with sputum and any other respiratory sample, we recommend testing either 30 sputum samples or a combination of upper respiratory samples and sputum samples, such as 15 NP and 15 sputum samples, or 15 combined upper respiratory samples and 15 sputum samples.**
**You may use frozen samples if you demonstrate analytically that preservation of samples (e.g., by freezing at ≤-70°C) does not affect the accuracy of test results compared to freshly collected samples.**
**You may use samples that previously tested positive by another authorized RT-PCR assay without additional comparator testing. *\[Please provide the type and source of the samples, results, and numerical output signals such as Ct values or numerical output for each tested sample, and the initial test date.\]***
**Approximately 25% of the positive samples should have a low viral load (i.e., low positives) as measured by the comparator test (i.e., Ct values should be within 3 Ct of the mean Ct at the LoD of the comparator test). When conducting a prospective study, if fewer than 25% of positive samples are low positives per the comparator assay, the prospective samples may be supplemented with additional low positive samples (i.e., archived samples, samples collected from convalescent patients, etc.).**
**Samples from each individual should be evaluated with the candidate test and an authorized RT-PCR test which uses a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction) and reports a Ct value. The comparator test may have the same, or different, targets as the candidate test; however, different primer and probe regions are recommended. The comparator test should be one of the more sensitive RT-PCR assays authorized by FDA. We encourage you to review the results from the FDA SARS-CoV-2 Reference Panel**[20] **and contact us to discuss your choice of comparator test. Evaluations with the comparator test should be conducted per the authorized instructions for use. If any modifications are made to the authorized comparator test, additional bridging studies may be necessary. Please contact FDA if you are considering using a modified configuration of an authorized RT-PCR assay.**
**When collecting samples, the standard of care sample (i.e., the sample used for clinical and not investigational purposes) should always be collected first, including when the comparator test is also the standard of care. If the comparator test is not the standard of care, swabs taken from the same anatomical area for the comparator test and candidate test (e.g., anterior nasal swabs, oropharyngeal (OP) swabs, etc.) should be randomized to ensure that bias is not introduced due to an unequal distribution of viral materials. When two distinct anatomical sites are being assessed, it is not necessary to randomize sample collection order (e.g., saliva compared to NP swabs).**
**You may consider use of an enrichment strategy in which individuals with a known COVID-19 infection status are invited to participate in your clinical evaluation study. If using an enrichment strategy, you should carefully consider how you will randomize and blind operators to the participant’s infection status and minimize potential bias. Data from an enriched study design should represent the full range of viral loads, with both low and high positives samples. Please contact FDA to discuss any alternative study designs or enrichment strategies.**
**All clinical samples tested in your study should be evaluated in accordance with the candidate test’s proposed diagnostic algorithm (i.e., tested using the procedure in the instructions for use), including retesting when appropriate. The limited volume of natural samples may preclude retesting. In instances where retesting is indicated but not performed, for the purposes of performance evaluation, initial results should be analyzed for performance and equivocal/indeterminate/inconclusive results should count against your final performance. Samples should be tested in a blinded fashion, e.g., positive, and negative samples should be presented to the end user in a blinded fashion. The end user should also be blinded to the results of any comparator method testing.**
**FDA recommends establishing a discordant analysis plan prior to your clinical study. Discordant samples should be tested with a second EUA authorized RT-PCR test that has also demonstrated high sensitivity, and which uses a chemical lysis step followed by solid phase extraction of nucleic acids (e.g., silica bead extraction). Results from a Discrepant analysis should not be included in the calculation of negative percent agreement (NPA) and positive percent agreement (PPA) but may be added to the performance table as a footnote.**
**Studies involving clinical samples (human specimens) conducted in support of an EUA request are subject to applicable requirements for Institutional Review Board (IRB) review and approval and informed consent (see 21 CFR parts 50, 56, and 812). FDA’s policy regarding informed consent requirements for certain studies using leftover, de-identified samples is outlined in the FDA guidance “[*Guidance on Informed Consent for In Vitro Diagnostic Device Studies Using Leftover Human Specimens that are Not Individually Identifiable*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-informed-consent-vitro-diagnostic-device-studies-using-leftover-human-specimens-are-not).”**[21]
**Candidate tests should demonstrate a minimum of 95% positive and negative agreement for all sample types requested. In addition, for studies where multiple sample types from the same patient are evaluated by the candidate test, there should be no significant evidence of a trend in Ct values that is indicative of the potential for false negative results.**
***\[Please describe the clinical study used to evaluate the clinical performance of the test.\]
***
***\[Please specify how the samples were generated, collected, and sourced. Please also specify if the samples were fully prospective or a mix of prospective and retrospective. Please specify inclusion/exclusion criteria, collection and testing sites, number of samples collected and tested, and number of operators performing the testing.\]***
##### a. Clinical Evaluation for Screening Individuals Without Symptoms or Other Reasons to Suspect COVID-19:
**The recommendations below reflect FDA’s current thinking. The study design and recommendations may change as additional information becomes available regarding asymptomatic infections, including but not limited to viral titer dynamics and transmission rates in this population.**
**If you seek claims for screening individuals without symptoms or other reasons to suspect COVID-19, FDA recommends that you conduct a prospective clinical study in asymptomatic individuals free of any symptoms of SARS-CoV-2 infection for at least two weeks prior to enrollment and testing, if not known to be previously positive. Asymptomatic individuals who are suspected of COVID-19 (i.e., via exposure) should be excluded. As part of your clinical study protocol and data, you should document how you screened and confirmed that all enrolled individuals were asymptomatic and consistent with your proposed intended use.**
**You should follow the clinical study recommendations listed above (i.e., 30 symptomatic positive and negative samples), except that the number of enrolled patients should be sufficient to ensure at least 20 positive samples (as per a highly sensitive comparator test) are consecutively collected. A minimum of 100 consecutive SARS-CoV-2 negative samples (as per the comparator test), should be collected. The total number of samples needed will depend on the prevalence of SARS-CoV-2 in the intended use population. If less than 20 SARS-CoV-2 positive samples, as determined by the highly sensitive comparator test, are obtained from the prospective study, or prevalence in the test population is very low, you may consider enrichment strategies. For example, you may conduct an additional prospective study in an asymptomatic screening population that is under quarantine due to possible exposure, to increase the chances of obtaining more SARS-CoV-2 positive samples. Please consult FDA prior to implementing enrichment approaches in your clinical study design.**
**In the clinical study, you should compare results from your candidate test and a highly sensitive comparator test for each patient enrolled. Please refer to recommendations above regarding selection of a comparator test. Samples for the candidate test should be collected according to the instruction for use. Samples for testing with the comparator test should be healthcare provider collected NP swabs. If an NP swab cannot be collected, a MT swab may be used. Sampling for the candidate test and comparator test should occur within a short timeframe to avoid biological variability in viral load.**
**In the context of an EUA request, FDA considers samples collected at one or two sites to be appropriate. However, if you are planning to use the same data to support a subsequent De Novo/510(k) submission, we recommend that you collect samples at a minimum of three geographically and demographically diverse sites.**
**It may be possible to use archived samples that were collected from asymptomatic patients. We recommend you contact FDA to discuss such an approach prior to initiating your study.**
**The data should be sufficient to demonstrate the following minimum performance:**
- **PPA ≥95% (Lower Bound of the two-sided 95% confidence interval >76%)**
- **NPA ≥98% (Lower Bound of the two-sided 95% confidence interval >95%)**
##### b. Adding Population Screening of Individuals Without Symptoms or Other Reasons to Suspect COVID-19 to an Authorized Test:
**Alternative approaches may be appropriate for candidate tests that have been previously authorized for use with common upper respiratory samples (i.e., NP, MT, nasal swabs, etc.) from symptomatic patients. For example, if your assay is highly sensitive as determined by testing with the FDA SARS-CoV-2 Reference Panel or a recognized international standard, FDA will consider expanding your authorization to cover asymptomatic screening with a condition of authorization that you complete the study outlined above. Developers may also refer to the [*Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing*](https://www.fda.gov/media/146695/download)**[22]** for additional options when seeking a screening claim with serial testing when a clinical evaluation with symptomatic patients suspected of COVID-19 infection by their healthcare providers has been performed. FDA is open to considering additional alternative study designs to demonstrate that the performance of the candidate test is appropriate for screening individuals without symptoms or other reasons to suspect COVID-19. We recommend contacting FDA to discuss alternative study designs prior to beginning such a study.**
#### 8) *Pooled Testing:*
**Combining multiple patient samples to create one pooled sample for testing could enable broader access to testing by increasing throughput, though it may also reduce the sensitivity of a test because samples are diluted. Therefore, FDA does not recommend sample pooling for tests with performance <95% PPA** **when testing individual samples, based on validation with positive patient samples. Use of pooling should be considered in the context of the positivity rate of a test in the test population, the analytical sensitivity of the test, and the percent of weak positive subjects in the tested population. The impact of decreased analytical sensitivity depends on the percent of subject samples with viral genetic material concentrations close to the LoD (weak positives) in the tested population. Therefore, analytical sensitivity of the test with n-sample pools should be evaluated, where n is the number of samples included in the pool. When resource availability is sufficient to meet testing demand, FDA recommends considering whether the risks of reduced test sensitivity with pooling continue to outweigh the benefits of resource conservation.**
**When pooling, a negative result implies that all samples in the pool are negative. A positive result indicates that at least one sample in the pool is positive. When an n-sample pool is positive, each sample within the pool must be individually tested to determine which is/are positive. Due to the reduction in analytical sensitivity, the test report should state that pooling was used during testing.**
**A test validated for a specific n-sample pooling strategy is also considered to be validated for any number of pooled samples below n. For example, a test validated for a 5-sample pooling strategy can be performed for any n≤5 pools.**
**If you seek authorization for testing of pooled specimens, your instructions for use should include instructions for laboratories to select and implement an initial validated sample pool size and to perform ongoing monitoring of the selected and implemented pool size.**
1. **Pooling Implementation – Determine the appropriate pool size based on percent positivity rate in the testing population and pooled testing efficiency. For swab pooling, this should include a detailed procedure describing a method to combine swabs into a single volume of transport media. The procedure should include recommendations to maximize the amount of sample resuspended into the transport media from the swab and help ensure that the user performs sample and swab handling in a manner consistent with current infection control procedures, which should also reduce the chance of carryover between sample pools.**
2. **Pooling Monitoring – Monitor the positivity rate from pooled samples.**
3. **Pooling Re-assessment – Reassess the impact of pooled testing on test performance.**
**These activities are described in more detail in Appendix B.**
**FDA is providing recommendations for two approaches to patient sample pooling: 1) pooling aliquots of transport media which each contain a single patient sample (media pooling) or 2) adding swabs from multiple patients into a single volume of transport media (swab pooling).**
##### a. *Media Pooling:*
**When pooling transport media, one individual sample is defined as a single sample swab collected from a subject and placed in a specific volume of transport media. In this type of pooling, an aliquot of each individual sample is combined into non-overlapping pools of n samples and each n-sample pool is tested. Therefore, the instructions for use should specify a sample volume great enough to allow for individual and pooled testing so that, during clinical use, any samples in a positive pool can be re-tested without the need for a second sample collection.**
**FDA believes an n=5 is a reasonable starting point for validation of pooling for a high-sensitivity test in populations with a positivity rate of approximately 5% to 6%. In populations with a lower positivity rate, larger sample pools may be feasible. In populations with higher prevalence, smaller sample pools may be needed. FDA recommends that developers begin by validating their tests for pooling using an n=5. Tests validated and authorized for n=5 can then be used with any n≤5 pools, depending on testing needs and taking into consideration local positivity rate.**
**We strongly recommend that test developers develop and validate a system for deconvoluting pooled test data which is intended to accurately identify individual patient samples composing each pooled sample. If a test developer plans to use a software solution intended to deconvolute pooled SARS-CoV-2 diagnostic test data, then we recommend providing validation data establishing that the software can achieve its intended use. For example, we recommend including evidence that the software has been validated to ensure that:**
- **The inputs and outputs of the software are appropriate for the intended use of the candidate test;**
- **All expected inputs produce the expected outputs for all functions critical for system operation; and**
- **The system will be provided to the customer free of defects or defects will be known and mitigated.**
**Please see section I(4) for more information on appropriate software validation approaches.**
i. ***Media pooling: adding a pooling strategy to a previously EUA-authorized test:***
**To add an n-sample pooling strategy to an authorized assay, *you* should submit a supplemental EUA request with the appropriate validation data, as described in Appendix A. If the authorized assay has a PPA ≥ 95% when testing individual samples, based on validation with positive patient samples, the authorized assay may be used as the comparator test for the pooling validation study.**
ii. ***Media pooling: new test (not previously authorized)***
**To include an n-sample pooling strategy for a candidate test that has not been previously authorized, you should submit an EUA request with the appropriate validation data for individual testing in the proposed intended use population (see section J(5)) as well as appropriate validation data for sample pooling, as described in Appendix A.**
##### b. *Swab Pooling:*
**Swab pooling is an approach which conserves transport media and has the potential to maintain sensitivity of the test; however, deconvoluting which swab was positive cannot be done without collecting another sample. This approach also results in a high concentration of swab samples in transport media and thus inhibition may be observed. The effects of inhibition due to high concentrations of swab samples (e.g., mucin) and high concentrations of virus when there are multiple positive swabs in the swab pool should be investigated.**
**The validation recommendations for swab pooling are the same for tests that have and have not been previously authorized for individual sample testing. We recommend performing the two swab pooling validation studies using the highest number of swabs that is both desired and deemed feasible. If the data do not meet the acceptance criteria noted below, we recommend evaluating a lower number of swabs until the recommended acceptance criteria are met. Laboratories can proceed with testing with any number of pooled swabs up to the highest number of pooled swabs that was successfully validated.**
**If the candidate test has not been previously authorized for individual sample testing, test developers should submit an EUA request that also includes the appropriate validation for individual sample testing in the proposed intended use population. Refer to section J(5) of this template for recommendations regarding recommended clinical evaluation of individual sample testing.**
***Swab pooling validation:***
***\[For n-swab pooling strategies, the two studies below should be conducted, and the results included in your EUA request\]*:**
1. **You should establish performance related to test interference from multiple swab samples in a single volume of transport media. N-swab samples containing the maximum number of swabs you intend to validate in the minimum volume of transport media you intend to validate should be tested with an analyte concentration of 2-3X LoD for the individual swab. The swabs should contain clinical matrix negative for SARS-CoV-2. The acceptable range of transport media volume and the maximum number of swabs should be noted in your instructions for use. We recommend testing replicates of three n-swab pooling samples at the same analyte concentration both with and without SARS-CoV-2.**
**For example, if the instructions for use for the candidate test recommends pooling three swabs (n = 3), then we recommend acquiring a total of nine confirmed negative swabs from individual subjects and adding three unique swabs to three unique tubes of transport media, thereby making three n-swab pooling samples. Each n-swab pooling sample should be spiked with either a positive patient sample (in transport media), live virus, or inactivated virus at a concentration of 2-3X the LoD of the candidate test. We recommend testing a total of at least 20 replicates, which can be composed of equal numbers of aliquots taken from each n-swab pooling sample (i.e., 7 replicates from each sample in this example). Ideally, negative n-swab sample matrix should be tested prior to spiking to ensure that the matrix is negative. Acceptance criteria should be at least 95% agreement with the expected results and an invalid rate of < 5%. *\[Please include the Ct value line data (if applicable) in your EUA request.\]***
1. **You should evaluate the effect of high viral concentrations on candidate test performance. It appears that patients with SARS-CoV-2 infection can exhibit unusually high viral loads. This, combined with the possibility of pooling multiple positive swabs into a single volume of transport media, could result in unexpectedly high viral titer in the pooled sample. We recommend evaluating existing data on viral loads in infected subjects and, in combination with your existing LoD data, propose a maximum expected viral titer per swab. Using this number, estimate the expected viral titer in transport media with at least three positive swabs. For instance, if you expect a maximum of 100,000X LoD per swab, we recommend spiking a single negative n-swab sample with 300,000X LoD target analyte and testing with 10 replicates. It is anticipated that all replicates are either positive or have an invalid rate of ≤5%.**
#### 9) Studies to Support Point of Care (POC) Use, as applicable:
***\[If the device is intended for POC testing, please provide a detailed study description and data to demonstrate that non-laboratory healthcare providers can perform the test accurately in the intended use environment\].* Your studies to support a POC claim should include the following: (1) a POC clinical evaluation including use of appropriate sites and test users, (2) supplemental POC samples, and (3) POC flex studies. For more details, please see each section below**
##### a. Clinical Evaluation
**The clinical study design should reflect how the test will be used in clinical practice. It is expected that a test with “POC” designation will be widely used in CLIA waived medical facilities (e.g., physician office, outpatient clinic, emergency room (ER)), but also in less traditional settings (e.g., tents, schools, etc., with health care provider oversight of testing) where health care providers are present.**
###### i. Sites and Test Users (Operators):
**You should select one or two non-laboratory sites in the United States (U.S.) to assure that the operators are representative of intended operators in the U.S., e.g., doctor’s office, ER, outpatient clinic, drive-through testing facility, or another area in a medical facility outside the central laboratory where samples are collected and tested in real time. This would allow evaluation of the sample collection and handling, including addition into the sample port/well of the test, both of which may be significant sources of error. Four to six operators, representing intended healthcare provider operators, but who are not laboratory trained (e.g., nurses, nursing assistants and doctors) should participate in the study. Testing should be performed using only Quick Reference Instructions (QRI) - supplemental materials, such as a video or a mobile application that can be easily accessed by the user, are encouraged to be included with the proposed candidate test but should not be used during this study to mimic the worst-case scenario.**
***\[Please provide the detailed individual replicate result data in an Excel-compatible formant and protocols for each of your studies, including:***
- ***The objective of the study;***
- ***Detailed test procedure;***
- ***Materials used;***
- ***A list of samples tested;***
- ***Results (presented in tabular format), including invalid results;***
- ***Conclusions;***
- ***Any appropriate mitigation** **measures (e.g., labeling changes, changes to test design, etc.); and***
- ***Operator background (e.g., education, training, experience, etc.)***
***As part of your EUA request, please include a table in which your study results are stratified by operator.\]***
###### ii. Comparator Method:
**A description of an appropriate clinical comparator test is included in section J7 above.**
###### iii. Clinical Samples
**A total of 30 prospectively collected positive (confirmed by an EUA-authorized test) and 30 negative natural clinical samples should be tested (mock clinical samples are not appropriate). Testing should be conducted for at least 2 weeks. If an insufficient number of positive results is observed after such time (<30), you may collect samples at another site to ship to the testing site or use banked samples to supplement your positive samples. Banked samples should not be pre-selected based on Ct value and should be presented blinded (mixed with negatives) to the testing site. Ideally, the same comparator test should be used for banked and prospectively collected samples.**
###### iv. *Clinical Performance*
**A molecular POC candidate test should demonstrate positive and negative agreement of ≥ 95%. However positive agreement of ≥ 80% may be considered with appropriate limitations added to the intended use that would mitigate the risk of false negative results. For example, negative results may be considered presumptive negative if the demonstrated PPA is lower than 95%.**
##### b. Performance around LoD
You should also conduct testing with samples prepared with SARS-CoV-2 viral load near the LoD of your assay in clinical matrix. The testing should be conducted by minimally trained operators and should consist of 10 low positives (<2 times LoD) and 10 negative samples per site. All contrived samples should be blinded and randomized and each operator should test at least three low positive and three negative samples integrated into the site’s workflow with the clinical samples above. These samples are intended to supplement, not replace, the clinical samples in your study.
***\[Please include a table in an Excel-compatible format in which your study results are stratified by operator.\]***
##### c. POC Flex Studies
**You should also conduct a thorough hazard analysis considering the main known sources of errors. Based upon your hazard analysis, you should conduct flex studies to evaluate the impact of errors, or out-of-specifications conditions, on the candidate test performance. Each sample should be prepared at 2xLoD in negative clinical matrix and should be evaluated in three replicates for each condition under evaluation. Flex studies can be conducted with trained operators at an internal testing site. Each study should be performed using a pre-defined study protocol that includes the following:**
- **The objective of the study;**
- **Detailed test procedure; and**
- **Materials used.**
**Potential stress conditions include:**
- **40°C and 95% room humidity (RH) (mimicking hot and humid climates);**
- **Delay in sample testing or reading time;**
- **Delay and/or disturbance in operational steps;**
- **Sample volume variability;**
- **Buffer volume variability;**
- **Read time variability; and**
- **Other, as appropriate.**
***\[Please provide a detailed, step-by-step description of how you prepared and tested each replicate and provide all study data in an Excel compatible format, with analyzer values, if applicable.*** ***Data for each sample evaluated (i.e., line data) should be provided. If erroneous results are observed during studies evaluating the robustness of the device, adequate mitigation(s) should be provided.\]***
**Please see the Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Home Use**[23] **for more in-depth flex study designs. Alternative sources of information on flex studies that may be appropriate for the candidate test can be found on the FDA CDRH website containing *[CLIA Waiver by Application Decision Summaries](https://www.fda.gov/about-fda/cdrh-transparency/clia-waiver-application-decision-summaries).***[24]
#### 10) Studies to Support Authorization of Multi-analyte Respiratory Panels:
**If you are requesting an EUA for a multi-analyte respiratory panel, analytical and clinical evaluations for each target analyte should be included. We recommend considering the study designs and data summaries noted in the published EUA Summaries and Instructions For Use of authorized multi-analyte tests.**
**If you are planning to use the Right of Reference to the CDC Influenza SARS-CoV-2 (Flu SC2) performance data, please see the web page **[25] **for more information.**
##### a. Addition of SARS-CoV-2 to Previously FDA-cleared Multi-Analyte Respiratory Panels:
**To add the SARS-CoV-2 target to respiratory panels previously cleared by the FDA where the SARS-CoV-2 reagents are run in a separate well (or tube) and no modifications are required to the cleared portion of the panel, only studies for validation of the SARS-CoV-2 reagents previously described in this template are recommended.**
**To add the SARS-CoV-2 target to respiratory panels previously cleared by the FDA where the SARS-CoV-2 reagents are combined in the same well as the reagents for previously cleared analytes (in a multiplex reaction), the following studies should be conducted to validate the SARS-CoV-2 reagents and the modifications made to the cleared respiratory panel:**
- **Studies previously described in this template to validate the SARS-CoV-2 reagents**
- **LoD confirmation of the previously cleared analytes by conducting side by side testing of 3-5 replicates of serially diluted viruses with modified and original versions of the test to show that the LoD is unchanged due to modifications**
- **Testing 10 retrospective positive samples for each previously cleared analyte**
- **Competitive inhibition study with clinically relevant titers of each analyte in the panel (viruses 10^5^ PFU/mL, bacteria 10^6^ CFU/mL)**
##### b. Multi-analyte Panels not Previously Cleared by the FDA:
**To support an EUA for a multi-analyte respiratory panel candidate test that was not previously cleared by FDA, analytical and clinical evaluations for each target analyte should be provided.**
###### A. Analytical Performance:
**The following analytical studies should be conducted by wet testing and data provided to the FDA for review:**
- **Limit of Detection (Analytical Sensitivity)**
- **Cross-Reactivity / Microbial Interference **
- **Inclusivity / Analytical Reactivity **
- **Collection Media Equivalency – each claimed additional sample collection media not used in your clinical study should be validated (if appropriate for study designs) **
- **Competitive microbial interference (for organisms for which the test is not indicated for use)**
- **Competitive inhibition (for analytes for which the test is indicated for use)**
- **Interfering Substances Study (Endogenous and Exogenous) **
- **Clinical Sample Stability **
- **Reagent Stability testing protocol **
- **Carry over/Cross-Contamination (if a new instrument not previously cleared/approved by the FDA is used with the candidate test) **
- **Reproducibility and Repeatability (if a new instrument not previously cleared/approved by the FDA is used with the candidate test) **
- **Fresh vs. Frozen Samples. If you intend submit data testing archived frozen samples in support of your EUA request, please conduct an analytical study to demonstrate that preservation of samples (e.g., by freezing at ≤-70°C) does not affect the accuracy of test results compared to freshly collected samples.**
##### c. Clinical Performance:
**To evaluate the clinical performance of your multi-analyte candidate test, a prospective clinical study should be conducted. Considering the public health needs in the current emergency, a clinical performance study in support of the EUA request may be conducted at one site testing archived positive and negative clinical samples with known sample types. The pre-selection of archived positive samples should represent a range of viral load or Ct values including low positive samples near the candidate test cut-off.**
**For the non-SARS-CoV-2 analytes, such as Influenza A, Influenza B, and Respiratory Syncytial Virus (RSV), etc., a minimum of 50 positive Influenza A, 30 positive Influenza B, and 30 positive RSV archived samples should be included in the clinical study.**
**Since your candidate test has not been FDA-cleared for the respiratory pathogens for which it is indicated, and it is likely that the candidate test would be used in patients with respiratory symptoms in lieu of an FDA-cleared respiratory panel, FDA generally intends to include a condition of authorization that you conduct a post EUA prospective clinical study. The prospective clinical study should include a minimum of three sample collection sites and three testing sites, prospectively enrolling patients with general respiratory symptoms. Until the post-EUA prospective clinical study is completed, and the study results are reviewed by the FDA, FDA recommends including a warning/limiting statement in the instructions for use for your test indicating that results (positive and negative) for the non-SARS-CoV-2 analytes should be confirmed with an FDA-cleared nucleic acid amplification test (NAAT) if clinically indicated.**
**For multiplex candidate devices that detect and differentiate SARS-CoV-2, Influenza A/B, and RSV viral nucleic acids, a minimum of 50 positive SARS-CoV-2, 50 positive Influenza A, 30 positive Influenza B, and 30 positive RSV prospectively collected and tested samples should be included in the prospective clinical study enrolling prospective samples (an all-comers study) post-authorization.**
**The clinical performance of the candidate test for the non-SARS-CoV-2 analytes (e.g., Influenza A/B and RSV, etc.) should be determined by comparison to an FDA-cleared molecular test used as a comparator test. Using an FDA-cleared molecular test with prospective clinical study data from the past 5 years as the comparator test for assessing clinical performance of your device is recommended.**
**Since most FDA-cleared comparator test options have been validated and cleared for use with NP swab and/or nasal swab samples only, if you intend to assess clinical performance of your device testing other typical upper respiratory tract sample types (e.g., nasal mid-turbinate swab, nasopharyngeal wash/aspirate, nasal wash/aspirate, and oropharyngeal swabs, etc.), and the FDA-cleared molecular test you intend to use as the comparator test has not been cleared for use with the other typical** **upper respiratory tract sample types you wish to claim, you should conduct a paired-sample study in which one of the paired samples of an FDA-cleared sample type (e.g., NPS or NS) is tested with the FDA-cleared comparator test and the other paired sample of a typical upper respiratory tract sample type you intend to claim (e.g., nasal mid-turbinate swab or nasopharyngeal wash, etc.) is tested with your candidate device. Alternatively, as a less burdensome approach, you could validate the FDA-cleared comparator test for use with the desired sample type by performing an analytical LoD comparison study between the desired typical upper respiratory tract sample type and an FDA-cleared upper respiratory tract sample type using the comparator test prior to initiating the clinical evaluations.**
**If you intend to assess clinical performance of your device testing an atypical sample type (e.g., saliva, buccal swabs, etc.), and the FDA-cleared molecular test you intend to use as the comparator test has not been cleared for use with the atypical sample type you wish to claim, you should conduct a paired-sample study in which one of the paired samples of an FDA-cleared sample type (e.g., NPS or NS) is tested with the FDA-cleared comparator test and the other paired sample of an atypical sample type you intend to claim (e.g., saliva, oral fluid, and buccal swabs, etc.) is tested with your candidate device. The alternative approach described above for the typical upper respiratory tract sample types is not appropriate, and therefore, not appropriate, for the atypical sample types.**
**The performance expectation and recommended comparator method for SARS-CoV-2 are noted in Section J(5). For Flu A/B, and other respiratory viruses,** **PPA should be >90% (with a lower bound of the two-sided 95% confidence interval >80%), and the NPA should be >95% (with a lower bound of the two-sided 95% CI >90%) in comparison to an FDA-cleared molecular test.**
**We recommend that you submit a Pre-EUA with an outline of the studies that you plan to conduct to support the FDA-authorization or contact FDA at for specific feedback.**
##### d. Claiming Multiple Typical Upper Respiratory Tract Sample Types for use with Multi-analyte Panels not Previously Cleared by the FDA:
We recommend that you conduct an LoD study using the most challenging typical upper respiratory tract sample type you wish to claim with your candidate device (e.g., NP swab and nasal swab, etc.). In addition, you should attempt to include all typical upper respiratory tract sample types that you intend to claim for use with the candidate test in the pre-authorization clinical performance evaluation study. If you are unable to include all desired typical upper respiratory tract sample types in the pre-authorization clinical performance evaluation study, after demonstrating due diligence on your part to enroll such samples, you may claim the following typical upper respiratory tract sample types if you have validated your device analytically and clinically with NP swabs, nasal swabs, and/or MT swabs: NP swabs, anterior nasal swabs, MT swabs, NP washes/aspirates, nasal washes/aspirates, and oropharyngeal swabs, as long as all your claimed typical upper respiratory tract sample types are incorporated into the post-authorization prospective clinical study. For any typical upper respiratory tract sample type(s) that was/were not evaluated in the pre-authorization clinical study, we recommend including a limiting statement in your test’s labeling indicating that the performance of your test testing such typical upper respiratory tract sample type(s) has not been evaluated. Once the post-authorization prospective clinical study is completed and the clinical performance of your test testing such typical upper respiratory tract sample type(s) is deemed appropriate by the FDA, you may remove this limiting statement from your test’s labeling.
Atypical sample types (e.g., saliva, oral fluid, and buccal swabs, etc.) and lower respiratory tract sample types (e.g., BAL and sputum, etc.) should be validated with LoD studies performed in each of the claimed sample matrices. Additionally, both the pre-authorization and post-authorization clinical evaluation studies should include these sample types in the study design.
#### 11) Claiming Multiple Instruments and/or Extraction Methods:
**FDA recommends the following analytical and clinical validation to validate use of a new test with multiple thermocyclers and extraction methods.**
- ***Limit of Detection (LoD):***
**These studies should be repeated for each clinical matrix for which the candidate test is indicated for use. Pick one RT-PCR instrument and determine the tentative LoD (using 5 replicates in 10-fold dilution) followed by the confirmatory LoD (20 replicates spiked at tentative LoD) for each extraction method on the chosen instrument. Note: If you detect 20/20 replicates in your confirmatory LOD study you should test the next lower concentration, using a 3-fold dilution, until you achieve a hit rate of <20/20.**
- **If the different extraction methods yield a similar LoD (≤3 times LOD) on the RT-PCR instrument chosen for initial testing, pick one extraction method for further LoD determination on the remaining RT-PCR instruments and follow the recommendations below.**
- **If the extraction methods do not yield a similar LoD on the chosen RT-PCR instrument, please choose the extraction method with the worst LoD for further comparison of the LoD on all RT-PCR instruments.**
**For all other RT-PCR instruments you should use the following adaptive LoD study design:**
- **Please perform a refined tentative LoD study with 5 replicates at 0.5, 1, and 1.5 to 2 times LoD. If you detect 4/5 replicates as positive at all the tested levels, you need to include the next higher concentration (i.e., 3 times LoD). If you obtain 5/5 replicates at 0.5 times LoD, you need to test the next lower concentration (i.e., 0.25 times LoD). You should test in this manner until you find the lowest concentration that gives you 5/5 positive results for the tested RT-PCR instrument. This concentration should be used for a confirmatory LoD study for that RT-PCR instrument using 20 replicates.**
**Final reported LoD: *\[Please include in your EUA request a list of all RT-PCR instruments with their respective LoDs, if different LoDs are obtained.\]* LoDs are considered comparable if they are between 1-3 times LoD. These studies should be repeated for each clinical matrix for which the candidate test is indicated.**
**Note, if there are differences in the extraction input volume, extraction elution volume, and PCR input volume (extracted nucleic acid) then the LoD should be confirmed for each.**
- ***Interference Substances Studies (if applicable):***
**FDA recommends evaluating interfering substances with the extraction method and RT-PCR instrument combination that has the least sensitive LoD.**
- ***Inclusivity Testing:***
**FDA recommends evaluating inclusivity with the extraction method and RT-PCR instrument combination that has the least sensitive overall LoD.**
- ***Exclusivity Testing:***
**FDA recommends evaluating exclusivity with all extraction/instrument combinations.**
- ***Clinical study:***
**If an LoD study confirms equivalency for all RT-PCR instruments (between 2-3 times LoD), then the clinical study may be conducted with any RT-PCR instrument. If one or more RT-PCR instruments have different LoDs, we recommend conducting the clinical study with the extraction method / RT-PCR instrument combination with the worst LoD.**
### K. UNMET NEED ADDRESSED BY THE PRODUCT
**This section will be completed by FDA.**
### L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
**There is no adequate, approved, and available alternative to the emergency use of the product.**
### M. BENEFITS AND RISKS:
**This section will be completed by FDA.**
### N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
**During review, FDA will make available Fact Sheet templates. See examples for authorized tests on our website.**[26]
### O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
***\[You should include Instructions for Use, Box Labels, Vial Labels, and any other proposed labeling.\]***
### P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
**As allowed by Section 564(e) of the FD&C Act, FDA may require certain conditions as part of an EUA. FDA generally includes the following record keeping and reporting information requirements in the EUA.**
***\[Test Developer name\]*** will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report on adverse events, and this website[27] is referenced in the Fact Sheet for Health Care providers as well as through the ***\[Test Developer name\]*** Product Support website: ***\[Include link to Test Developer’s Website\]***. Each report of an adverse event will be processed according to ***\[Test Developer name\]***’s Non-Conformance Reporting Requirements, and Medical Device Reports will be filed with the FDA as required. Through a process of inventory control, ***\[Test Developer name\]*** will also maintain records of device usage/purchase. ***\[Test Developer name\]*** will collect information on the performance of the test, and report to FDA any suspected occurrence of false positive or false negative results of which ***\[Test Developer name\]*** becomes aware. ***\[Test Developer name\]*** will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
### Appendix A: Media Pooling Validation
***Preliminary Clinical Sample Pooling Validation Study***
**The test developer should conduct a preliminary clinical sample pooling validation study with individual positive clinical samples, comparing the performance of the candidate test when testing n-sample pools to the performance of a comparator test when assaying individual samples. We recommend using only a high sensitivity EUA-authorized RT-PCR assay which uses a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction) as the comparator test. If available, FDA recommends selecting a comparator test that has established high sensitivity with an internationally recognized standard or FDA SARS-CoV-2 Reference Panel.** [28] **This study design is written assuming the study uses a separate comparator test. As discussed earlier, if requesting to add pooling to a previously authorized test, a separate comparator may not be needed, and this study design can be modified accordingly.**
**We recommend that the test developer evaluate in this preliminary clinical sample pooling validation study a minimum of 20 positive clinical samples (can be archived samples), as determined by the comparator test, with sufficient volume. The 20 samples should include 25% weak positive samples, as determined by the comparator test (i.e., (Ct values in a SARS-CoV-2 positive samples should be within 1-3 Ct of the mean Ct at the LoD of the comparator test). If weak positive samples, as determined by the comparator test, represent less than 25% of the total number of positive samples, the test developer should preferably supplement the validation sample set with additional natural weak positive samples to make up to 25% of the total enrolled positive samples. However, diluting individual natural positive samples with individual or pooled natural negative samples to reach the 25% goal is also appropriate. If archived samples are acquired, the test developer should consider using the most recently archived samples to minimize the potential risk of sample degradation due to prolonged storage.**
**All positive samples in the preliminary clinical sample pooling validation study should be individually tested by the candidate test and the comparator test. To characterize the performance of the candidate test when testing pooled samples, each individual positive sample (as determined by the comparator test) should be pooled with n-1 (e.g., where n=5, n-1=4) negative samples, as determined by the candidate test. The resulting sample pools, each consisting of 1 positive sample and n-1 negative samples, should be tested by the candidate test.**
**In order to construct the 20 n-sample pools for testing in this preliminary validation study, the test developer should use an appropriate number of individual negative samples (as determined by the candidate test) from the intended use population. While the (n-1) negative samples in a given n-sample positive pool should all be different negative samples collected from unique individuals, the same negative samples may be used in building different n-sample positive pools.**
**Based on this recommended study design, the preliminary clinical sample pooling validation study should generate the following three types of results for each enrolled positive sample: Candidate test individual sample testing result (Candidate~individual~), Candidate test pooled sample testing result (Candidate~pool~), and Comparator individual sample testing result (Comparator~individual~).**
**PPA between testing individual samples using the candidate test and testing individual samples using the comparator test (PPA, Candidate~individual~ vs. Comparator~individual~) should be estimated initially. If PPA (Candidate~individual~ vs. Comparator~individual~) is <95%, the candidate test should not be used to test pooled samples. If PPA (Candidate~individual~ vs. Comparator~individual~) is ≥95%, PPA between testing pooled samples using the candidate test and testing individual samples using the comparator test (PPA, Candidate~pool~ vs. Comparator~individual~) should then be calculated as the percent of positive pools by the candidate test among 20 individual positive samples by the comparator test. When calculating PPA for the preliminary clinical sample pooling validation study, all non-negative results testing pooled samples should be counted as in agreement with positive individually tested results.**
**If PPA (Candidate~pool~ vs. Comparator~individual~) is ≥80%, the n-sample pool is preliminarily validated. If PPA (Candidate~pool~ vs. Comparator~individual~) is <80%, the test developer should repeat the preliminary validation study with smaller pool sizes to compensate for excessive loss in test sensitivity due to pooling at the larger sample size tested, until the PPA (Candidate~pool~ vs. Comparator~individual~) for a smaller pool size is ≥80%. If there is sufficient volume, the same positive samples utilized in the evaluation of a larger pool size can be used in the validation of a smaller pool size. If ≥80% PPA (Candidate~pool~ vs. Comparator~individual~) cannot be achieved for any pool sizes evaluated, the candidate test should not be used to test pooled samples.**
**To confirm that negative samples remain negative in n-sample pools, the test developer should also test in the preliminary clinical sample pooling validation study a sufficient number of individual negative samples, as determined by the candidate test, to generate at least 20 pools, each consisting of n negative samples for testing using the candidate test. For example, 100 negative samples are recommended to make up 20 5-sample negative pools (5x20 negatives). If there is sufficient volume, the same negative samples can be used to create positive and negative pooled samples.**
***Clinical Sample Pooling Validation Study with Samples from Three Geographically Diverse US Sites:***
**For tests intended to be performed at multiple laboratory sites (i.e., distributed tests), or at a single laboratory site receiving samples from geographically diverse sites, the below validation should be conducted to evaluate pooled testing in populations that may have different distributions of viral loads and different positivity rates.**
A. ***Option A (appropriate for all tests):***
**The test developer should conduct an additional clinical sample pooling validation study with individual positive clinical samples at three geographically diverse sites in the US, assessing the PPA (Candidate~pool~ vs. Candidate~individual~) between testing n-sample pools (n is the preliminarily validated pool size) and assaying single samples using the candidate test. Each of the three sites should initiate n-sample pooling and enroll a minimum of 15 consecutive positive samples with sufficient volume for a minimum of 45 consecutive positive samples in total.**
**The validation study at each site should start from the starting time T0 and should consist of individual sample testing in parallel with the pooled testing. However, since all non-negative sample pools require testing of all individual samples included in the pool as a part of the n-sample pooling and deconvoluting workflow, the validation study essentially adds testing individual samples from the negative n-sample pools.**
**The validation study at each site may conclude at time T1, when a minimum of 15 consecutive positive individual results are obtained, including both positive individual results generated from individual testing of samples from the non-negative sample pools following the n-sample pooling and deconvoluting workflow, and positive individual results obtained from individual testing of samples from the negative sample pools for the time period from T0 to T1 \[T0, T1\].**
**Defining the number of positive individual sample results among negative sample pools as K, PPA between testing n-sample pools (n is the preliminarily validated pool size) and individual samples using the candidate test at each site should be calculated as PPA (Candidate~pool~ vs. Candidate~individual~) = 100% x (15-K)/15. It is critical that all consecutive positive samples from time period \[T0, T1\] are included in the PPA calculations. When calculating PPA for this sample pooling validation study, all non-negative results testing pooled samples should be counted as in agreement with positive individually tested results. Test developers should present PPA (Candidate~pool~ vs. Candidate~individual~) for each of three geographically diverse sites in the US separately.**
***Acceptance Criteria for Option A of the Clinical Sample Pooling Validation Study at Three Geographically Diverse US Sites:***
- **If PPA (Candidate~pool~ vs. Candidate~individual~) for each site is ≥85%, the validation data supports n-sample pooling.**
- **If PPA (Candidate~pool~ vs. Candidate~individual~) is ≥85% at 2 out of 3 sites, at the site where PPA (Candidate~pool~ vs. Candidate~individual~) is <85%, additional data with at least 15 additional consecutive positive samples should be generated and an estimate of the PPA (Candidate~pool~ vs. Candidate~individual~) for the combined data of at least 30 consecutive positive samples should be calculated with an overall PPA target of ≥85%.**
- **If PPA (Candidate~pool~ vs. Candidate~individual~) is ≥85% at 0 or 1 out of 3 sites, or 1 site has PPA (Candidate~pool~ vs. Candidate~individual~) <85% calculated with a combined data of at least 30 consecutive individual positive samples, the validation data does not support n-sample pooling and a new decreased n (e.g., n-1) should be considered and validated.**
B. ***Option B (appropriate for RT-PCR tests that can generate Ct values):***
**As an alternative and potentially less burdensome approach for assessing the PPA (Candidate~pool~ vs. Candidate~individual~) at three geographically diverse sites in the US using the candidate RT-PCR test that can generate Ct values, the test developer may acquire historical individual sample testing positive results from three geographically diverse sites in the US to perform in silico analysis of PPA (Candidate~pool~ vs. Candidate~individual~) for each site. We recommend acquiring at least 30 consecutive individually positive sample results by the candidate test (could be recently acquired historical data) from each of the three sites, for a minimum of 90 consecutive individually positive sample results in total.**
**In order to conduct in silico PPA (Candidate~pool~ vs. Candidate~individual~) analyses, for each candidate test target, the test developer should estimate the Ct shift that corresponds to n-sample pools (dilution of 1:n) using both the wet testing data generated from the preliminary clinical sample pooling validation study and additional wet testing of dilutions of a positive clinical sample in replicates using the candidate test at n x LoD, LoD and LoD/n, as described below:**
- **Assess LoD by testing serial dilutions of a positive clinical sample in pooled negative clinical samples;**
- **Test 5 replicates of this positive clinical sample at a concentration of n x LoD (designated as sample A);**
- **Test 10 replicates of sample A combined with (n-1) individual negative clinical samples at the LoD concentration (designated as sample B);**
- **Test 10 replicates of sample B combined with (n-1) individual negative clinical samples at the concentration of LoD/n (designated as sample C). Percent of positive results for sample C is designated as %D.**
**Recommendations regarding estimating the Ct shift corresponding to n-sample pools (dilution of 1:n) are provided below:**
- **Construct and present a scatter plot of Ct ~pool~ (Y-axis) vs Ct ~individual~ (X-axis) using the data from wet testing the 20 positive clinical samples in the preliminary clinical sample pooling validation study, and the first replicate of sample A (Sample A Ct ~individual~) and first replicate of sample B (Sample A Ct ~pool~).**
- **Divide the data points into 3 subintervals based on individual Ct values: ~7 points of high Ct values, ~7 points of medium Ct values, and ~7 points of low Ct values.**
- **Calculate the difference between Ct ~pool~ (Y-axis) vs Ct ~individual~ (X-axis) for each data point and calculate the average of differences for each subinterval as Average ~Low\ Ct\ Values,~ Average ~Medium\ Ct\ Values~, Average ~High\ Ct\ Values~.**
- **Analyze visually whether there is a tendency that the average of the differences for high individual Ct values is larger than the average of the differences for low individual Ct values.**
- **If such tendency is observed, use Average ~High\ Ct\ Values~ as the estimate of Ct shift for the n-sample pools. If such tendency is not observed, take an average of the differences of all 21 samples, and use this average value as the estimate of Ct shift for the n-sample pools.**
**Using the estimated Ct shift for the n-sample pools (Ct Shift) and data from the wet testing of dilutions of a positive clinical sample in replicates at n x LoD, LoD, and LoD/n, the following rules for in silico PPA (Candidate~pool~ vs. Candidate~individual~) analyses for each candidate test target can be established:**
| **Interval of individual Ct values** | **Percent of Detected in n-Sample Pools** |
|------------------------------------|------------------------------------|
| ***\[Cutoff Ct, Cutoff Ct – Ct Shift\]*** | ***0% detected*** |
| ***\[Cutoff Ct – Ct Shift, Ct at the LoD\],*** | ***(D+0)/2 % detected*** |
| ***\[Ct at the LoD, Ct at the LoD - Ct Shift\]*** | ***(95+D)/2 % detected*** |
| ***\[Ct less than Ct at the LoD - Ct Shift\]*** | ***100% detected*** |
||
**Test developers should calculate and present PPA (Candidate ~pool~ vs. Candidate ~individual~) in silico for each of the three geographically diverse sites in the US separately.**
**To lessen the burden of individual laboratory customers intending to utilize the candidate test for testing pooled samples after FDA authorization, with regard to continued monitoring after sample pooling implementation, we strongly recommend that test developers perform preliminary clinical sample pooling validations and wet testing of dilutions of a positive clinical sample in replicates at n x LoD, LoD, and LoD/n for all pool sizes that are less than or equal to n (i.e., n = 5, 4, 3, and 2) to characterize the reduction in test analytical sensitivity (i.e., shift in Ct values and the percent of individual positive samples with low viral load that may be missed due to sample pooling) with respect to each of the pool sizes. The goal of the validation is to generate the following reference table to be included in the instructions for use:**
- **A reference table containing rules for in silico PPA (Candidate~pool~ vs. Candidate~individual~) analyses for each candidate test target for all validated pool sizes, so that each laboratory that intends to utilize the assay for testing pooled samples may utilize these rules to perform in silico PPA analyses as part of a continued monitoring plan after sample pooling implementation. See Appendix B for more information regarding the pooling re-assessment.**
***Acceptance Criteria for Option B of the Clinical Sample Pooling Validation Study at Three Geographically Diverse US Sites:***
- **If the PPA (Candidate~pool~ vs. Candidate~individual~) in silico for each site is ≥85%, the historical data supports n-sample pooling.**
- **If PPA (Candidate~pool~ vs. Candidate~individual~) in silico is ≥85% at 2 out of 3 sites, at the site where PPA (Candidate~pool~ vs. Candidate~individual~) in silico is <85%, additional recent historical individual testing data from at least 30 additional consecutive positive samples should be acquired and an estimate of the PPA (Candidate~pool~ vs. Candidate~individual~) in silico for the combined data of at least 60 consecutive positive samples should be calculated.**
- **If PPA (Candidate~pool~ vs. Candidate~individual~) in silico is ≥85% at 0 or 1 out of 3 sites, or 1 site has PPA (Candidate~pool~ vs. Candidate~individual~) in silico <85% calculated with a combined data of at least 60 consecutive individual positive samples, the in silico validation data does not support n-sample pooling and a new decreased n (e.g., n-1) should be considered and validated.**
**Appendix B: Pooling Implementation and Monitoring**
**The recommendations in this appendix use media pooling as the basis for examples. However, the concepts also apply to swab pooling.**
***Pooling Implementation (Laboratory Monitoring Part A):***
**Prior to implementation of pooled testing using a test authorized for such indication, a laboratory should determine the appropriate pool size based on percent positivity rate in the testing population and pooling testing efficiency. Test developers should include directions in their instructions for use to enable laboratories to complete this step, such as using historical data and the information included in Table 2, as described below.**
***A.1 If Historical Data for Individual Samples are Available***
**Positivity Rate of Individual Testing**
- **Estimate positivity rate (P~individual~) in the laboratory based on individual sample testing, considering the previous 7-10 days. P~individual~ is the number of positive results divided by the total number of tested patients during these 7-10 days.**
**Selection of n for n-sample pooling**
- **n should never be higher than the n validated by the test developer and included in the EUA-authorized instructions for use.**
- **Use P~individual~ and Table 2 to choose an appropriate validated pool size. Table 2 presents the maximum efficiency for the validated pool sizes corresponding to different positivity rates. If the positivity rate (P~individual~) is in Table 2, choose n from Table 2 which corresponds to the maximum efficiency (F).**
- **If P ~individual~ in your laboratory is not listed in Table 2, you should calculate the efficiency for the maximum n which was validated, using formula F=1/ (1+ 1/n-(1-P)^n^). For example, if P ~individual~ in your laboratory is 1% and the maximum n which was validated is 5, the efficiency F=4.02 for n=5. An F of 4.02 generally means that an average of 4,020 individual samples can be tested using only 1,000 tests. You can use the same formula to calculate the efficiency for smaller sample sizes with a particular P ~individual~ as well.**
- **If P ~individual~ is greater than 25%, then pooling patient samples is not efficient and should not be implemented.**
***A.2 If Historical Individual Data for Individual Samples is Unavailable:***
**If historical data from the previous 7-10 days is unavailable, the maximum pool size validated in the EUA and any smaller pool sizes can still be implemented, as the EUA-authorized test has been validated for the maximum pool size sample pooling. However, note that without P ~individual~, the laboratory may choose a pooling size that does not maximize pooling efficiency.**
**Table 2: Efficiency of pooling based on the positivity of SARS-CoV-2 RNA in individual samples (as an example)**
| P~individual~, percent of positive subjects in the tested population | n~maxefficiency~ (n corresponding to the maximal efficiency) | F (Efficiency of n-sample pooling corresponding to n~maxefficiency~ (a maximum increase in the number of tested patients when Dorfman n- pooling strategy used)) |
| --- | --- | --- |
| 1% | 11 | 5.11 |
| 2% | 8 | 3.65 |
| 3% | 6 | 3.00 |
| 4% | 6 | 2.60 |
| 5% | 5 | 2.35 |
| 6% | 5 | 2.15 |
| 7% | 4 | 1.99 |
| 8% | 4 | 1.87 |
| 9% | 4 | 1.77 |
| 10% | 4 | 1.68 |
| 11% | 4 | 1.61 |
| 12% | 4 | 1.54 |
| 13% | 3 | 1.48 |
| 14% | 3 | 1.43 |
| 15% | 3 | 1.39 |
| 16% | 3 | 1.35 |
| 17% | 3 | 1.31 |
| 18% | 3 | 1.28 |
| 19% | 3 | 1.25 |
| 20% | 3 | 1.22 |
| 21% | 3 | 1.19 |
| 22% | 3 | 1.16 |
| 23% | 3 | 1.14 |
| 24% | 3 | 1.12 |
| 25% | 3 | 1.10 |
||
***Pooling Monitoring (Laboratory Monitoring Part B):***
**After implementation of pooled testing using a test authorized for such indication, a laboratory should perform ongoing monitoring of the positivity rate of pooled samples (i.e., P~individual~ is the historical positivity rate and P~pool~ = the positivity rate from pooled samples from a rolling 7-10 day\* period) to ensure pooled testing remains efficient. Test developers should include directions in their instructions for use to enable laboratories to complete this monitoring, as described below.**
**\* It is recommended that P~individual~ be calculated from the previous 7-10 days (i.e., prior to implementing pooled testing), while P~pool~ is calculated from data collected during a rolling 7-10 day time frame. However, when determining if 7-10 days is appropriate, take into consideration the laboratory testing volume and percent positivity, among other factors. Note that if the number of individual or pooled positive results collected during a given time frame is less than 10, P~individual~ and P~pool~ may not be representative of the percent positivity in the testing population and the laboratory may want to consider extending the time period to increase the chance of capturing positives.**
***B.1 Historical Data for Individual Samples is Available:***
**If historical data for individual samples is available, compare P ~pool~ to P ~individual~ periodically, where P~individual~ is the historical positivity rate. If P ~pool~ is less than 85% of P ~individual~ (P ~pool~ < 0.85 × P ~individual~), it is recommended that:**
- **The n-sample pooling should be re-assessed by conducting a re-assessment study as described in “Pooling Re-assessment (Laboratory Monitoring Part C)” below.**
- **Alternatively, if the EUA-authorized test is a high sensitivity RT-PCR assay which uses a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction), and has established high sensitivity with an internationally recognized standard or FDA SARS-CoV-2 Reference Panel,** [29] **the size of pools may be increased taking into consideration Table 2, and the new n should not be more than the test developer validated as the maximum n in the EUA.**
- **If P ~pool~ is greater than 25%, pooling of patient samples is not efficient and should be discontinued until the percent positivity rate decreases.**
***B.2 Historical Data for Individual Samples is Unavailable:***
**If historical data for individual samples is not available, it is recommended that n-sample pooling be assessed as follows:**
- **After implementing a n-sample pooling strategy, first calculate the positivity rate (P ~pool-initial~) based on n-sample pool size using the data from testing pooled samples from the first 7-10 days.**
- **If P ~pool-initial~ is greater than 25%, pooling of patient samples is not efficient and should be discontinued until the percent positivity rate decreases.**
- **If P ~pool-initial~ is less than or equal to 25%, pooling of patient samples can be continued.**
- **Continue to monitor n-sample pooling strategy by calculating the positivity rate among patient samples during n-sample pooling (P ~pools-x~) for ongoing 7-10 day periods based on n-sample pool testing. (P ~pool-x~) should be updated daily using a moving average.**
**Compare P ~pool-initial~ to P ~pool-x~ periodically. If P ~pool-x~ is less than 90% of P ~pool-initial~ (P ~pool-x~ < 0.90 × P ~pool-initial~), it is recommended that:**
- **The n-sample pooling should be re-assessed by conducting a re-assessment study, as described in “Pooling Re-assessment (Laboratory Monitoring Part C)” below.**
- **Alternatively, if the EUA-authorized test is a high sensitivity RT-PCR assay which uses a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction), and has established high sensitivity with an internationally recognized standard or FDA SARS-CoV-2 Reference Panel,** [30] **the size of pools may be increased taking into consideration Table 2, and the new n should not be more than the test developer validated as the maximum n in the EUA.**
- **If P ~pool~ is greater than 25%, pooling of patient samples is not efficient and should be discontinued until the percent positivity rate decreases.**
***Pooling Re-assessment (Laboratory Monitoring Part C):***
**If, during monitoring of the positivity rate of pooled samples, a laboratory determines a drop in the positivity rate, as discussed above, the laboratory should conduct a re-assessment study. Test developers should include directions in their instructions for use to enable laboratories to complete this step, as described below.**
***Option 1: Re-assess pooling using individually tested samples:***
- **Pause n-sample pooling and return to individual testing.**
- **Patient samples should be tested individually until 10 consecutive positive samples have been collected. The total number of samples, tested individually, depends on the positivity rate.**
- **Using these samples, 10 pools should be created and tested with 1 positive and (n-1) negative samples and the PPA between testing sample pools and individual samples should be calculated.**
- **Alternatively, if the laboratory is using an EUA-authorized RT-PCR test that can generate Ct values, the laboratory may be able to assess PPA (PPA~pool~ vs. PPA~individual~) in silico based on the individually tested sample results without performing any testing of pooled samples. In order to perform this in silico PPA assessment, the instructions for use of this EUA-authorized test must include a reference table containing information regarding the in silico PPA (PPA~pool~ vs. PPA~individual~) analysis rules established by the test developer for each test target for all validated pool sizes. Refer to the “Clinical Sample Pooling Validation Study at Three Geographically Diverse US Sites” section in Appendix A for more information regarding this reference table.**
***Option 2: Re-assess pooling using individual testing and n-sample pooled testing:***
- **The re-assessment study should start from starting time T0 and should consist of individual sample testing in parallel with the pooled testing. However, since all non-negative sample pools should include individual testing of all individual samples included in the pool as a part of the n-sample pooling and deconvoluting workflow, the re-assessment study essentially consists of testing individual samples from the negative n-sample pools.**
- **The re-assessment study may stop and assess at time T1 when a minimum of 10 consecutive positive individual results are obtained, including both positive individual results generated from individual testing of samples from the non-negative sample pools following the n-sample pooling and deconvoluting workflow, and positive individual results obtained from individual testing of samples from the negative sample pools for the time period from T0 to T1 \[T0, T1\].**
- **Defining the number of positive individual sample results among negative pools as K, PPA between testing n-sample pools and individual samples using the EUA-authorized test should be calculated as PPA (PPA~pool~ vs. PPA~individual~) = 100% x (10-K)/10. It is critical that all consecutive positive samples from time period \[T0, T1\] are included in the PPA calculations. With regard to calculating the PPA, all non-negative results testing pooled samples should be counted as in agreement with positive individually tested results.**
***Re-assessment Acceptance Criteria for Option 1 and Option 2:***
- **If the PPA (PPA~pool~ vs. PPA~individual~) is ≥ 90% (9 out of 10 or 10 out of 10), then implementation of testing using n-sample pooling is appropriate.**
- **If the PPA between pooled-testing results and individual-testing results is less than 90%:**
- **If PPA ≤70% (7 out of 10), reduce the pool size (consider a new n as n-1).**
- **If PPA is 80% (8 out of 10), collect an additional 10 consecutive individually positive samples. Then, calculate the PPA from the combined data of 20 samples, between pooled testing results and individual testing results. If the PPA is ≥ 85%, then implementation of testing using n-sample pooling is appropriate. Or, to compensate for lost sensitivity, reduce the pool size (consider a new n as n-1) and continue with the re-assessment testing until PPA of pooled compared to individual testing is ≥ 90%.**
- **If PPA of at least 85% cannot be reached for any pool size evaluated in the re-assessment, cease pooling patient samples.**
**If n-sample pooling is acceptable based on re-assessment, re-establish P ~individual~ in your laboratory by estimating the positivity rate from individual testing in the population from which the 10 (or 20) consecutive individual positive samples were collected. If the total number of samples (N\*) that needed to be tested to obtain the 10 (or 20) consecutive positive samples is stopped at the 10^th^ (or 20^th^) positive sample, then the positivity rate of 10/N\* (or 20/N\*) is overestimated. The positivity rate should be corrected by the following corresponding multiplier:**
- **Positivity rate for 10 samples is (10/N\*) × (10/11).**
- **Positivity rate for 20 samples is (20/N\*) × (20/21).**
**This updated new positivity rate should be used as P ~individual~ in the future laboratory monitoring (see “Pooling Monitoring (Laboratory Monitoring Part B)” above.**
[1] This template is part of the “[Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised),” available at .
[2] Available at .
[3] All EUA templates can be found at .
[4] Available at .
[5] Available at .
[6] The CDC has granted a right of reference to the performance data contained in the CDC's EUA request for the [CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel (CDC)](https://www.fda.gov/media/134919/download) (FDA submission number EUA200001) to any entity seeking authorization for a COVID-19 diagnostic device. The CDC has also granted a right of reference to the performance data contained in the CDC's EUA request for their [Influenza SARS-CoV-2 (Flu SC2) Multiplex Assay](https://www.fda.gov/media/139744/download) (FDA submission number EUA201781) to any entity seeking authorization for a multi-analyte respiratory panel that includes SARS-CoV-2. CDC has published the primer and probe sequences for the Influenza SARS-CoV-2 Multiplex Assay on [the CDC website](https://www.cdc.gov/coronavirus/2019-ncov/lab/multiplex-primer-probes.html).
[7] Available at *(last accessed on July 7, 2021). Note this website is not controlled by FDA.*
[8] Available at [https://www.hhs.gov/coronavirus/testing/covid-19-diagnostic-data-reporting/index.html](https://www.hhs.gov/coronavirus/testing/covid-19-diagnostic-data-reporting/index.html%20%20) *(last accessed on July 24, 2021). Note this website is not controlled by FDA.*
[9] Available at [https://www.hhs.gov/sites/default/files/hhs-guidance-implementation.pdf](https://www.hhs.gov/sites/default/files/hhs-guidance-implementation.pdf%20) *(last accessed on July 24, 2021). Note this website is not controlled by FDA.*
[10] Available at [https://www.hhs.gov/sites/default/files/non-lab-based-covid19-test-reporting.pdf](https://www.hhs.gov/sites/default/files/non-lab-based-covid19-test-reporting.pdf%20) *(last accessed on July 24, 2021). Note this website is not controlled by FDA.*
[11] Available at .
[12] Further information regarding cybersecurity is available at .
[13] Available at .
[14] Available at .
[15] Available at .
[16] Available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/shelf-software-use-medical-devices#:~:text=Off%2Dthe%2Dshelf%20(OTS,to%20run%20device%2Dspecific%20functions](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/shelf-software-use-medical-devices#:~:text=Off%2Dthe%2Dshelf%20(OTS,to%20run%20device%2Dspecific%20functions.).
[17] GISAID is a global science initiative and primary source that provides open-access to genomic data of influenza viruses and the novel coronavirus responsible for COVID-19 (See *(last accessed on July 26, 2021). Note this website is not controlled by FDA.*)
[18]
[19] *Last accessed on July 9, 2021. Note this website is not controlled by FDA.*
[20] Available at https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-reference-panel-comparative-data.
[21] .
[22] Available at .
[23] All templates can be accessed at .
[24] Available at *.*
[25] *Last accessed on July 6, 2021. Note this website is not controlled by FDA.*
[26] A list of EUA-authorized tests and their accompanying fact sheets are available at .
[27] Report Adverse events, including problems with test performance or results, to MedWatch by submitting the online FDA Form 3500 (https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.home) or by calling 1-800-FDA-1088
[28]
[29] Please see the following website for the most recent list of FDA authorized SARS-CoV-2 molecular tests: .
Please see the following website for the results of the FDA SARS-CoV-2 reference panel testing: .
[30] Please see the following website for the most recent list of FDA authorized SARS-CoV-2 molecular tests: .
Please see the following website for the results of the FDA SARS-CoV-2 reference panel testing: .
# 2,420 2021-10-25_FDA Template - Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-10-25_FDA Template - Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing.md
file_date: 2021-10-25
title: FDA Template - Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing
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summary_short: The FDA “Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing” provides recommendations for supporting EUA screening claims that rely on repeat testing rather than pre-authorization asymptomatic studies. It specifies expected serial testing intervals, minimum clinical performance thresholds in symptomatic populations, post-authorization study obligations for asymptomatic performance, and labeling requirements for serial, POC, and at-home use. It is used alongside primary molecular or antigen EUA templates to structure submissions and labeling for serial screening programs.
CONTENT
***INTERNAL TITLE:*** Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing
This template provides the Food and Drug Administration’s (FDA) current recommendations concerning what data and information should be submitted to FDA in support of a pre-Emergency Use Authorization (EUA) submission/EUA request for a molecular or antigen diagnostic test for SARS-CoV-2 used for screening with serial testing. FDA generally recommends certain validation studies be conducted for a SARS-CoV-2 molecular or antigen diagnostic assays. These recommendations are captured in EUA templates specific to each test type. Test developers should utilize the appropriate template when determining required testing to support each type of test.
As described in the FDA guidance document: [*Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised),[2] FDA is providing recommendations in this and other EUA templates regarding testing that should be performed to ensure appropriate analytical and clinical validity, including descriptions of appropriate comparators, for different types of tests and indications.
The [EUA Templates](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas#covid19ivdTemplates)[3] are intended to help test developers provide recommended validation data and other information to FDA, but alternative approaches can be used. Current templates for molecular and antigen diagnostic tests include recommendations that the developer provide validation data on asymptomatic individuals prior to authorization of a screening claim, including when using a serial testing approach. This template is intended to provide supplemental recommendations for developers of molecular and antigen tests seeking claims for screening with serial testing without studying asymptomatic individuals prior to authorization, including for point of care (POC) and at-home tests. This template reflects FDA’s current thinking on the topic, and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should,* means that something is suggested or recommended, but not required. For more information about EUAs in general, please see the FDA guidance document: [*Emergency Use Authorization of Medical Products and Related Authorities*](https://www.fda.gov/media/97321/download).[4]
Test developers interested in pursuing an EUA may submit a pre-EUA to begin discussions with the FDA or may submit an EUA request [to covid19dx@fda.hhs.gov](mailto:to%20covid19dx@fda.hhs.gov).
FDA recommends that all developers of molecular SARS-CoV-2 tests include the [Molecular EUA Template Cover Sheet](https://www.fda.gov/media/152768/download)[5] when submitting their EUA request to to help streamline the routing, triage, and review of EUA requests.
## GENERAL INFORMATION ABOUT THIS TEMPLATE
- Text highlighted in yellow ***\[Text\]*** should be completed by the test developer as applicable to their specific test. Text in **bold** outlines the FDA’s additional recommendations for the developers’ consideration when completing the suggested information in each section.
- This template should be used by developers of molecular or antigen diagnostic tests for use in serial testing programs. This template also applies to tests for serial at-home[6] use by individuals separate from a testing program, including to support authorization for over-the-counter (OTC) use, intended to detect SARS-CoV-2 from individuals with or without symptoms or other epidemiological reasons to suspect COVID-19 infection. **This template is not applicable to tests for which data has already demonstrated poor performance (e.g., less than 80% PPA) for testing asymptomatic individuals.**
- **This is not a complete template.** The information in this template does not reflect complete validation data or information that FDA recommends be included in a pre-EUA submission/EUA request; it supplements the recommendations in the Template for Molecular Diagnostic Test Developers, Template for Antigen Test Developers, and Template for Test Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Home Use, all available for download from FDA’s website.[7] Test developers should use the referenced template most appropriate for their test type as their primary template and incorporate information from this supplemental template as applicable.
- A test authorized under an EUA is only authorized for emergency use while the EUA is in effect.
- We plan to update the template as appropriate as we learn more about COVID-19 and gain experience with the EUA process for these kinds of tests.
## EXAMPLE TEMPLATE:
### A. PROPOSED INTENDED USE
**FDA recommends including the following in the requested intended use:**
***\[…******individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested twice over three days with at least 24 hours and no more than 48 hours between tests.\]***
**Alternative testing intervals, such as testing twice a week (e.g., Monday/Thursday or Tuesday/Friday), may be considered for molecular or antigen tests intended for use as part of a testing program.**
**A weekly testing interval may be considered for higher sensitivity molecular tests.**
**When requesting an intended use that includes both serial testing and single-use testing for different patient populations, FDA recommends including a requested intended use in the following format, with the details adjusted based on your test and validation:**
***\[The \[test name\] is a lateral flow assay intended for the qualitative detection of nucleocapsid protein antigen from SARS-CoV-2.***
***This test is authorized for non-prescription home use with self-collected direct anterior nasal (nares) swab samples from individuals aged 14 years or older with symptoms of COVID-19 within the first 10 days of symptom onset. This test is also authorized for non-prescription home use with adult-collected nasal swab samples from individuals aged 2 years or older with symptoms of COVID-19 within the first 10 days of symptom onset.***
***This test is also authorized for non-prescription home use with self-collected anterior nasal (nares) swab samples from individuals aged 14 years or older, or adult collected anterior nasal swab samples from individuals aged 2 years or older, with or without symptoms or other epidemiological reasons to suspect COVID-19 when tested twice over three days with at least 24 hours (and no more than 48 hours) between tests.\]***
### B. CLINICAL PERFORMANCE EVALUATION
**FDA recommends following the recommendations for clinical performance evaluation in the appropriate EUA template to demonstrate a positive percent agreement (PPA) of at least 80% with 70% at the lower bound of the two-sided 95% confidence interval, in symptomatic patients suspected of COVID-19 infection by their healthcare providers.**
**When FDA authorizes a test for screening with serial testing, but the clinical validation does not include at least 20 asymptomatic individuals, FDA intends to include a condition of authorization that the developer conduct a study to establish performance with asymptomatic individuals within a pre-specified timeframe. A study protocol for the study, generally including at least 20 positive asymptomatic individuals, should be agreed upon with FDA prior to study initiation. If the post-authorization study is not completed within the agreed upon timeframe or does not demonstrate adequate performance in asymptomatic individuals, FDA will consider taking additional actions as appropriate under section 564 of the FD&C Act, including revoking or revising the authorization to remove any intended use(s) not adequately supported.**
### C. INSTRUCTIONS FOR USE/PROPOSED LABELING/PACKAGE INSERT:
**Proposed labeling should indicate that testing be done twice over three days with at least 24 hours and no more than 48 hours between tests. Alternative testing intervals may be considered for molecular or antigen tests intended for use as part of a testing program.**
**Proposed labeling should clearly identify the population in which the test’s performance has been validated. The labeling should also clearly identify any populations included in the intended use for which the test’s performance has not yet been established but will be established during the post-authorization study.**
**The test package should contain adequate testing materials to support your intended use. Therefore, tests intended for serial testing should be packaged to enable serial testing, such as providing at least two tests in a package or, when also intended for single-use testing for symptomatic individuals, include language in the labeling, including on the outer box, such as “If you do not have symptoms of COVID-19, you will need at least two tests per person. You may need to purchase additional tests to perform serial (repeat) testing.”**
**FDA recommends including the following limitations in your Instructions for Use, especially when requesting an intended use that includes both serial testing and single-use testing for different patient populations:**
- **Testing for asymptomatic individuals should be performed at least twice over three days, with at least twenty-four hours and no more than 48 hours between tests. You may need to purchase additional tests to perform this serial (repeat) testing.**
- **There is a higher chance of false negative results with home use tests than with laboratory-based molecular tests. This means that there is a higher chance this test will give you a negative result when you have COVID-19.**
- **Serial testing (i.e., testing every day or every other day) is more likely to detect COVID-19, especially when you do not have any symptoms.**
[1] This template is part of the “[Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised)”, available at .
[2] Available at .
[3] All EUA templates can be found at .
[4] Available at https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities.
[5] Available at .
[6] At-home tests are tests labeled for self-testing in any environment outside a clinical laboratory setting, professional healthcare facility, or point of care patient care setting operating under a Clinical Laboratory Improvement Amendments (CLIA) certificate. This includes but is not limited to homes, outdoor environments, office environments, schools, vehicles, emergency shelters, and independent living retirement homes. If the test is intended to be used in a clinical laboratory setting, professional healthcare facility, or patient care setting operating under a CLIA certificate and also outside those facilities, it meets this definition.
[7] All EUA templates can be found at .
# 10,768 2021-11-09_FDA Template - For Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Home Use.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-11-09_FDA Template - For Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Home Use.md
file_date: 2021-11-09
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category: regulatory
subcategory: fda-policy
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summary_short: The FDA “Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Home Use” outlines recommended validation and labeling for SARS-CoV-2 tests intended for self-testing at home and other non-laboratory settings, including OTC and prescription pathways. It specifies expected analytical and clinical performance evidence plus home-use specific studies such as usability, user comprehension, flex/robustness testing, and software/mobile-app validation and reporting workflows. It is used by test developers to structure pre-EUA/EUA submissions and create clear, low-reading-level instructions, packaging, and mitigations appropriate for lay users.
CONTENT
***INTERNAL TITLE:*** Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Home Use
This template provides the Food and Drug Administration’s (FDA) current recommendations concerning what data and information should be submitted to FDA in support of a pre-Emergency Use Authorization (EUA) submission/EUA request for a SARS-CoV-2 molecular or antigen diagnostic test for home use. Home use tests may also be used in additional non-laboratory settings, such as offices, sporting events, airports, schools, etc., where an individual performs the test themselves, including reading and receiving the results themselves.[2] This template does not apply to home collection kits.[3] FDA generally recommends that the following validation studies be conducted for a SARS-CoV-2 molecular or antigen diagnostic assay: limit of detection (LOD), clinical evaluation, inclusivity, cross-reactivity, usability, and flex.
As described in the FDA guidance document [*Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)*](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised), [4] FDA is providing recommendations in this and other EUA templates regarding testing that should be performed to ensure appropriate analytical and clinical validity, including descriptions of appropriate comparators, for different types of tests.
The EUA templates[5] are intended to help test developers provide appropriate validation data and other information to FDA, but alternative approaches can be used. This template reflects FDA’s current thinking on the topic, and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should,* means that something is suggested or recommended, but not required. For more information about EUAs in general, please see the FDA Guidance document: [*Emergency Use Authorization of Medical Products and Related Authorities*](https://www.fda.gov/media/97321/download).[6]
Test developers interested in pursuing an EUA may submit a pre-EUA to begin discussions with the FDA or may submit an EUA request [to covid19dx@fda.hhs.gov](mailto:to%20covid19dx@fda.hhs.gov).
FDA recommends that all developers of molecular SARS-CoV-2 tests include the [Molecular Diagnostic EUA Templates Cover Sheet](https://www.fda.gov/media/152768/download)[7] when submitting their EUA request to to help streamline the routing, triage, and review of EUA requests.
## GENERAL INFORMATION ABOUT THIS TEMPLATE
- Text highlighted in yellow ***\[Text\]*** should be completed by test developers as applicable to their specific test. Text in **bold** outlines the FDA’s additional recommendations for the developers’ consideration when completing the suggested information in each section.
- Not all portions of this template may be relevant for all developers/tests. FDA recommends developers complete all portions that are relevant to facilitate a streamlined review.
- This template addresses tests intended for use with respiratory samples or saliva; if you are considering non-respiratory samples (e.g., blood, stool, etc.), please contact FDA at CDRH-EUA-Templates () to discuss your validation strategy.
- This template is for developers of molecular or antigen diagnostic tests for home use, including non-laboratory settings outside of the home (such as offices, sporting events, airports, schools etc.), that are intended to detect SARS-CoV-2 from individuals.
- A test authorized under an EUA is only authorized for emergency use while the EUA is in effect.
- We may update the template as appropriate as we learn more about COVID-19 and gain experience with the EUA process for these tests.
- A developer that has provided data to the FDA may grant a right of reference to other developers, either broadly or to individual developers, to leverage that data. A right of reference provides a developer the ability to rely upon, and otherwise use, existing information in one regulatory submission for the purpose of supporting a different regulatory submission. In these cases, if the data is applicable to the new developer’s test, the new developer may not have to repeat that validation for its submission to the FDA or FDA may recommend a bridging study. Any developer seeking to leverage data regarding another developer’s EUA-authorized assay must obtain a right of reference from that developer.
## EXAMPLE TEMPLATE:
### A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the ***\[test name\]*** for the *in vitro* qualitative detection of ***\[ribonucleic acid (RNA) or antigen\]*** from SARS-CoV-2 in ***\[add all sample types, e.g., nasal swab or saliva\]***. This test is for ***\[prescription and/or over-the-counter (OTC) use\]*** at home and other non-laboratory sites.
### B. MEASURAND
Specific nucleic acid sequences from the genome of SARS-CoV-2 **\[*please specify the targeted gene(s) of the pathogen*\]**.
***OR***
Specific antigen(s) from SARS-CoV-2 **\[*please specify the targeted antigen(s)*\]**.
### C. APPLICANT
***\[Official name, address, and contact information (including phone number and email address) of applicant and primary correspondent.\]***
### D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name - ***\[test name\]***
Established Name - ***\[test name\]***
### E. REGULATORY INFORMATION
***Approval/Clearance Status:***
The ***\[test name\]*** test is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
***\[If the test has been previously reviewed in an EUA request or pre-EUA submission, please provide the submission number.\]***
***Product Code:***
QJR-molecular diagnostic for SARS-CoV-2
**OR**
QKP-coronavirus antigen detection test system
### F. PROPOSED INTENDED USE
#### *1) Intended Use (IU):*
**The proposed intended use will be finalized based on, among other things, the data provided and recommendations from public health authorities at the time of authorization. Example text is provided below for a home use qualitative molecular or antigen test that detects organism RNA or antigen in adults and children 2 years and older, but may be adapted according to the specific emergency situation addressed by the device*. ***
The ***\[test name\]*** is a ***\[specify test technology such as, real-time reverse-transcriptase-polymerase chain reaction (RT-PCR) test, lateral flow immunoassay, etc.\]*** intended to detect ***\[RNA, \[protein name\] antigen\]*** from the SARS-CoV-2 virus that causes COVID-19 in ***\[describe all the sample types, e.g., anterior nasal swab, saliva\]*** from ***\[individuals age 2 years and older; describe the testing population requested, such as symptomatic individuals who are suspected of COVID-19 by a healthcare provider, or individuals with or without symptoms or other epidemiological reasons to suspect COVID-19 infection\]***.
Persons who test positive with the **\[test name\]** should seek follow up care with their physician or healthcare provider as additional testing and public health reporting may be necessary. Positive results do not rule out bacterial infection or co-infection with other viruses. Persons who test negative and continue to experience COVID-19 like symptoms of fever, cough and/or shortness of breath may still have SARS-CoV-2 infection and should seek follow up care with their physician or healthcare provider.
Laboratories within the United States and its territories are required to report all results to the appropriate public health authorities.
The ***\[test name\]*** is intended for home use ***\[and/or, as applicable for a lay user testing another person\],*** including self-testing in a non-laboratory setting ***\[and, as applicable, for healthcare provider testing of another person in laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, that meet the requirements to perform moderate complexity, high complexity, or waived tests and, as applicable, Point of Care (POC), i.e., in patient care settings operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation\].***
The ***\[test name\]*** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
#### *2) Special Conditions for Use Statements:*
For prescription use only **(as applicable)**
For *in vitro* diagnostic use
For Emergency Use Authorization only
#### *3) Special Instruments:*
The ***\[test name\]*** test is to be used with the *\[**list all instruments, software, cameras, smart phones, operating systems, other applicable instrumentation, etc.**\]*.
**If your test system includes an instrument, the instrumentation manual should be submitted as part of the EUA request. If your test system includes an instrument that was not previously cleared, approved, or authorized by FDA, please see additional discussion in the Product Manufacturing section and note that additional labeling information may be discussed during the EUA review.**
### G. DEVICE DESCRIPTION AND TEST PRINCIPLE
***\[Provide a Device Description and Test Principle consistent with the recommendations in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate*.*\]* For new technologies, FDA may request additional information so we can adequately assess the known and potential risks and benefits associated with the device.**
**Because of the greater potential for error in testing of samples collected at home, FDA recommends that the test include an internal control to indicate that adequate human sample was collected and placed into the test for analysis. If your assay does not have such a control, you should address this risk using another mitigation, such as video observation of user by a trained healthcare professional or a design feature of the collection device.**
**FDA recommends that your test use either anterior nares (nasal) swabs, mid-turbinate swabs (collected using the appropriate swab type), or saliva as sample types. Generally, FDA does not consider self-collection of nasopharyngeal (NP) and oropharyngeal swabs by lay persons to be safe because such collection requires training to accurately collect the sample from the proper anatomical location. Moreover, incorrect technique can result in patient harm such as nose bleeds or esophageal spasms and choking.**
#### 1. *Product Overview/Test Principle:*
***\[Describe the technology of the test and how this technology works to identify the measurand (i.e., the test principle), the instruments/reader employed/required to perform the test from sample collection to result (include all instruments, software, mobile applications, etc.), and the sample types for which you claim to have specific performance characteristics, as described below. If applicable, list all primer and probe sets and briefly describe what they detect. Please include the nucleic acid sequences for all primers and probes used in the test. Please indicate if the test uses biotin-Streptavidin/avidin chemistry in any of the steps for coupling reagents.\]***
#### 2. *Description of Test Steps:*
***\[List and describe in detail all the steps of the test sequentially from sample collection to assay report.\]***
1. ***\[Step one\]***
2. ***\[Step two\]***
3. ***\[Etc.…\]***
#### 3. *Control Material(s):*
***\[For any controls that you intend to be used with your test, please provide information consistent with the recommendations in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate.\]***
#### 4. *Quick Reference Instructions:*
**You should develop a test procedure that will be easy to follow in the format of a Quick Reference Instructions (QRI). User instructions should be oriented to users at no higher than a 7^th^ grade level. It is highly recommended that developers consider adding pictures and diagrams to facilitate performance of the test by a lay user and that the instructions be limited to 1-2 pages. Web or mobile application-based material such as videos may be particularly helpful**. **We recommend you perform Human Usability Studies on your device using the QRI before conducting your final clinical study as the final QRI should be evaluated in the clinical study.**
**The QRI may eliminate the need for a separate Patient Fact Sheet if the QRI contains all necessary elements of a Patient Fact Sheet.**
#### 5. *Test Result Reporting:*
All test results are to be reported to healthcare providers and relevant public health authorities in accordance with local, state, and federal requirements, using appropriate LOINC and SNOMED codes, as defined by the [*Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests*](https://www.cdc.gov/csels/dls/sars-cov-2-livd-codes.html)[8] provided by CDC. Core diagnostic data elements[9] are to be collected for all tests, which have been defined by the Department of Health and Human Services (HHS), along with technical specifications for implementation for lab-based[10] and non-lab-based[11] tests.
***\[You should describe how you will ensure all users of the test can report** **all test results to public health and/or other authorities to whom reporting is required, in accordance with local, state, and federal requirements. Please note whether identified information will be sent to local public health authorities and/or if de-identified information will be sent to CDC. If the test produces results that will be used as part of a CDC recommended testing algorithm, please indicate what follow-up testing/process should be conducted, if applicable. Please also describe how test reporting will capture the appropriate LOINC and SNOMED codes, in addition to location data, and other patient information that may be relevant or required.\]*** **The approach adopted should facilitate reporting by all users and be easy to use and understand. There are several options to allow for reporting of test results, including automatic reporting through a mobile application, instructions directing users to a website where reporting is easily facilitated, etc. FDA is open to alternative approaches that ensure appropriate reporting.**
**Note that in some cases, developers may add a reporting mechanism post-authorization to ensure that all test results are reported in accordance with local, state, and federal requirements.**
#### 6. *Mobile Applications and Software*
**Any smartphone application should be simple. Error messages should be readily understandable, and troubleshooting should be included in the device instruction. The display should promote understanding of results and what individuals should do next, including how to care for themselves and when to seek follow up care. The application should automatically report all test results when appropriate in accordance with local, state, and federal requirements. If your application is intended to interpret test results or otherwise function as part of the test system, it should be included in your analytical and clinical validation studies.**
***\[Please list and describe any mobile applications, software, or web applications used with the test and provide the following information:***
- ***A summary of the verification and validation performed on your software/application. To validate use of your application with a smartphone, you should develop a set of minimum smartphone specifications (e.g., memory, processor capability, minimum operating system (OS) requirements, etc.). You should validate the software on smartphones with each OS that meets those minimum hardware specifications. Full functionality for the application should be demonstrated for the full range of platforms intended for use (e.g., if a web application, then demonstrating on popular modern browsers such as Chrome, Firefox, Microsoft Edge; if a mobile application, then demonstrating on popular modern smartphones and other mobile devices such as Android, and iOS-based devices, etc.).***
- ***Address the cybersecurity of your device, including information that may be contained on your device or in a mobile application or web application. For communications between components (e.g., application to reader, application to cloud service provider), the security of the communications protocol should be described (including version number, configuration, cipher suite), tested, and assessed for risks, especially when the communication security could impact the integrity of the results. For cloud-based functionality, the security of the application programming interface (API), communications, and updates should also be described, tested, and assessed for risks.***
- ***A software update plan that covers mobile application updates, algorithm updates, and web application updates that may impact the performance or safe reporting of the device.\]***
### H. INTERPRETATION OF RESULTS
**Results that are displayed to the user should be simple and easy to interpret (e.g., positive, negative, and invalid). Additional information about test results should also be provided that instructs the users to seek follow up care from a healthcare physician if their symptoms persist or if they are concerned about their health.**
***\[Please describe the testing algorithm/calculation that is used by the device to return the simple qualitative result, for example a ratio value, fluorescence reading, cycle threshold and cut-off, etc. Please also provide any text for users that will accompany test results. Please clearly indicate how invalid results will be displayed to the user and how the user will resolve invalid results, e.g., if repeat testing may be required, call hotline for replacement, etc.\]***
### I. PRODUCT MANUFACTURING
The ***\[test name\]*** has been validated using only the components referenced in this request and will not be changed after authorization without prior concurrence from the FDA.
#### 1. *Overview of Manufacturing and Distribution:*
***\[Please provide information consistent with the recommendations in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate.*\]**
#### 2. *Components and Other Materials/Information Included with the Test:*
Components manufactured by ***\[test developer’s name and FDA registration number (if applicable)\]*** and supplied with the test include:
***\[List all components and other materials/information included with your test, including a description of the primers and probes, volumes, concentrations, quantities, buffer components, etc.\]***
***\[Present a detailed assessment of the toxicology profile of the components of your assay, and propose assay labeling that informs users of the risks associated with use of your device, as well as any recommendations for personal protective equipment. Please specify the volumes and concentrations of each reagent included in your test kit.\]* FDA will conduct an independent risk assessment to determine if the proposed mitigations are appropriate.**
***\[If you plan to use non-traditional sources of swabs or media, please describe your qualification testing and validation procedures.\] ***
**Example: Kit components**
| **Name** | **Description** | **Quantity** | **Material Supplier** | **Catalog Number** |
|----------------|-------------------|-----------|--------------|--------------|
| | | | | |
||
#### 3. *Software Validation:*
***\[Please provide information consistent with the recommendations in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate.*\]**
#### 4. *Basic Safety and Essential Performance:*
***\[Please provide information consistent with the recommendations in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate.\]***
#### 5. *Electromagnetic Compatibility (EMC) Testing*
***\[Please provide information consistent with the recommendations in the*** ***Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate.\]***
#### 6. *Manufacturing and Testing Capabilities:*
***\[Please provide the number of kits you can manufacture per day/week for distribution in the United States.\]***
#### 7. *Distribution Plan:*
This product will be distributed by ***\[please describe the distribution plan for the product and list all current US distributors.\]***
#### 8. *Reagent Stability*
***\[Briefly describe the stability test plan for reagents and include any accelerated stability information, if available.\]* Reagent stability studies generally do not need to be completed at the time of EUA issuance; however, the study design should be agreed upon during interactive review and the stability studies started immediately following authorization, if not before. You should consider the recommendations** **in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate, when designing your stability study.**
### J. PERFORMANCE EVALUATION
***\[Please provide information consistent with the recommendations in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate, with additional considerations and recommendations specific to Home Use Tests provided here.\]***
**The following validation studies should be performed to support your EUA request. Please note that, particularly for new technologies, FDA may request additional studies so we can adequately assess the risks and benefits associated with the candidate test. *\[For each validation study, you should provide a study protocol that includes a detailed, step-by-step description of how samples were prepared and how testing was conducted. You should also include the study data from each validation study in an Excel-compatible format.\]***
#### 1. *Limit of Detection (LoD) - Analytical Sensitivity:*
***\[Please provide information consistent with the recommendations in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate.\]***
#### 2. *Inclusivity (Analytical Sensitivity):*
***\[Please provide information consistent with the recommendations in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate.\]***
#### 3. *Cross-reactivity (Analytical Specificity):*
***\[Please provide information consistent with the recommendations in the Antigen Template for Test Developers or Molecular Diagnostic Template for Test Developers, as appropriate.\]* Additionally, for home use tests, FDA recommends wet testing of Cross-reactivity and Microbial Interference in addition to in silico analysis.**
a. **Cross-reactivity (organisms tested in the absence of SARS-CoV-2)**
b. **Microbial Interference Studies (organisms tested in the presence of SARS-CoV-2)**
c. **Endogenous Interference Substances Studies (including common household items such as cleaners, lotions, soap etc.)**
#### 4. *Biotin interference for antigen tests:*
***\[Please provide information consistent with the recommendations in the Antigen Template for Test Developers.\]***
#### 5. *High-dose Hook Effect Study for antigen tests:*
***\[Please provide information consistent with the recommendations in the Antigen Template for Test Developers.\]***
#### 6. *Flex Studies:*
**Flex studies assess the robustness of an assay performed with the device in its final design/format and should be performed in-house by staff who have been trained in the use of the test. The flex studies should evaluate the most common or likely sources of error based on the use locations and test procedure. Flex studies should be conducted by testing a negative sample and a low positive sample (at 1.5 - 2 times LoD) for each condition being evaluated. In general, the flex studies should be conducted to the point of failure to determine the maximum deviation that will still generate accurate results. We recommend testing 3 replicates per condition per sample concentration. *\[You provide the line data from each flex study in an Excel-compatible format.\]* If erroneous results are observed during studies evaluating the robustness of the device, adequate mitigation(s) should be provided.**
**Each study should be performed using a pre-defined study protocol that includes the following:**
i. **The objective of the study**
ii. **Detailed test procedure**
iii. **Materials used**
**Examples of some conditions that may be evaluated as potential user errors and anticipated environmental stresses (temperature and humidity extremes) are shown below:**
- **40°C and 95% relative humidity (RH) (mimicking hot and humid climates)**
- **Delay in sample testing**
- **Delay in operational steps**
- **Delay in reading results**
- **Sample volume variability (if applicable)**
- **Buffer volume variability (if applicable)**
- **Environmental stability of electronics (temperature and humidity, in combination)**
- **Vibrations**
- **Mixing/swab expression variability (if applicable)**
- **Disturbance during analysis**
- **Placement on non-level surface**
- **Impact of different light sources (if applicable)**
- **Sensitivity to power failures (e.g., surge protection, battery power failure)**
- **Error reporting and device failure handling instructions**
- **Electrical interference testing (e.g., validation of system functions in the presence of potential EM interference sources including cell phones, Bluetooth, Wi-Fi radios, medical equipment expected in the intended environment, etc.)**
**Please see Appendix A for detailed Flex Study designs. CLIA Waiver by Application Decision Summaries**[12] **available on the FDA website may include additional alternative flex study designs potentially applicable to your test.**
**Please contact FDA to discuss the design of a flex study for a multiplexed test.**
#### 7. *Usability Study:*
**FDA recommends a usability study be performed to evaluate the ability of users to perform the test when the test design or instructions for use are not similar to previously authorized home use COVID-19 tests. If you believe that your test design and instructions for use are similar to previously authorized home use COVID-19 tests, such that a usability study may not be needed, FDA recommends that you provide information to help FDA understand how the proposed test design and instructions for use are similar to currently authorized tests and why any differences do not reduce the usability of the test. FDA recommends that you include a comprehensive description of the similarities and differences between the new test and previously authorized tests.**
**FDA encourages developers to submit their usability study protocols, including questions for study participants, to FDA for feedback prior to conducting the study. This is especially important for multiplexed tests.**
**It may be possible to combine the usability study with the clinical evaluation study; however, this presents risk of a failed clinical study if there are problems with the instructions for use. FDA strongly recommends you discuss this option with FDA before design and execution.**
**FDA recommends evaluating the ability of users to perform the entire workflow in an actual use environment or simulated environment as follows:**
- **The study should have pre-defined acceptance criteria and a defined strategy to mitigate risk of errors identified in the study (e.g., modifying the instructions).**
- **For home use tests, we recommend evaluating a minimum of 30 participants split evenly into two sections: 15 participants testing themselves and 15 participants testing another person (child or adult, depending on your intended use population). FDA generally expects demonstrated usability for nasal swab** **samples for children ≥ 2 years of age when collected by an adult and for saliva samples for school aged children.**
- **Participants with prior medical or laboratory training or prior experience with self-collection or self-testing (including infectious disease home tests) should be excluded.**
- **The entire workflow should be performed by each individual participant using the kit, including kit registration, sample collection, testing, and results interpretation.**
- **The participants should be observed (either in person or by remote visual monitoring, such as a video conference) during sample collection and all difficulties should be noted.**
- **Enrollment population should represent different socioeconomic and educational backgrounds. You should collect data on any controls that are run during the test to assess sample adequacy. These data should support that individuals can effectively collect an adequate sample and run the test without introducing contaminants or inhibitors.**
- **After the entire process is completed, participants should be given a questionnaire to assess the ease of use of sample collection, test procedure, and results interpretation as well as the user’s ability to understand the consequences if steps are not performed correctly. The participants should be able to provide comments.**
***\[Please provide FDA with the version of the instructions that was used in the usability study and resulting summary and line data from your usability study\]***
#### 8. *User Comprehension of Test Results/Procedure:*
**FDA recommends performing a study to evaluate user comprehension of test results (i.e., interpreting positive, negative, and invalid results) and instructions for use when the test design or instructions for use are not similar to previously authorized home use COVID-19 tests. This is particularly important for tests intended to be run by lay users without involvement of a physician, as there are significant risks associated with misinterpretation and misuse of test results.**
**If you believe that your test design and instructions for use are similar to previously authorized tests home use COVID-19 tests, such that a user comprehension study may not be needed, FDA recommends that you provide information to help FDA understand how the proposed test design and instructions for use, including reading and interpreting results, are similar to currently authorized tests and why any differences do not reduce the user comprehension for the test. FDA recommends that you include a comprehensive description of the similarities and differences between the new test and previously authorized tests.**
***\[Please provide FDA with user comprehension study data to verify that users can accurately interpret the test results and carry out any follow up actions.\]***
#### 9. *Clinical Evaluation:*
**FDA recommends conducting a prospective, randomized clinical evaluation in the intended use population in which fresh samples are collected, tested, and interpreted by lay-users and results are compared to paired samples evaluated with an authorized high sensitivity molecular test. Please contact FDA regarding recommendations for clinical evaluation designs of multiplexed tests.**
##### a. Testing Sites
- **The clinical evaluation should generally include a minimum of 2 testing sites in the United States to encourage diverse enrollment. This may include an at home clinical study or a study at a testing site with a simulated home environment.**
- **Prior to conducting the at home clinical study, you should first complete an observed usability study to evaluate clarity and demonstrate robustness in using the instructions for use, unless you have provided information to FDA as to why a usability study may not be needed, as described in Section J(7) above.**
- **Recruitment by internet, especially if using monetary incentives, can drastically bias the population who enrolls in the study. We recommend that you consult FDA before starting a recruitment involving a monetary incentive.**
- **Sample types should be non-invasive and safe to prevent possible injury during sample collection. Mid-turbinate swabs may need additional safety features to be appropriate, specifically for pediatric populations.**
- **If collected at home, comparator samples should be collected using an FDA authorized home collection kit, which in combination with a SARS-COV-2 molecular assay comprise the comparator test for the study.**
- **Testing sites should be set up in a way that precludes a user from seeing or hearing other users performing the test (e.g., in separate rooms or areas partitioned with curtains).**
- **The entire workflow should be performed by each individual participant using the kit, including kit registration, sample collection, testing, and results interpretation.**
##### b. Patient Enrollment
- **Parents or legal guardians must consent for children as required by law.**
- **Enrollment population should represent different socioeconomic and educational backgrounds.**
- **High risk individuals should not be excluded from the study.**
- **If you are seeking an OTC or prescription authorization for a home test for use in all patient populations, including individuals with or without symptoms or other epidemiological reasons to suspect COVID-19, you should evaluate both symptomatic and asymptomatic individuals and include an adequate number of pediatric subjects from ages 2-13 years of age. We recommend testing at least 30 children between the ages of 2-13 years of age between your usability and clinical evaluations, to ensure that your proposed sample collection techniques can be conducted by parents or guardians in a home use setting. Study population should include individuals across all ages 2 years - 65+ years**
- **<14 years of age, where the Parent or legal guardian collects a sample from their child (e.g., age 2-13) and performs the test**
- **14-24 years of age**
- **24-64 years of age**
- **≥65 years of age**
- **If you believe that your test design and instructions for use are similar to previously authorized home use COVID-19 tests, such that inclusion of pediatric subjects may not be needed to confirm performance across different age ranges, FDA recommends that you provide information to help FDA understand how the proposed test design and instructions for use are similar to currently authorized tests and why any differences do not impact the performance of the test across different age ranges. FDA recommends that you include a comprehensive description of the similarities and differences between the new test and previously authorized tests.**
- **If you are not able to enroll sufficient asymptomatic individuals in your clinical validation study, you may consider seeking an OTC or prescription home use authorization for use only in individuals with symptoms of COVID-19. For antigen tests, all recommended elements of the clinical study data should be provided, including the days since symptom onset for each symptomatic individual included in your clinical validation study. If your clinical validation study includes symptomatic individuals only (or insufficient numbers of asymptomatic individuals) and you are interested in seeking authorization for serial testing of asymptomatic individuals based on this data, please consult the “[Supplemental Template for Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing](https://www.fda.gov/media/146695/download)”.** [13]
##### c. Reference Sample/Comparator method
- **FDA recommends the comparator sample type be either a health care provider-collected NP or mid-turbinate swab sample (collected from each patient in the study within a reasonable time frame from when the test sample was obtained/tested, preferably during the same visit) or a home-collected nasal swab. If you conduct the study remotely without in-person visits with health care professionals, the comparator sample should be collected with an FDA authorized home collected nasal swab.**
- **You should describe your randomization approach for swab collection, as applicable. If study participants are collecting the reference sample for comparator testing and the study sample, you should clearly describe the order in which swabs will be collected and describe how swab order was randomized to ensure that bias is not introduced due to an unequal distribution of viral materials. If healthcare providers are collecting the reference sample for comparator testing, you should ensure that study participants are not provided additional training by observing how healthcare providers collected a sample, particularly if collected from the same anatomical area as the study sample.**
- **All comparator samples should be tested with a comparator test. The comparator test selected should be an authorized highly-sensitive RT-PCR test that uses both a chemical lysis step and solid phase extraction of nucleic acids (e.g., silica bead extraction). The comparator test should be one of the more sensitive RT-PCR assays authorized by FDA. We encourage you to review the results from the FDA SARS-CoV-2 Reference Panel**[14] **and contact us to discuss your choice of comparator test. The same comparator test should be used for all samples, if possible. Evaluations with the comparator test should be conducted per the authorized instructions for use. If any modifications are made to the authorized comparator test, additional bridging studies may be necessary. Please contact FDA if you are considering using a modified configuration of an authorized RT-PCR assay. *\[Please submit the instrumentation and detailed laboratory protocols, including the platform and extraction kit, for each RT-PCR assay used in your validation studies.\]***
##### d. Discrepant analysis
- **You can establish a discordant analysis plan prior to your clinical study, if preferred. Discordant samples should be tested with a second authorized RT-PCR test that has also demonstrated high sensitivity, and which uses both a chemical lysis step and solid phase extraction of nucleic acids (e.g., silica bead extraction). Results from a Discrepant analysis should not be included in the calculation of negative percent agreement (NPA) and positive percent agreement (PPA) but may be added to the performance table as a footnote.**
##### e. Study Size
- **Individuals should be consecutively enrolled (i.e., in an “all comers” style) until 30 positives and 30 negatives are obtained.**
- **If your test is intended for use in asymptomatic individuals not suspected of COVID-19, you should enroll at least 10 positive individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection. Additional post-authorization studies in individuals with or without symptoms or other epidemiological reasons to suspect COVID-19 infection may be recommended. If you do not enroll at least 10 positive individuals without symptoms, you may consider the approach in the “[Supplemental Template for Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing](https://www.fda.gov/media/146695/download)”.** [15]
- **If using an enrichment strategy to speed enrollment, you should carefully consider how you will randomize and blind study participants to their infection status or the infection status of the individual they are testing and describe how you will minimize potential bias when conducting self-testing. Blinding study participants to their infection status, particularly if positive, raises potential ethical issues and should be discussed with FDA and the study IRB. Data from an enriched study design should represent the full range of viral loads, with both low and high positives samples. Therefore, it is not appropriate to use a rapid antigen test to enrich for participants, as it will select for strong positive samples. We strongly recommend discussing your proposed enrichment strategy with FDA prior to conducting your clinical validation study.**
##### f. Performance
**FDA believes that data should generally demonstrate the following:**
- **NPA ≥98%**
- **PPA**
- **For OTC single-use testing in all patient populations, including individuals with or without symptoms or other epidemiological reasons to suspect COVID-19: ≥ 80% PPA demonstrated in a clinical evaluation including both symptomatic and asymptomatic individuals;**
- **For OTC testing in all patient populations, including individuals with or without symptoms or other epidemiological reasons to suspect COVID-19, with additional mitigations such as serial screening, as discussed in the “Supplemental Template for Developers of Molecular and Antigen Diagnostic COVID-19 Tests for Screening with Serial Testing”**[16]**: ≥ 80% PPA with a lower bound (LB) of the two sided 95% confidence interval (CI) ≥70%, demonstrated in a clinical evaluation including symptomatic individuals only or both symptomatic and asymptomatic individuals;**
- **For prescription home use single-use testing in individuals suspected of COVID-19 by their healthcare provider: ≥ 80% PPA demonstrated in a clinical evaluation including symptomatic individuals only (note that, for antigen tests, the indication may be limited to symptomatic individuals within a certain number of days of symptom onset, depending on the data); or**
- **For OTC single-use testing in symptomatic individuals: ≥80% PPA demonstrated in a clinical evaluation including symptomatic individuals only (note that, for antigen tests, the indication may be limited to symptomatic individuals within a certain number of days of symptom onset, depending on the data).**
**The indications for use for tests with PPA <95% should be limited to providing presumptive negative results.**
#### 10. *Standard Material Testing*
**All molecular tests for home use should demonstrate high analytical sensitivity as determined by testing with a recognized international standard. If you do not have access to a recognized international standard, then please contact to discuss options. If this is not completed prior to submission of an EUA request, it may be required as a Condition of Authorization.**
### K. UNMET NEED ADDRESSED BY THE PRODUCT
**This section will be completed by FDA.**
### L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
**There is no adequate, approved, and available alternative to the emergency use of the product.**
### M. BENEFITS AND RISKS:
**This section will be completed by FDA.**
### N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
**During review, FDA will make available Fact Sheet templates. See examples for authorized tests on our website.** [17]
### O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
**\[*You should include Instructions for Use, Box Labels, Vial Labels and any other proposed labeling.*\]**
***\[You should submit for review your packaging and directions for your specimen collection kit.\]*** **FDA will review these documents for their ease of use and clarity of instructions. We recommend all directions be written at a 7^th^ grade reading level or below.**
**The following limitations should be included in the Instructions for Use of a home use test, as applicable:**
- **Testing for asymptomatic individuals should be performed at least twice over three days, with at least twenty-four hours and no more than 48 hours between tests. You may need to purchase additional tests to perform this serial (repeat) testing.**
- **There is a higher chance of false negative results with home use tests than with laboratory-based molecular tests. This means that there is a higher chance this test will give you a negative result when you have COVID-19.**
- **Serial testing (i.e., testing every day or every other day) is more likely to detect COVID-19, especially when you do not have any symptoms.**
**The following should be included on the outer box of a home use test, as applicable:**
- **Expiration date (sticker): Based on component of kit with the earliest expiration date**
- **For Emergency Use Authorization (EUA) only**
- **For in vitro diagnostic use**
- **Must be 18+ to use this kit**
- **If you have symptoms of COVID-19, you can use a single test**
- **If you do not have symptoms of COVID-19, you will need at least two tests per person**
- **You may need to purchase additional tests to perform serial (repeat) testing**
- **This test is more likely to give you a false negative result when you have COVID-19 than a lab-based molecular test**
- **Storage temperature**
- **Summary of box contents**
- **Items necessary to use the kit: e.g., access to computer/smartphone, internet, email account**
- **Summary of how the kit works**
- **Warnings and related information from EUA letter of authorization**
### P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
**As allowed by Section 564(e) of the FD&C Act, FDA may require certain conditions as part of an EUA. FDA generally includes the following record keeping and reporting information requirements in the EUA.**
\[***Test Developer name***\] will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report on adverse events, and this website is referenced in the Fact Sheet for Health Care providers as well as through the \[***Test Developer name***\] Product Support website: \[***Include link to Test developer’s Website***\]. Each report of an adverse event will be processed according to \[***Test Developer name******\]***’s Non-Conformance Reporting Requirements, and Medical Device Reports will be filed with the FDA as required. Through a process of inventory control, \[***Test Developer name******\]*** will also maintain records of device usage/purchase. \[***Test Developer name******\]*** will collect information on the performance of the test, and report to FDA any suspected occurrence of false positive or false negative results of which \[***Test Developer name******\]*** becomes aware. \[***Test Developer name******\]*** will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
### Appendix A: Recommended Flex Study Design Details, as appropriate for the device:
If incorrect results are observed under the test conditions, the test developer should implement adequate mitigations to prevent reporting of erroneous results.
1. **Reading Time:**
**You should evaluate test results at multiple reading times four-fold below and three-fold above the recommended reading time for the candidate test. For example, where the recommended read time is 20 minutes, you should evaluate read times of 5, 10, 15, 20, 30, and 60 minutes, at a minimum. If incorrect results are observed, the developer should propose adequate mitigations.**
2. **Sample Volume:**
**You should evaluate candidate test results at sample volumes two times below and two times above the recommended sample volume, and the maximum possible added. For example, where the recommended sample volume is 10 μL, you should evaluate sample volumes of 5, 10, and 20 μL, as well as at the maximum sample volume. If incorrect results are observed at either 5 or 20 uL, additional testing at 7.5 and/or 15 uL may be needed. The amount of diluent/buffer added should be that specified in the instructions for use.**
3. **Sample Diluent/Buffer Volume:**
**You should evaluate candidate test results at diluent/buffer volumes at two times below and two times above the recommended diluent/buffer volume specified in the instructions for use and the maximum volume. For example, where the recommended buffer/diluent volume is 2 drops, you should evaluate sample diluent volumes of 1, 2, 3, 4 drops and the whole bottle.**
4. **Sample Elution:**
**You should evaluate how mixing the swab in elution buffer (or other reagent) affects candidate test results. You should evaluate all extremes from not-mixing to vigorous shaking, including generating bubbles and intermediate mixing (i.e. swirling 1 or 2 times).**
5. **Temperature and Humidity:**
**You should evaluate candidate test results at temperature and humidity extremes that are likely to occur in the United States (i.e., 40°C and 95% RH to mimic a hot and humid climate and 5°C and 5% RH to mimic a cold and dry climate.)**
6. **Light:**
**You should evaluate candidate test results in different lighting conditions that would be expected during use (i.e., fluorescent, incandescent, and natural lighting mimicking the outside environment.)**
7. **Disturbance during analysis:**
**You should evaluate the effect on expected candidate results of moving the candidate test while the candidate test is running. This could include dropping the candidate test while it is being run, moving the candidate test to another surface, unplugging the candidate test, receiving a phone call while the mobile app is running, etc.**
8. **Device Orientation:**
**You should evaluate unique device characteristics, as determined by a robust risk analysis. For example, if the candidate test is intended to be run upright, you should evaluate candidate test results if the candidate test is run horizontally, or vice versa.**
[1] This template is part of the [Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised) - Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised).
[2] Operators of non-traditional testing sites should consult with the Centers for Medicare and Medicaid Services (CMS) to determine whether testing at their site would be considered “home use” or would be considered a laboratory under the Clinical Laboratory Improvement Amendments (CLIA). Please see *(last accessed on July 6, 2021). Note this website is not controlled by FDA.*
[3] Please refer to the Home Specimen Collection Molecular Diagnostic Template available at .
[4] Available at .
[5] All EUA templates can be found at .
[6] Available at .
[7] Available at .
[8] Available at *(last accessed on July 7, 2021). Note this website is not controlled by FDA.*
[9] Available at [https://www.hhs.gov/coronavirus/testing/covid-19-diagnostic-data-reporting/index.html](https://www.hhs.gov/coronavirus/testing/covid-19-diagnostic-data-reporting/index.html%20%20) *(last accessed on July 24, 2021). Note this website is not controlled by FDA.*
[10] Available at [https://www.hhs.gov/sites/default/files/hhs-guidance-implementation.pdf](https://www.hhs.gov/sites/default/files/hhs-guidance-implementation.pdf%20) *(last accessed on July 24, 2021). Note this website is not controlled by FDA.*
[11] Available at [https://www.hhs.gov/sites/default/files/non-lab-based-covid19-test-reporting.pdf](https://www.hhs.gov/sites/default/files/non-lab-based-covid19-test-reporting.pdf%20) *(last accessed on July 24, 2021). Note this website is not controlled by FDA.*
[12] Available at .
[13] Available at .
[14] Available at https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-reference-panel-comparative-data.
[15] Available at .
[16] Available at .
[17] A list of EUA-authorized tests and their accompanying fact sheets are available at .
# 2,806 2021-11-15_FDA Fact Sheet - Fact Sheet for Health Care Providers Template.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-11-15_FDA Fact Sheet - Fact Sheet for Health Care Providers Template.md
file_date: 2021-11-15
title: FDA Fact Sheet - Fact Sheet for Health Care Providers Template
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subcategory: fda-policy
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summary_short: The FDA “Fact Sheet for Health Care Providers Template” (v1.0, Nov 15, 2021) is a standardized, fill-in document for EUA-authorized COVID-19 tests that explains authorized use (including serial testing in individuals with or without symptoms), specimen type, and key result interpretation and reporting expectations. It includes required language on false positives/negatives, considerations for asymptomatic testing, optional pooling and home-collection language, and a variant-performance limitation statement. It helps test sponsors and high-complexity laboratories produce consistent provider-facing labeling that aligns with EUA conditions and public health reporting needs.
CONTENT
***INTERNAL TITLE:*** FACT SHEET FOR HEALTHCARE PROVIDERS
**Coronavirus Disease 2019 (COVID-19)**
**v1.0 (November 15, 2021)**
**LABORATORY NAME - TEST NAME Month DD, YYYY**
This Fact Sheet informs you of the significant known and potential risks and benefits of the emergency use of the \[DEVICE/TEST NAME\].
**This test is to be performed only using anterior nasal respiratory specimens from individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.**
The \[DEVICE/TEST NAME\] is authorized for use with anterior nasal respiratory specimens from individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.
**All patients whose specimens are tested with this assay will receive the Fact Sheet for Patients: \[LABORATORY NAME\] - \[DEVICE/TEST NAME\].**
**What are the symptoms of COVID-19?**
Many patients with COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, dyspnea), although some individuals experience only mild symptoms or no symptoms at all. The current information available to characterize the spectrum of clinical illness associated with COVID-19 suggests that, when present, symptoms include cough, shortness of breath or dyspnea, fever, chills, myalgias, headache, sore throat, new loss of taste or smell, nausea or vomiting or diarrhea. Signs and symptoms may appear any time from 2 to 14 days after exposure to the virus, and the median time to symptom onset is approximately 5 days. For further information on the symptoms of COVID-19 please see the link provided in “*Where can I go for updates and more information?*” section.
Public health officials have identified cases of COVID-19 throughout the world, including the United States. Please check the CDC COVID-19 webpage (see link provided in “*Where can I go for updates and more information?*” section at the end of this document) or your local jurisdictions website for the most up to date information.
**What do I need to know about COVID-19 testing?**
Current information on COVID-19 for healthcare providers is available at CDC’s webpage, *Information for Healthcare Professionals* (see links provided in “*Where can I go for updates and more information?*” section).
- The \[DEVICE/TEST NAME\] can be used to test anterior nasal respiratory specimens.
- The \[DEVICE/TEST NAME\] should be ordered for the detection of SARS-CoV-2 in individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.
- \[INCLUDE THE FOLLOWING BULLET IF YOUR TEST INCLUDES USE OF AN AUTHORIZED HOME COLLECTION KIT – MODIFY TO INCLUDE HOME COLLECTION INDICATION BASED ON THE APPENDIX YOU ARE CLAIMING: The \[DEVICE/TEST NAME\] can also be used to test anterior nasal respiratory specimens collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP or self-collected at home using the following authorized home collection kit(s) \[INCLUDE NAME OF AUTHORIZED KIT\]\].
- \[INCLUDE THE FOLLOWING BULLET IF YOUR TEST ALLOWS SPECIMEN POOLING – BASED ON THE APPENDIX YOU ARE CLAIMING\]: The \[DEVICE/TEST NAME\] can also be used to test up to \[INCLUDE POOLING INDICATION BASED ON THE APPENDIX YOU ARE CLAIMING\].
- The \[DEVICE/TEST NAME\] is only authorized for use at the \[NAME OF LABORATORY\] that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
Specimens should be collected with appropriate infection control precautions. Current guidance is available at the CDC’s website (see links provided in “*Where can I go for updates and more information?*” section).
When collecting and handling specimens from individuals suspected of being infected with the virus that causes COVID-19, appropriate personal protective equipment should be used as outlined in the CDC *Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with Coronavirus Disease 2019 (COVID-19)*. For additional information, refer to CDC *Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons Under Investigation (PUIs) for Coronavirus Disease 2019 (COVID-19) (*see links provided in “*Where can I go for updates and more information?*” section).
**What does it mean if the specimen tests positive for the virus that causes COVID-19?**
A positive test result for COVID-19 indicates that RNA from SARS-CoV-2 was detected, and therefore the patient is infected with the virus and presumed to be contagious. Laboratory test results should always be considered in the context of clinical observations and epidemiological data (such as local prevalence rates and current outbreak/epicenter locations) in making a final diagnosis and patient management decisions. Patient management should be made by a healthcare provider and follow current CDC guidelines.
The \[DEVICE/TEST NAME\] has been designed to minimize the likelihood of false positive test results. However, it is still possible that this test can give a false positive result, even when used in locations where the prevalence is below 5%. In the event of a false positive result, risks to patients could include the following: a recommendation for isolation of the patient, monitoring of household or other close contacts for symptoms, patient isolation that might limit contact with family or friends and may increase contact with other potentially COVID-19 patients, limits in the ability to work, delayed diagnosis and treatment for the true infection causing the symptoms, unnecessary prescription of a treatment or therapy, or other unintended adverse effects.
\[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: Individuals included in a pool that returns a positive or invalid result should be treated as a presumptive positive unless or until they receive a negative result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, they should isolate until receiving a negative result when re-tested individually and should **not** be cohorted with other individuals who have received a positive or presumptive positive result.\]
All laboratories using this test must follow the standard testing and reporting guidelines according to their appropriate public health authorities.
**What does it mean if the specimen tests negative for the virus that causes COVID-19?**
A negative test result for this test means that SARS-CoV-2 RNA was not present in the specimen above the limit of detection. However, a negative result does not rule out COVID-19 and should not be used as the sole basis for treatment or patient management decisions. It is possible to test a person too early or too late during SARS-CoV-2 infection to make an accurate diagnosis via \[DEVICE/TEST NAME\].
In addition, asymptomatic people infected with the virus that causes COVID-19 may not shed enough virus to reach the limit of detection of the test, giving a false negative result. In the absence of symptoms, it is difficult to determine if asymptomatic people have been tested too late or too early. Therefore, negative results in asymptomatic individuals may include individuals who were tested too early and may become positive later, individuals who were tested too late and may have serological evidence of infection, or individuals who were never infected.
\[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: Specimens with low viral loads may not be detected in sample pools due to the decreased sensitivity or increased interference of pooled testing. Your interpretation of negative results should take into account clinical and epidemiological risk factors.\]
When diagnostic testing is negative, the possibility of a false negative result should be considered in the context of a patient’s recent exposures and the presence of clinical signs and symptoms consistent with COVID-19. The possibility of a false negative result should especially be considered if the patient’s recent exposures or clinical presentation indicate that COVID-19 is likely, and diagnostic tests for other causes of illness (e.g., other respiratory illness) are negative.
If COVID-19 is suspected based on exposure history together with other clinical findings, re-testing using a new sample with a sensitive method \[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: or without pooling\] should be considered by healthcare providers in consultation with public health authorities. Additional testing may be helpful to ensure testing was not conducted too early.
Risks to a patient of a false negative test result include: delayed or lack of supportive treatment, lack of monitoring of infected individuals and their household or other close contacts for symptoms resulting in increased risk of spread of COVID-19 within the community, or other unintended adverse events.
The performance of this test was established based on the evaluation of a limited number of clinical specimens. The clinical performance has not been established in all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation. Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2 and their prevalence, which change over time.
**What is an EUA?**
The United States FDA has made this test available under an emergency access mechanism called an Emergency Use Authorization (EUA). The EUA is supported by the Secretary of Health and Human Service’s (HHS’s) declaration that circumstances exist to justify the emergency use of in vitro diagnostics (IVDs) for the detection and/or diagnosis of the virus that causes COVID-19. An IVD made available under an EUA has not undergone the same type of review as an FDA-approved or cleared IVD. FDA may issue an EUA when certain criteria are met, which includes that there are no adequate, approved, available alternatives, and based on the totality of scientific evidence available, it is reasonable to believe that this IVD may be effective in diagnosing COVID-19.
This test is authorized under the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing \[include link to this letter\] for use in \[the specific laboratory, that is certified under CLIA and meets requirements to perform high complexity tests, in which it was developed\] for \[insert indication(s) from applicable appendix(ces)\] using the test procedures validated in accordance with the requirements of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing.
The EUA for this test is in effect for the duration of the COVID-19 declaration justifying emergency use of IVDs, unless terminated or revoked (after which the test may no longer be used).
**What are the approved available alternatives?**
Any tests that have received full marketing status (e.g., cleared, approved), as opposed to an EUA, by FDA can be found by searching the medical device databases here: . A cleared or approved test should be used instead of a test made available under an EUA, when appropriate and available. FDA has issued EUAs for other tests that can be found at:
.
**Where can I go for updates and more information?**
**CDC webpages:**
**General:**
**Symptoms:**
**Healthcare Professionals:**
[https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html](https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html)
**Information for Laboratories:**
**Laboratory Biosafety:**
**Isolation Precautions in Healthcare Settings:**
[https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html](https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html%20)
**Specimen Collection:**
**Infection Control:**
**FDA webpages:**
**General:** [www.fda.gov/novelcoronavirus](http://www.fda.gov/novelcoronavirus)
**EUAs:**(includes links to fact sheet for individuals and manufacturer’s instructions)
**LABORATORY NAME:**
ADDRESS LINE 1
ADDRESS LINE 2
**Customer Support:**
+1 800 XXX-XXXX
customersupportemail@company.com
**Technical Support:**
+1 800 XXX-XXXX
techsupportemail@company.com
# 2,447 2021-11-15_FDA Fact Sheet - Fact Sheet for Healthcare Providers.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-11-15_FDA Fact Sheet - Fact Sheet for Healthcare Providers.md
file_date: 2021-11-15
title: FDA Fact Sheet - Fact Sheet for Healthcare Providers
category: regulatory
subcategory: fda-policy
tags:
source_file_type: pdf
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
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conversion: megaparse-v
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notes:
summary_short: The FDA “Fact Sheet for Healthcare Providers – Molecular Laboratory Developed Test (LDT) COVID-19 Authorized Tests” (updated Nov 15, 2021) provides standardized provider-facing risk/benefit, intended-use, and result-interpretation language for EUA-authorized molecular LDTs used on respiratory specimens from individuals suspected of COVID-19. It explains what positive and negative results mean, highlights false positive/false negative risks and variant-related performance limitations, and reiterates CLIA high-complexity and public health reporting expectations. It supports consistent communication to clinicians across laboratories operating under the molecular LDT umbrella EUA.
CONTENT
***INTERNAL TITLE:*** FACT SHEET FOR HEALTHCARE PROVIDERS
Molecular Laboratory Developed Test (LDT) COVID-19 Authorized Tests
Updated: November 15, 2021
Coronavirus Disease 2019 (COVID-19)
This Fact Sheet informs you of the significant known and potential risks and benefits of the emergency use of a Molecular Laboratory Developed Test (LDT) COVID-19 Authorized Test (Molecular LDT COVID-19 Authorized Test) that has been issued an Emergency Use Authorization (EUA) by FDA.
The Molecular LDT COVID-19 Authorized Test is authorized for use on respiratory specimens collected from individuals suspected of COVID-19 by their healthcare provider.
**All patients whose specimens are tested with an authorized test will receive the Fact Sheet for Patients: Molecular Laboratory Developed Test (LDT) COVID-19 Authorized Tests.**
**This test is to be performed only using respiratory specimens collected from individuals suspected of COVID-19 by their healthcare provider.**
### What are the symptoms of COVID-19?
Many patients with COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, dyspnea), although some individuals experience only mild symptoms or no symptoms at all. The current information available to characterize the spectrum of clinical illness associated with COVID-19 suggests that, when present, symptoms include cough, shortness of breath or dyspnea, fever, chills, myalgias, headache, sore throat, new loss of taste or smell, nausea or vomiting or diarrhea. Signs and symptoms may appear any time from 2 to 14 days after exposure to the virus, and the median time to symptom onset is approximately 5 days. For further information on the symptoms of COVID-19 please see the link provided in "Where can I go for updates and more information?" section.
Public health officials have identified cases of COVID-19 throughout the world, including the United States. Please check the CDC COVID-19 webpage (see link provided in "Where can I go for updates and more information?" section at the end of this document) or your local jurisdictions website for the most up to date information.
### What do I need to know about COVID-19 testing?
Current information on COVID-19 for healthcare providers is available at CDC’s webpage, *Information for Healthcare Professionals* (see links provided in "Where can I go for updates and more information?" section).
- The Molecular LDT COVID-19 Authorized Test can be used to test respiratory specimens validated in the laboratory that developed the test for COVID-19.
- The Molecular LDT COVID-19 Authorized Test should be ordered for the detection of nucleic acid from SARS-CoV-2 in individuals suspected of COVID-19 by their healthcare provider.
- The Molecular LDT COVID-19 Authorized Test is only authorized for use at the laboratory that developed the test for COVID-19 that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. 263a, to perform high complexity tests.
Specimens should be collected with appropriate infection control precautions. Current guidance for COVID-19 infection control precautions are available at the CDC’s website (see links provided in "Where can I go for updates and more information?" section).
When collecting and handling specimens from individuals suspected of being infected with the virus that causes COVID-19, appropriate personal protective equipment should be used as outlined in the CDC Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with Coronavirus Disease 2019 (COVID-19). For additional information, refer to CDC Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons Under Investigation (PUIs) for Coronavirus Disease 2019 (COVID-19) (see links provided in "Where can I go for updates and more information?" section).
### What does it mean if the specimen tests positive for the virus that causes COVID-19?
A positive test result for COVID-19 indicates that RNA from SARS-CoV-2 was detected, and therefore the patient is infected with the virus and presumed to be contagious. Laboratory test results should always be considered in the context of clinical observations and epidemiological data (such as local prevalence rates and current outbreak/epicenter locations) in making a final diagnosis and patient management decisions. Patient management should be made by a healthcare provider and follow current CDC guidelines.
The Molecular LDT COVID-19 Authorized Test has been designed to minimize the likelihood of false positive test results. However, it is still possible that this test can give a false positive result, even when used in locations where the prevalence is below 5%. In the event of a false positive result, risks to patients could include the following: a recommendation for isolation of the patient, monitoring of household or other close contacts for symptoms, patient isolation that might limit contact with family or friends and may increase contact with other potentially COVID-19 patients, limits in the ability to work, the delayed diagnosis and treatment for the true infection causing the symptoms, unnecessary prescription of a treatment or therapy, or other unintended adverse effects.
All laboratories using this test must follow the standard testing and reporting guidelines according to their appropriate public health authorities.
### What does it mean if the specimen tests negative for the virus that causes COVID-19?
A negative test result for this test means that SARS-CoV-2 RNA was not present in the specimen above the limit of detection. However, a negative result does not rule out COVID-19 and should not be used as the sole basis for treatment or patient management decisions. It is possible to test a person too early or too late during infection to make an accurate diagnosis via the Molecular LDT COVID-19 Authorized Test.
When diagnostic testing is negative, the possibility of a false negative result should be considered in the context of a patient’s recent exposures and the presence of clinical signs and symptoms consistent with COVID-19. The possibility of a false negative result should especially be considered if the patient’s recent exposures or clinical presentation indicate that COVID-19 is likely, and diagnostic tests for other causes of illness (e.g., other respiratory illness) are negative. If COVID-19 is still suspected based on exposure history together with other clinical findings, re-testing with an alternative method should be considered by healthcare providers in consultation with public health authorities. Additional testing may be helpful to ensure testing was not conducted too early.
Risks to a patient of a false negative test result include: delayed or lack of supportive treatment, lack of monitoring of infected individuals and their household or other close contacts for symptoms resulting in increased risk of spread of COVID-19 within the community, or other unintended adverse events.
The performance of this test was established based on the evaluation of a limited number of clinical specimens. The clinical performance has not been established in all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation. Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARSCoV-2 and their prevalence, which change over time.
### What is an EUA?
The United States FDA has made this test available under an emergency access mechanism called an Emergency Use Authorization (EUA). The EUA is supported by the Secretary of Health and Human Service’s (HHS’s) declaration that circumstances exist to justify the emergency use of in vitro diagnostics (IVDs) for the detection and/or diagnosis of the virus that causes COVID-19.
An IVD made available under an EUA has not undergone the same type of review as an FDA-approved or cleared IVD. FDA may issue an EUA when certain criteria are met, which includes that there are no adequate, approved, available alternatives, and based on the totality of scientific evidence available, it is reasonable to believe that this IVD may be effective in diagnosing COVID-19.
The EUA for this test is in effect for the duration of the COVID-19 declaration justifying emergency use of IVDs, unless terminated or revoked (after which the test may no longer be used).
### What are the approved available alternatives?
Any tests that have received full marketing status (e.g., cleared, approved), as opposed to an EUA, by FDA can be found by searching the medical device databases here: [https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases](https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases). A cleared or approved test should be used instead of a test made available under an EUA, when appropriate and available. FDA has issued EUAs for other tests that can be found at: [https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization).
### Where can I go for updates and more information?
#### CDC webpages:
**General:** [https://www.cdc.gov/coronavirus/2019-ncov/index.html](https://www.cdc.gov/coronavirus/2019-ncov/index.html)
**Symptoms:**
[https://www.cdc.gov/coronavirus/2019-ncov/symptoms-](https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html)
[testing/symptoms.html](https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html)
**Healthcare Professionals:** [https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html](https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html)
**Information for Laboratories:** [https://www.cdc.gov/coronavirus/2019-nCoV/lab/index.html](https://www.cdc.gov/coronavirus/2019-nCoV/lab/index.html)
**Laboratory Biosafety:** [https://www.cdc.gov/coronavirus/2019-nCoV/lab-biosafety-guidelines.html](https://www.cdc.gov/coronavirus/2019-nCoV/lab-biosafety-guidelines.html)
**Isolation Precautions in Healthcare Settings:** [https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html](https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html)
**Specimen Collection:** [https://www.cdc.gov/coronavirus/2019-nCoV/guidelines-clinical-specimens.html](https://www.cdc.gov/coronavirus/2019-nCoV/guidelines-clinical-specimens.html)
**Infection Control:** [https://www.cdc.gov/coronavirus/2019-ncov/php/infection-control.html](https://www.cdc.gov/coronavirus/2019-ncov/php/infection-control.html)
#### FDA webpages:
**General:** [www.fda.gov/novelcoronavirus](http://www.fda.gov/novelcoronavirus)
**EUAs:**(includes links to fact sheet for individuals and manufacturer’s instructions) [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas)
#### LABORATORY CONTACT:
Contact information for the laboratory that developed the Molecular LDT COVID-19 Authorized Test must be provided to the Healthcare Provider in the test report or material/mechanism (e.g., email) that accompanies this Fact Sheet and the test results.
# 1,791 2021-11-15_FDA Fact Sheet - Fact Sheet for Patients Template.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-11-15_FDA Fact Sheet - Fact Sheet for Patients Template.md
file_date: 2021-11-15
title: FDA Fact Sheet - Fact Sheet for Patients Template
category: regulatory
subcategory: fda-policy
tags:
source_file_type: docx
xfile_type: docx
gfile_url: https://docs.google.com/document/d/1buxdsyDhN_T_c6FVW3PIPMM_duc8Nnv4
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pdf_gdrive_url: https://drive.google.com/file/d/1NIqDxLqy-csW9Upw2VhSpQtXYZ90LoM7
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2021-11-15_FDA%20Fact%20Sheet%20-%20Fact%20Sheet%20for%20Patients%20Template.pdf
conversion_input_file_type: docx
conversion: pandoc
license: Public Domain
tokens: 1791
words: 1327
notes:
summary_short: The FDA “Fact Sheet for Patients Template” (v1.0, Nov 15, 2021) is a fill-in patient-facing document for EUA-authorized COVID-19 testing that explains what the test is, why someone may be tested (including serial testing), and how to interpret positive and negative results. It includes optional standardized language for pooled testing, follow-up and emergency-care guidance, and required EUA status and alternatives statements tied to the umbrella EUA for serial testing. It helps labs and test sponsors provide consistent, plain-language risk/benefit and next-step instructions to individuals receiving results.
CONTENT
***INTERNAL TITLE:*** FACT SHEET FOR PATIENTS
**Coronavirus Disease 2019 (COVID-19)**
**v1.0 (November 15, 2021)**
**LABORATORY NAME - TEST NAME Month DD, YYYY**
You are being given this Fact Sheet because your sample(s) was tested for the Coronavirus Disease 2019 (COVID-19) using the \[DEVICE/TEST NAME\].
This Fact Sheet contains information to help you understand the risks and benefits of using this test for the diagnosis of COVID-19. After reading this Fact Sheet, if you have questions or would like to discuss the information provided, please talk to your healthcare provider.
**For the most up to date information on COVID-19 please visit the CDC Coronavirus Disease 2019 (COVID-19) webpage:**
[**https://www.cdc.gov/COVID19**](https://www.cdc.gov/nCoV)
**What is COVID-19?**
COVID-19 is caused by the SARS-CoV-2 virus which is a new virus in humans causing a contagious respiratory illness. COVID-19 can present with a mild to severe illness, although some people infected with COVID-19 may have no symptoms at all. Older adults and people of any age who have underlying medical conditions have a higher risk of severe illness from COVID-19. Serious outcomes of COVID-19 include hospitalization and death. The SARS-CoV-2 virus can be spread to others not just while one is sick, but even before a person shows signs or symptoms of being sick (e.g., fever, coughing, difficulty breathing, etc.). A full list of symptoms of COVID-19 can be found at the following link: .
**What is the \[DEVICE/TEST NAME\]?**
The test is designed to detect the virus that causes COVID-19 in anterior nasal swabs.
**Why was my sample tested?**
You were tested because your healthcare provider believes you may have been exposed to the virus that causes COVID-19 based on your signs and symptoms (e.g., fever, cough, difficulty breathing), and/or because:
- You are being tested at regular intervals (serial testing) even though you do not have symptoms or risk factors for COVID-19; or
- You live in or have recently traveled to a place where transmission of COVID-19 is known to occur; or
- You have been in close contact with an individual suspected of or confirmed to have COVID-19; or
- You and your healthcare provider believe there is another reason to investigate your COVID-19 status.
Testing of the samples will help find out if you may have COVID-19.
\[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: Laboratories may use pooling when testing your specimen, which means they combine your sample with other individuals’ samples prior to testing and test them as a “pool”. The laboratory may return a result for the entire pool together or may return individual results.\]
**What are the known and potential risks and benefits of the test?**
Potential risks include:
- Possible discomfort or other complications that can happen during sample collection.
- Possible incorrect test result (see below for more information).
Potential benefits include:
- The results, along with other information, can help your healthcare provider make informed recommendations about your care.
- The results of this test may help limit the spread of COVID-19 to your family and those you come in contact with.
**What does it mean if I have a positive test result?**
If you have a positive test result, it is very likely that you have COVID-19. Therefore, it is also likely that you may be placed in isolation to avoid spreading the virus to others. You should follow CDC guidance to reduce the potential transmission of disease.
\[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: If you were tested as part of a pool that returned a positive or invalid test result, you may have COVID-19 and should consider yourself to have a positive test result unless or until you receive a negative test result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, you should isolate until receiving a negative result when re-tested individually and should not be grouped with other individuals who have received a positive or presumptive positive result.\]
There is a smaller possibility that this test can give a positive result that is wrong (a false positive result) particularly when used in a population without many cases of COVID-19 infection. Your healthcare provider will work with you to determine how best to care for you based on the test results along with medical history, and your symptoms
**What does it mean if I have a negative test result?**
A negative test result means that the virus that causes COVID-19 was not found in your sample.
However, it is possible for this test to give a negative result that is incorrect (false negative) in some people with COVID-19. You might test negative if the sample was collected early during your infection. You could also be exposed to COVID-19 after your sample was collected and then have become infected.
In particular, people infected with COVID-19 but who have no symptoms may not shed enough virus to trigger a positive test. This means that you could possibly still have COVID-19 even though the test result is negative. If your test is negative, your healthcare provider will consider the test result together with all other aspects of your medical history (such as symptoms, possible exposures, and geographical location of places you have recently traveled) in deciding how to care for you.
\[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: If your test result indicates your specimen was pooled and you have a negative test result there a small chance that your result is incorrect. You should talk with your healthcare provider if you are concerned.\]
If you have no symptoms but have been tested because your healthcare provider thought you may have been exposed to COVID-19, you should continue to monitor your health and let your healthcare provider know if you develop any symptoms of COVID-19. If you develop symptoms you may need another test to determine if you have contracted the virus causing COVID-19.
**If you develop symptoms or your symptoms get worse, you should seek medical care. If you have the following symptoms you should seek immediate medical care at the closest emergency room:**
\- Trouble breathing
\- Persistent pain or pressure in the chest
\- New confusion
\- Inability to wake up or stay awake
\- Bluish lips or face
It is important that you work with your healthcare provider to help you understand the next steps you should take.
**Is this test FDA-approved or cleared?**
No. This test is not yet approved or cleared by the United States FDA. FDA may issue an Emergency Use Authorization (EUA) when certain criteria are met, which includes that there are no adequate, approved, available alternatives. The EUA for this test is supported by the Secretary of Health and Human Service’s (HHS’s) declaration that circumstances exist to justify the emergency use of in vitro diagnostics for the detection and/or diagnosis of the virus that causes COVID-19. This EUA will remain in effect (meaning this test can be used) for the duration of the COVID-19 declaration justifying the emergency use of in vitro diagnostics, unless it is terminated or revoked by FDA (after which the test may no longer be used).
This test is authorized under the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing \[include link to this letter\] for use in \[the specific laboratory, that is certified under CLIA and meets requirements to perform high complexity tests, in which it was developed\] for \[insert indication(s) from applicable appendix(ces)\] using the test procedures validated in accordance with the requirements of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing.
**What are the approved alternatives?**
Any tests that have received full marketing status (e.g., cleared, approved), as opposed to an EUA, by FDA can be found by searching the medical device databases here:. A cleared or approved test should be used instead of a test made available under an EUA, when appropriate and available. FDA has issued EUAs for other tests that can be found at:
# 1,407 2021-11-15_FDA Fact Sheet - Fact Sheet for Patients.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-11-15_FDA Fact Sheet - Fact Sheet for Patients.md
file_date: 2021-11-15
title: FDA Fact Sheet - Fact Sheet for Patients
category: regulatory
subcategory: fda-policy
tags:
source_file_type: pdf
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: https://drive.google.com/file/d/15IYuV9oStHUdX__pWbgcong0pukyfFSz
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2021-11-15_FDA%20Fact%20Sheet%20-%20Fact%20Sheet%20for%20Patients.pdf
conversion_input_file_type: pdf
conversion: megaparse-v
license: Public Domain
tokens: 1407
words: 960
notes:
summary_short: The FDA “Fact Sheet for Patients – Molecular Laboratory Developed Test (LDT) COVID-19 Authorized Tests” (updated Nov 15, 2021) explains, in plain language, what an EUA-authorized molecular LDT COVID-19 test is and why a patient may have been tested. It describes what positive and negative results mean, including the possibility of false results, and emphasizes follow-up with a healthcare provider for next steps. It also clarifies that the test is authorized under an EUA (not fully FDA approved/cleared) and points patients to CDC and FDA resources for current information.
CONTENT
***INTERNAL TITLE:*** FACT SHEET FOR PATIENTS
Molecular Laboratory Developed Test (LDT) COVID-19 Authorized Tests
Updated: November 15, 2021
Coronavirus Disease 2019 (COVID-19)
You are being given this Fact Sheet because your sample(s) was tested for the Coronavirus Disease 2019 (COVID-19) using a Molecular Laboratory Developed Test (LDT) COVID-19 Authorized Test (Molecular LDT COVID-19 Authorized Test) that has been issued an Emergency Use Authorization (EUA) by FDA.
This Fact Sheet contains information to help you understand the risks and benefits of using this test for the diagnosis of COVID-19. After reading this Fact Sheet, if you have questions or would like to discuss the information provided, please talk to your healthcare provider.
**For the most up to date information on COVID-19 please visit the CDC Coronavirus Disease 2019 (COVID-19) webpage:**
[https://www.cdc.gov/COVID19](https://www.cdc.gov/COVID19)
### What is COVID-19?
COVID-19 is caused by the SARS-CoV-2 virus which is a new virus in humans causing a contagious respiratory illness. COVID-19 can present with a mild to severe illness, although some people with COVID-19 may have no symptoms at all. Older adults and people of any age who have underlying medical conditions have a higher risk of severe illness from COVID-19. Serious outcomes of COVID-19 include hospitalization and death. The SARS-CoV-2 virus can be spread to others not just while one is sick, but even before a person shows signs or symptoms of being sick (e.g., fever, coughing, difficulty breathing, etc.). A full list of symptoms of COVID-19 can be found at the following link:
[https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html](https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html).
### What is the Laboratory Developed Test?
The Molecular LDT COVID-19 Authorized Test is designed, for use in a single laboratory, to detect the virus that causes COVID-19 in respiratory specimens, for example nasal or oral swabs.
### Why was my sample tested?
You were tested because your healthcare provider believes you may have been exposed to the virus that causes COVID-19 based on your signs and symptoms (e.g., fever, cough, difficulty breathing), and/or because:
- You live in or have recently traveled to a place where transmission of COVID-19 is known to occur, and/or
- You have been in close contact with an individual suspected of or confirmed to have COVID-19.
Testing of the samples will help find out if you may have COVID-19.
### What are the known and potential risks and benefits of the test?
Potential risks include:
- Possible discomfort or other complications that can happen during sample collection.
- Possible incorrect test result (see below for more information).
Potential benefits include:
- The results, along with other information, can help your healthcare provider make informed recommendations about your care.
- The results of this test may help limit the spread of COVID-19 to your family and others in your community.
### What does it mean if I have a positive test result?
If you have a positive test result, it is very likely that you have COVID-19. Therefore, it is also likely that you may be placed in isolation to avoid spreading the virus to others. You should follow CDC guidance to reduce the potential transmission of disease. There is a smaller possibility that this test can give a positive result that is wrong (a false positive result) particularly when used in a population without many cases of COVID-19. Your healthcare provider will work with you to determine how best to care for you based on the test results along with medical history, and your symptoms.
### What does it mean if I have a negative test result?
A negative test result means that the virus that causes COVID-19 was not found in your sample.
However, it is possible for this test to give a negative result that is incorrect (false negative) in some people with COVID-19. You might test negative if the sample was collected early during your infection. You could also be exposed to COVID-19 after your sample was collected and then have become infected.
This means that you could possibly still have COVID-19 even though the test is negative. If your test is negative, your healthcare provider will consider the test result together with all other aspects of your medical history (such as symptoms, possible exposures, and geographical location of places you have recently traveled) in deciding how to care for you.
It is important that you work with your healthcare provider to help you understand the next steps you should take.
### Is this test FDA-approved or cleared?
No. This test is not yet approved or cleared by the United States FDA. FDA may issue an Emergency Use Authorization (EUA) when certain criteria are met, which includes that there are no adequate, approved, available alternatives. The EUA for this test is supported by the Secretary of Health and Human Service’s (HHS’s) declaration that circumstances exist to justify the emergency use of in vitro diagnostics for the detection and/or diagnosis of the virus that causes COVID-19. This EUA will remain in effect (meaning this test can be used) for the duration of the COVID-19 declaration justifying the emergency use of in vitro diagnostics, unless it is terminated or revoked by FDA (after which the test may no longer be used).
### What are the approved alternatives?
Any tests that have received full marketing status (e.g., cleared, approved), as opposed to an EUA, by FDA can be found by searching the medical device databases here:
[https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases](https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases). A cleared or approved test should be used instead of a test made available under an EUA, when appropriate and available. FDA has issued EUAs for other tests that can be found at:
[https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization).
**Where can I go for updates and more information?** The most up-to-date information on COVID-19 is available at the CDC General webpage: [https://www.cdc.gov/COVID19](https://www.cdc.gov/COVID19). In addition, please also contact your healthcare provider with any questions/concerns.
# 3,812 2021-11-15_FDA Fact Sheet - Test Summary Template.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-11-15_FDA Fact Sheet - Test Summary Template.md
file_date: 2021-11-15
title: FDA Fact Sheet - Test Summary Template
category: regulatory
subcategory: fda-policy
tags:
source_file_type: docx
xfile_type: docx
gfile_url: https://docs.google.com/document/d/1hCGpvQwuLnzFif5So2fCKvXc6HbzDlqf
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pdf_gdrive_url: https://drive.google.com/file/d/1YClkMKU4YVojP28wnwyDhl_7QIzaQylH
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fda-policy/2021-11-15_FDA%20Fact%20Sheet%20-%20Test%20Summary%20Template.pdf
conversion_input_file_type: docx
conversion: pandoc
license: Public Domain
tokens: 3812
words: 2611
notes:
summary_short: The FDA “Test Summary Template” is an EUA-ready summary document for a laboratory-developed SARS-CoV-2 molecular test that standardizes how intended use, test principles, instruments/reagents, controls, result interpretation, and performance data are presented. It includes optional sections for pooling, home collection, and asymptomatic screening, plus required language on confirmatory testing considerations and variant-related performance limitations. It helps CLIA high-complexity laboratories package key validation and labeling elements in a consistent format aligned with the umbrella EUA for serial testing.
CONTENT
***[Laboratory Name - Test Name]***
Test Summary - ***[DATE]***
**EMERGENCY USE AUTHORIZATION (EUA) TEST SUMMARY FOR THE *\[LABORATORY NAME – TEST NAME\]***
For *In vitro* Diagnostic Use
Rx Only
For use under Emergency Use Authorization (EUA) only
**The *\[test name\]* will be performed at the *\[laboratory name\]* located at *\[laboratory address\]*, which is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets the requirements to perform high complexity tests.**
### INTENDED USE
The ***\[test name\]*** is intended for the *in vitro* ***\[insert indication(s) from applicable appendix(ces)\]***. Testing is limited to ***\[laboratory name\]*** laboratory located at ***\[laboratory address\]***, which is certified under Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets the requirements to perform high-complexity testing.
The ***\[test name\]*** is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of real-time PCR and in vitro diagnostic procedures. The ***\[test name\]*** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
Results are for the detection and identification of SARS-CoV-2 RNA. The SARS-CoV-2 nucleic acid is generally detectable in anterior nasal swab specimens during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
Laboratories within the United States and its territories are required to report all results to the appropriate public health authorities.
\[INCLUDE THIS PARAGRAPH IF YOUR INDICATION INCLUDES POOLING:\] Negative results from pooled testing should not be treated as definitive. If a patient’s clinical signs and symptoms are inconsistent with a negative result or results are necessary for patient management, then the patient should be considered for individual testing. Specimens included in pools with a positive or invalid result must be reported as presumptive positive or tested individually prior to reporting a result. Individuals included in a pool that returns a positive or invalid result should be treated as a presumptive positive unless or until they receive a negative result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, they should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result. Specimens with low viral loads may not be detected with pooled testing due to decreased sensitivity or increased interference from pooled testing.
For serial testing programs, additional confirmatory testing for negative results may be necessary, if there is a high likelihood of COVID-19, such as an individual with a close contact with COVID-19 or with suspected exposure to COVID-19 or in communities with high prevalence of infection. Additional confirmatory testing for positive results may also be necessary, if there is a low likelihood of COVID-19, such as in individuals without known exposure to COVID-19 or residing in communities with low prevalence of infection.
#### 1. *Special Conditions for Use Statements:*
For use under Emergency Use Authorization (EUA) only
For prescription use only
For *in vitro* diagnostic use only
\[INCLUDE THIS PARAGRAPH IF YOUR INDICATION INCLUDES HOME COLLECTION:\] Testing of specimens self-collected at home is limited to specimens collected with the ***\[name of authorized home collection kit with which your test is validated\]*** by ***\[the patient population authorized in the home collection kit EUA\]***.
This test is authorized under the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing \[include link to this letter\] for use in \[the specific laboratory, that is certified under CLIA and meets requirements to perform high complexity tests, in which it was developed\] for \[insert indication(s) from applicable appendix(ces)\] using the test procedures validated in accordance with the requirements of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing.
### DEVICE DESCRIPTION AND TEST PRINCIPLE
The \[***Test Name*\]** assay is a reverse transcription polymerase chain reaction (RT -PCR) test. The SARS-CoV-2 primer and probe set(s) is designed to detect RNA from the SARS-CoV-2 ***\[genes/regions\]*** in anterior nasal swab specimens that were collected from individuals, including individuals without symptoms or other reasons to suspect COVID-19.
***\[Describe the processes used to perform the test, including, as applicable, 1) nucleic acid extraction, 2) reverse transcription of target RNA to cDNA, 3) PCR amplification of target and internal control, and 4) simultaneous detection of PCR amplicons by fluorescent dye labeled probes. Include key parameters such as input volumes, reverse transcription (RT) time and temperature, PCR cycling parameters including dwell temperature and dwell times.\]***
### INSTRUMENTS USED WITH TEST
#### Instruments
The \[***test name***\], a real-time RT-PCR test, is to be used with the \[***list extraction kit(s)***\] and the \[***list RT-PCR Instrument(s)***\] and \[***RT-PCR Instrument Software***\].
#### Collection Kits (if applicable)
This assay can be used with the **\[*list EUA authorized Home Collection Kit(s)*\].**
#### Reagents
The primary reagents used in \[***test name***\] assay:
| Kits and Reagents | Manufacturer | Catalog # |
| --- | --- | --- |
||
### CONTROL MATERTIAL(s) TO BE USED WITH *\[test name\]:*
***\[List all control materials used with the test and describe what they are, how they are expected to work, where in the testing process they are used, and the frequency of use. If a control is commercially available, provide supplier’s name and catalog number or other identifier; if your device relies on external controls that are manufactured by a third party please note that these controls must also be validated within your analytical and clinical studies.\]***
Controls that are used with the test include:
1. A “no template” (negative) control is needed to ***\[describe need\]*** and is used ***\[describe use – please also specify frequency of use\]***
2. A positive template control is needed to ***\[describe need\]*** and is used ***\[describe use – please specify the concentration of the positive control relative to the LoD of your test (note that ideally the positive control concentration should be such that it is close to the LoD of your test) and also specify frequency of use\]***
3. An extraction control ***\[describe control\]*** is needed to ***\[describe need\]*** and is used ***\[describe use – please also specify frequency of use\].*** **Please note that if the no template control and positive control, are taken through the entire sample processing procedure, including the extraction, then a separate extraction control is not required**.
4. An internal control ***\[describe control\]*** is needed to ***\[describe need\]*** and is used ***\[describe use\]***.
### INTERPRETATION OF RESULTS
All test controls must be examined prior to interpretation of patient results. If the controls are not valid, the patient results cannot be interpreted. Appropriate control interpretation criteria and result interpretation criteria are described here. **You must describe if a Ct cutoff is used as part of your testing algorithm and/or if the end user is required to review curves before final result interpretation. Although not typical for molecular-based tests, if the test result involves the use of an algorithm/calculation, for example a ratio value, when determining the final patient test result, include a detailed description and any additional calibration materials that may be required.**
#### 1. Examination and Interpretation of Control Results
***\[Describe in detail the expected results generated, including acceptance criteria, for all the controls used in test. Describe the measured values (if applicable) for valid and invalid controls and outline the actions to take in the event of an invalid control result.\]***
#### 2. Examination and Interpretation of Patient Specimen Results:
Assessment of clinical specimen test results must be performed after the controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
***\[Describe when clinical specimen test results should be assessed and outline the criteria for test validity**. **Clearly indicate how to interpret numeric test values (if applicable) as positive or negative for presence of SARS-CoV-2. Indicate if the end user is required to review curves before final result interpretation and, if applicable, how to identify indeterminate/inconclusive/equivocal results. When applicable, we recommend providing a table clearly describing the possible combinations of test result values for each primer/probe set. Describe how they should be combined into a final interpretation of the result for your test. If the test produces an equivocal or indeterminate result, please indicate what follow-up testing/process should be conducted, if applicable.\]***
***\[If your test is indicated for pooling, also include a pooling results interpretation table, indicating how to interpret each possible result, including when samples should be retested individually.\]***
### PERFORMANCE EVALUATION
#### 1. Limit of Detection (LoD) -Analytical Sensitivity:
The LoD for the ***\[test name\]*** was evaluated and verified using ***\[validation material, e.g., SARS-CoV-2 inactivated virus (e.g., heat treated or irradiated)\]*** per the validation required by Appendix A of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing. Nucleic acid was extracted from the swabs using ***\[specify nucleic acid extraction\]*** and the reverse transcription RT-PCR was performed using the ***\[specify RT-PCR Instrument and, if applicable, interpretive software version\]***. Preliminary and Confirmation LoD results are included in the tables below.
***\[insert table such as:\]* Table Example: Preliminary Determination of LoD**
| Virus Concentration | Target 1 Ct Value | Target 2 Ct Value | Internal Control Ct Value | # of Replicates |
| --- | --- | --- | --- | --- |
||
***\[insert table such as:\]* Table Example: LoD Confirmation**
| **Targets** | **Target 1** | **Target 2** |
|-----------------------|--------------|--------------|
| Analyte Concentration | | |
| Positives/Total | | |
| % Detected | | |
| Mean Ct | | |
| Mean SD | | |
| CV | | |
||
The data confirmed the assay analytical sensitivity is ***\[specify LoD represented as genome copies or equivalents/mL\]***.
#### 2. Inclusivity (Analytical Reactivity):
An alignment was performed with the oligonucleotide primer and probe sequences of the ***\[test name\]*** with ***\[number of sequences\]*** publicly available SARS-CoV-2 sequences (including mutation variants of high prevalence, i.e., B.1.617.2 and sub-lineages at the time of issuance of this letter) from ***\[specify sequence data base, e.g., GISAID\]*** to demonstrate the predicted inclusivity of the assay.
***\[Insert summary of results of inclusivity analysis.\]***
#### 3. Cross-reactivity (Analytical Specificity):
Analytical specificity of the primer/probe combination for ***\[test name\]*** was evaluated by conducting sequence alignment of the primer/probe sequences of the test with publicly available genome sequences for potential cross-reacting microorganisms. The following organisms were tested with ***\[test name\]*** primer probe set.
***\[insert table such as:\]* Table Example: Organisms Analyzed for Cross Reactivity**
| Organism | Strain | Target 1 | Target 2 |
| --- | --- | --- | --- |
||
#### 4. Clinical Evaluation:
Clinical evaluation of the ***\[test name\]*** was conducted with 30 individual natural positive and 30 negative anterior nasal swab clinical specimens collected from patients suspected of SARS-CoV-2 infection by a healthcare provider in COVID-19 disease endemic region(s). These specimens were ***\[prospective, retrospective, or leftover samples\]***. Nucleic acid was extracted from the swabs using ***\[specify nucleic acid extraction\]*** and the reverse transcription RT-PCR was performed using the ***\[specify RT-PCR Instrument and, if applicable, interpretive software version\]***.
Data is summarized in the Table below:
**Table: Summary Performance on individual anterior nasal swab specimens in comparison to an FDA-authorized method for specimens collected from individuals suspected of COVID-19 by a healthcare provider**
| [Test Name] | FDA EUA RT-PCR Assay | Total | % Performance Agreement | 95% CI | |
| --- | --- | --- | --- | --- | --- |
| Detected | Not Detected | | | | |
| Detected | A | B | A+B | PPA= 100% x A/(A+C) | |
| Not Detected | C | D | C+D | NPA= 100% x D/(B+D) | |
| Total | A+C | B+D | | | |
||
\[IF VALIDATION WAS ALSO COMPLETED WITH SPECIMENS COLLECTED FROM INDIVIDUALS WITHOUT SYMPTOMS OR OTHER REASONS TO SUSPECT COVID-19, ALSO INCLUDE THOSE RESULTS:\] Clinical evaluation of the ***\[test name\]*** was conducted with 20 positive and 100 negative specimens collected from individuals without symptoms or other reasons to suspect COVID-19 in COVID-19 disease endemic region(s). These specimens were ***\[prospective, retrospective, or leftover samples\]***. Nucleic acid was extracted from the swabs using ***\[specify nucleic acid extraction\]*** and the reverse transcription RT-PCR was performed using the ***\[specify RT-PCR Instrument and, if applicable, interpretive software version\]***.
Data is summarized in the Table below:
**Table: Summary Performance on individual anterior nasal swab specimens in comparison to an FDA-authorized method for specimens collected from individuals without symptoms or other reasons to suspect COVID-19**
| [Test Name] | FDA EUA RT-PCR Assay | Total | % Performance Agreement | 95% CI | |
| --- | --- | --- | --- | --- | --- |
| Detected | Not Detected | | | | |
| Detected | A | B | A+B | PPA= 100% x A/(A+C) | |
| Not Detected | C | D | C+D | NPA= 100% x D/(B+D) | |
| Total | A+C | B+D | | | |
||
#### 5. Additional Validation for *\[indication provided by appendix(ces) B -K, e.g., Media Pooling up to n=10 with validation option 2\]*:
***\[For each additional indication, include a section with the required validation and documentation from the applicable appendix.\]***
### LIMITATIONS
- The performance of this test was established based on the evaluation of a limited number of clinical specimens collected between ***\[include collection window dates between MONTH, YEAR AND MONTH, YEAR, and the location(s) of clinical evaluation (Countr(ies)– identify if it was multiple sites in the country or limited locations – if known)\]***. The clinical performance of this test has not been established in all circulating variants but is anticipated to be reflective of the variants in circulation at the time and location(s) of the clinical evaluation. As such, performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2, and their prevalence, which change over time.
- \[If evaluation of specimens collected from individuals without symptoms or other reasons to suspect COVID-19 have not yet been evaluated, include this statement:\] Clinical performance has been established in specimens collected from subjects suspected of COVID-19 by a healthcare provider. Performance of specimens collected from individuals without symptoms or other reasons to suspect COVID-19 has not been established. A study to determine the performance in individuals without symptoms or other reasons to suspect COVID-19 will be completed.
### WARNINGS:
- This product has not been FDA cleared or approved, but has been authorized by FDA under an Emergency Use Authorization (EUA) for use by the laboratory that developed the test and which is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets the requirements to perform high complexity tests.
- This product has been authorized only for the detection of nucleic acid from SARS- CoV-2, not for any other viruses or pathogens; and
- The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
# 11,054 2021-11-15_FDA Guidance - COVID IVD Test Developers v5.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-11-15_FDA Guidance - COVID IVD Test Developers v5.md
file_date: 2021-11-15
title: FDA Guidance - COVID IVD Test Developers v5
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summary_short: The FDA “Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)” (v5, Nov 15, 2021) sets the overarching regulatory and enforcement framework for COVID-19 diagnostic and serology IVDs during the pandemic. It defines FDA’s EUA review priorities, expectations for validation, rules for offering tests during FDA review, state and laboratory policies, and how authorized tests may be modified. It guides developers and laboratories on which tests FDA will prioritize, how to maintain compliance, and when EUA authorization is expected before distribution.
CONTENT
***INTERNAL TITLE:*** Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)*
Guidance for Developers and Food and Drug Administration Staff
Document issued on the web on November 15, 2021.
This document supersedes “Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised): Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff” issued May 11, 2020.
U.S. Department of Health and Human Services
Food and Drug Administration
Center for Devices and Radiological Health
*This is the fifth edition of this guidance, which originally issued February 29, 2020 and was subsequently revised on March 16, May 4, and May 11, 2020.
## Preface
### Public Comment
This guidance is being issued to address the Coronavirus Disease 2019 (COVID-19) public health emergency. This guidance is being implemented without prior public comment because the Food and Drug Administration (FDA or Agency) has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is being implemented immediately, but it remains subject to comment in accordance with the Agency’s good guidance practices.
Comments may be submitted at any time for Agency consideration. Submit written comments to the Dockets Management Staff (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. Submit electronic comments to [https://www.regulations.gov](https://www.regulations.gov). All comments should be identified with the docket number FDA-2020-D-0987 and complete title of the guidance in the request.
### Additional Copies
Additional copies are available from the FDA webpage titled “COVID-19-Related Guidance Documents for Industry, FDA Staff, and Other Stakeholders,” available at [https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders](https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders), and the FDA webpage titled “Search for FDA Guidance Documents,” available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents](https://www.fda.gov/regulatory-information/search-fda-guidance-documents). You may also send an e-mail request to CDRH-Guidance@fda.hhs.gov to receive an additional copy of the guidance. Please include the document number 20010-R4 and complete title of the guidance in the request.
### Questions
For questions about this document, contact CDRH-EUA-Templates@fda.hhs.gov.
## Table of Contents
I. Introduction ............................................................................................................................. 4
II. Background ............................................................................................................................ 5
III. Scope .................................................................................................................................... 6
IV. Policy ..................................................................................................................................... 7
A. Prioritization of Review of EUA Requests for Tests ............................................................... 7
B. State Authorization of High-Complexity CLIA-Certified Laboratories ................................. 10
C. Distribution and Offering of SARS-CoV-2 Diagnostic and Serology Tests During FDA
Review ...................................................................................................................................... 11
(1) Diagnostic and Serology Tests on Notification Lists for which an EUA Request was
Submitted ................................................................................................................................. 12
(2) Laboratory Serology Tests on the Notification List and Certain LDTs for Which an
EUA Request was Not Submitted ............................................................................................ 13
(3) Recommendations Regarding Test Reports and Other Information for Tests Offered
During FDA Review of EUA Requests ....................................................................................... 14
(4) FDA Review of EUA Requests ............................................................................................. 14
D. Modifications to EUA-Authorized Diagnostic COVID-19 Tests ............................................ 15
(1) Certain Modifications Made After Issuance of this Updated Guidance .............................. 16
(2) Certain Modifications Made Before Issuance of this Updated Guidance ........................... 16
V. Validation .............................................................................................................................. 17
VI. Availability of EUA Templates .............................................................................................. 18
Appendix A – FDA Review of EUA Requests for COVID-19 Tests Not Offered Prior to
November 15, 2021* ................................................................................................................. 19
Appendix B – FDA Review of EUA Requests for COVID-19 Tests Offered Prior to November
15, 2021 and Policies for Distribution and Offering of Such Tests During FDA Review * ......... 20
## I. Introduction
FDA plays a critical role in protecting the United States from threats such as emerging infectious diseases, including the Coronavirus Disease 2019 (COVID-19) pandemic. FDA is committed to providing timely guidance to support response efforts to this pandemic.
FDA is issuing this guidance to provide FDA’s enforcement policies regarding certain novel coronavirus (COVID-19) tests for the duration of the public health emergency. Rapid detection of COVID-19 cases in the United States requires wide availability of testing to control this rapidly spreading, severe illness. This document supersedes “Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised): Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff” issued May 11, 2020.
The policies in this guidance are intended to remain in effect only for the duration of the public health emergency related to COVID-19 declared by the Secretary of Health and Human Services (HHS) on January 31, 2020, effective January 27, 2020, including any renewals made by the HHS Secretary in accordance with section 319(a)(2) of the Public Health Service Act (PHS Act). FDA continues to assess the evolving situation and intends to update this guidance as appropriate.
Given this public health emergency, and as discussed in the Notice in the _Federal Register_ of March 25, 2020, titled “Process for Making Available Guidance Documents Related to Coronavirus Disease 2019,” _available at_ [https://www.govinfo.gov/content/pkg/FR-2020-03-25/pdf/2020-06222.pdf](https://www.govinfo.gov/content/pkg/FR-2020-03-25/pdf/2020-06222.pdf), this guidance is being implemented without prior public comment because FDA has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is being implemented immediately, but it remains subject to comment in accordance with the Agency’s good guidance practices.
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. FDA guidance documents, including this guidance, should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word _should_ in Agency guidance means that something is suggested or recommended, but not required.
## II. Background
There is currently a pandemic of respiratory disease caused by a novel coronavirus. The virus has been named “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2) and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). On January 31, 2020, HHS issued a declaration of a public health emergency related to COVID-19 and mobilized the Operating Divisions of HHS.^1^ In addition, on March 13, 2020, the President declared a national emergency in response to COVID-19.^2^
Under section 564 of the FD&C Act, the FDA Commissioner may authorize the use of unapproved medical products, or unapproved uses of approved medical products, in certain emergency circumstances, after the HHS Secretary has made a declaration of emergency or threat justifying authorization of emergency use, to diagnose, treat, or prevent serious or life-threatening diseases or conditions caused by chemical, biological, radiological, and nuclear (CBRN) threat agents when certain criteria are met. The Emergency Use Authorization (EUA) authorities allow FDA to help strengthen the nation’s public health protections against CBRN threats by facilitating the availability and use of medical countermeasures needed during certain public health emergencies.
As of November 15, 2021, FDA has authorized more than 420 tests for COVID-19, including more than 300 diagnostic and 90 serology tests. In the context of a public health emergency involving pandemic infectious disease, it is critically important that tests are validated because false results not only can negatively impact the individual patient but also can have a broad public health impact. False positive results for diagnostic tests, for example, can lead to unnecessary quarantine, wasted contact tracing and testing resources, and delay in accurate diagnosis and appropriate treatment for the individual. False negative results can lead to lack of appropriate treatment for the individual and further spread of the disease.
Previous versions of this guidance described policies regarding the distribution and offering of certain tests for clinical use prior to or without an EUA. These policies were issued to help quickly increase availability of tests in the early stages of the pandemic. Unless and until an EUA is issued that authorizes additional testing environments for a specific test, under the Clinical Laboratory Improvement Amendments (CLIA), section 353 of the Public Health Service Act (42 USC 263a), use of that test is limited to laboratories that are certified under CLIA, and meet the requirements to perform tests of high-complexity, and at the point-of-care (POC) when covered by such a laboratory’s CLIA certificate. Throughout this guidance, references to “high-complexity CLIA-certified laboratories” are referring to laboratories that are certified under CLIA and meet the requirements to perform tests of high-complexity. In addition, these policies did not apply to at-home tests or tests with home specimen collection. As such, these policies did not increase the availability of at-home tests, tests with home specimen collection, or other tests for use outside of a high-complexity CLIA-certified laboratory, including most POC tests.
We are now in a different stage of the COVID-19 pandemic than when the previous versions of this guidance were issued, and many more EUA-authorized COVID-19 tests are available than in May 2020. To facilitate the availability of tests for COVID-19 that FDA believes will be most beneficial at the current stage of the pandemic, FDA has revised this guidance to clarify the types of tests on which the Agency intends to focus its review to facilitate development and authorization of tests that will increase testing capacity, accessibility, and increased understanding of immune responses to SARS-CoV-2. In addition, FDA has revised the enforcement policies in this guidance to reflect that at this stage of the pandemic, the Agency generally expects COVID-19 tests to have been issued an EUA prior to the tests being distributed or offered.
## III. Scope
This guidance applies to diagnostic and serology tests for COVID-19.^3^ The policies and recommendations described in this guidance are intended to facilitate availability of tests for COVID-19 that FDA believes will be most beneficial at the current stage of the public health emergency.
FDA notes that the enforcement policies in this guidance do not address medical device reporting (MDR) under 21 CFR Part 803 for tests offered prior to authorization as described in the guidance. Developers offering such tests are expected to comply with applicable MDR requirements, including reporting of medical device events that reasonably suggest that their device may have caused or contributed to a death or serious injury, and malfunctions that would be likely to cause or contribute to a death or serious injury if they were to recur. Moreover, unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to laboratories certified under CLIA that meet the requirements to perform tests of high-complexity, including testing at the point-of-care when the site is covered by the laboratory’s CLIA certificate for high-complexity testing.
## IV. Policy
### A. Prioritization of Review of EUA Requests for Tests
The issuance of an EUA is discretionary. FDA's decision to review and process an EUA request, and ultimately issue an EUA if the relevant statutory criteria are met, is based on a determination, on a case-by-case basis, that such action is necessary to protect the public health in an emergency. It is an authorization that the government “may” issue when necessary to protect the public health in an emergency (see section 564(a)(1) of the FD&C Act (21 U.S.C. 360bbb-3(a)(1)), which states, in relevant part, “subject to the provisions of this section, the Secretary may authorize the introduction into interstate commerce…a drug, device, or biological product intended for use in an actual or potential emergency”). FDA’s January 2017 guidance, [Emergency Use Authorization of Medical Products and Related Authorities](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities),^4^ describes factors that FDA intends to use in its prioritization of EUA requests, such as the public health need for the product, the availability of the product, the availability and adequacy of the information concerning the likelihood that the product may be safe and effective in preventing, treating, or diagnosing the condition, and whether the product is included in government stakeholder stockpiles. Additionally, given the need to address urgent public health priorities, FDA may need to further prioritize among the EUA requests it receives for COVID-19 tests. At this stage in the pandemic, for SARS-CoV-2 diagnostic tests, FDA intends to encourage development and facilitate the authorization of tests that will significantly increase testing capacity and accessibility. For serology tests, FDA intends to focus on quantitative and neutralizing antibody tests that promote an increased understanding of immune responses to SARS-CoV-2.
Specifically, at this stage of the pandemic, FDA intends to focus its review on EUA requests for the following types of tests:
- **Diagnostic tests (molecular and antigen)** that can be used at the POC or completely at home from developers who have indicated the ability to scale up manufacturing capacity shortly after authorization (e.g., a manufacturing capacity of ≥500,000 tests per week within 3 months of authorization);^5^
- **Laboratory-based molecular diagnostic tests** that are: highly sensitive; high throughput;^7^ intended for pooling, home specimen collection, screening, or detection of multiple analytes; and from experienced developers^8^ who have indicated the ability to scale up manufacturing capacity shortly after authorization (e.g., a manufacturing capacity of ≥500,000 tests per week within 3 months of authorization);^9^
- **Home specimen collection kits** intended for use with laboratory-based molecular diagnostic tests, where the manufacturer has indicated the ability to scale up to a manufacturing capacity shortly after authorization (e.g., ≥500,000 kits per week within 3 months of authorization);^10^
- **Laboratory-based and POC serology tests** that are: high throughput, if laboratory-based; intended for the quantitative measurement of antibody titers; and from developers who have indicated the ability to scale up manufacturing capacity shortly after authorization (e.g., a manufacturing capacity of ≥500,000 tests per week within 3 months of authorization);^11^
- **Laboratory-based and POC serology tests** that are: intended for the quantitative detection of neutralizing antibodies; and from developers who have indicated the ability to scale up manufacturing capacity shortly after authorization (e.g., a manufacturing capacity of ≥500,000 tests per week within 3 months of authorization);^12^ and
- **Tests for which the EUA request is from (or supported by) a US government stakeholder**, such as tests funded by the Biomedical Advanced Research and Development Authority (BARDA) or the National Institutes of Health’s Rapid Acceleration of Diagnostics (RADx).
Further, for tests intended for use on instruments not used for previously authorized tests, FDA intends to prioritize those tests where the developer indicates sufficient instrument and kit production capacity.^14^ For tests intended for use with home collection kits, FDA intends to prioritize those tests where there is sufficient assay and collection kit production capacity.
In order to make effective use of FDA resources, FDA generally intends to focus its review on EUA requests for tests that are within these priorities.^15^ Appendix A includes a visual overview of these review priorities. FDA believes these priorities are appropriate to address the public health needs at the current stage of the public health emergency and may adjust these priorities as more tests are authorized or public health needs change. FDA encourages test developers to consider these priorities and focus on these areas of need as they develop and validate their tests.
For tests not authorized and not being offered at the time this updated guidance issues, FDA expects it will only review EUA requests for priority tests. FDA intends to notify test developers of such tests by email if FDA declines to review or otherwise decides not to authorize the test.^16^
For tests on one of the notification lists on FDA’s website at the time this guidance issues and laboratory developed tests (LDTs) being offered following the HHS August 2020 Web Statement entitled “Rescission of Guidances and Other Informal Issuances Concerning Premarket Review of Laboratory Developed Tests” (“August 2020 HHS Announcement”), FDA generally intends to review EUA requests as outlined in Section IV.C of this guidance.
### B. State Authorization of High-Complexity CLIA-Certified Laboratories
Previous versions of this guidance described a policy regarding States and territories that authorize laboratories within their State or territory to develop their own COVID-19 tests and perform specimen testing, where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA.
Under such policy, a State or territory choosing to authorize laboratories within that State or territory to develop and perform a test for COVID-19 would do so under authority of its own State law, and under a process that it established, and FDA did not intend to object to the use of such tests for specimen testing where the notification of SARS-CoV-2 test validation was not submitted to FDA and the laboratory did not submit an EUA request to FDA, and where instead the State or territory took responsibility for COVID-19 testing by laboratories in its State during the COVID-19 outbreak. This policy applied only to tests designed, developed, and used within a single, high-complexity, CLIA-certified laboratory. The policy did not apply to at-home tests or tests with home specimen collection, or any testing outside of a high-complexity CLIA-certified laboratory.
In previous versions of this guidance, FDA requested that the State or territory notify us if it chose to use this flexibility to expedite COVID-19 testing. FDA indicated that it would not be reviewing the process adopted by the State or territory. FDA expected that such States and territories as part of their oversight process would require laboratories developing SARS-CoV-2 tests to validate those tests prior to use. FDA encouraged laboratories that developed and performed a test for COVID-19 that was authorized by a State or territory to notify FDA that they have started clinical testing by sending an email to [CDRH-EUA-Templates@FDA.HHS.GOV](mailto:CDRH-EUA-Templates@FDA.HHS.GOV), and provide information on testing capacity.
At the current stage of the pandemic, FDA is revising this policy such that FDA no longer intends to apply the policy to any additional States or territories going forward. For the States and territories listed on the notification list on FDA’s website prior to the date of issuance of this updated guidance that are continuing to authorize laboratories within that State or territory to develop and perform a test for COVID-19, FDA does not intend to object to the use of such tests for specimen testing where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA, and where instead the State or territory takes responsibility. This policy applies only to tests designed, developed, and used within a single, high-complexity CLIA-certified laboratory. This policy does not apply to at-home tests or tests with home specimen collection, or any testing outside of a high-complexity CLIA-certified laboratory.
FDA notes that laboratories offering testing authorized by States or territories should be aware of requirements to report test results to appropriate federal, state, and local public health agencies in accordance with applicable federal, state, and local laws.
### C. Distribution and Offering of SARS-CoV-2 Diagnostic and Serology Tests During FDA Review
For the enforcement policies in the May 2020 editions of this guidance, where a developer notified FDA that it intended to distribute or offer its validated test as outlined in the guidance, FDA would generally add the developer/test to one of the notification lists on FDA’s website. As discussed in those policies, FDA generally did not intend to object to developers distributing and offering a test on the notification list as described in the policies.
FDA is revising the prior policies because we are at a different stage of the pandemic, and there are many more EUA-authorized COVID-19 tests available now. In addition, experience has shown that many of the COVID-19 tests offered prior to FDA review were determined to have poor performance, either upon FDA review of the EUA request or, for some serology tests, upon evaluation by the National Institutes of Health’s National Cancer Institute (NIH/NCI).
As outlined below, among other things, FDA no longer intends to add tests to the notification lists. Further, for tests already on the notification lists, FDA intends to remove tests for which FDA has either issued an EUA or has notified the test developer by email that FDA declines to review, declines to issue, or otherwise decides not to authorize the test for any reason.
#### (1) Diagnostic and Serology Tests on Notification Lists for which an EUA Request was Submitted
For SARS-CoV-2 diagnostic or serology tests on one of the notification lists and for which an EUA request was submitted prior to issuance of this updated guidance, FDA does not intend to object to continued distribution or offering of those tests for a period of time while FDA reviews the EUA requests for the tests where:
1. The developer submitted its EUA request after February 1, 2021; or
2. The developer submitted its EUA request prior to February 1, 2021 and the developer confirms to FDA (through an email to [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov)), within 45 calendar days from the date of issuance of this updated guidance, that:
a. the developer wants FDA to continue reviewing its EUA request;
b. the EUA request is for the current version of the test; and
c. either the developer does not have additional data to add, or the developer submits updated information to FDA within that 45 calendar-day timeframe including, if not previously provided, validation with clinical specimens using an appropriate comparator. FDA believes that 45 calendar days is reasonable for this.
If FDA does not receive confirmation from a test developer that submitted its EUA request prior to February 1, 2021 confirming that the developer wants FDA to continue reviewing its EUA request, FDA intends to decline to review (or decline to further review where review has already begun) the EUA request.
For tests described in this section, FDA intends to notify test developers by email if FDA declines to review, declines to issue, or otherwise decides not to authorize the test for any reason, including lack of response or a determination that there is a lack of adequate data to support authorization. If so notified, FDA generally expects developers to cease distributing, marketing, and offering their tests within 15 calendar days. Moreover, if FDA identifies a significant problem or concern with a test, based either on the provided information or external reports, FDA generally would expect the developer to take appropriate steps to address such problems, which could include conducting a recall of the test and/or notification concerning corrected test reports indicating prior test results may not be accurate.
#### (2) Laboratory Serology Tests on the Notification List and Certain LDTs for Which an EUA Request Was Not Submitted
Certain serology tests developed by laboratories are being offered without FDA authorization after the developer notified FDA as described in the previous version of this guidance. In addition, FDA understands that some LDTs for SARS-CoV-2 are being offered without FDA authorization or submission of an EUA request following the August 2020 HHS Announcement. The policy below applies to serology tests developed by laboratories offered without submission of an EUA request after notifying FDA as described in the previous version of this guidance and LDTs being offered without submission of an EUA request following the August 2020 HHS Announcement. ^25^
For such tests, FDA does not intend to object to continued offering of the tests while FDA reviews the EUA requests where the developer submits the EUA request to FDA through an email to [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov) within 60 calendar days from the date of issuance of this updated guidance. ^26^ ^27^ FDA believes this is sufficient time for a test developer to prepare and submit an EUA request, considering that the validation recommendations included in the EUA templates ^28^ have been publicly available and generally consistent since Spring 2020, and such tests should have already been validated prior to being offered. As for all test developers seeking an EUA, these laboratories may use the optional EUA templates, which generally recommend providing information on the indication of the test, a description of the test, the validated performance of the test, a description of how the test was validated, and validation data. FDA understands that developers of these tests may not have files that align with the templates or EUA process. As such, FDA is clarifying that, because the EUA templates are optional, instead of using the EUA templates, laboratories may submit an email to FDA with supporting information, such as a description of their test and intended use and attach existing validation test reports and excel data files that they already have on file in accordance with their internal procedures. Laboratories should submit this and any additional information they believe would support authorization. ^29^ If the test developer does not submit an EUA request within 60 calendar days from the date of issuance of this updated guidance, FDA generally expects developers to cease marketing and offering their tests within 60 calendar days from the date of issuance of the updated guidance. ^30^
For tests described in this section, FDA intends to notify test developers by email if FDA declines to issue or otherwise decides not to authorize a test for any reason, including a determination that there is a lack of adequate data to support authorization. If so notified, FDA generally expects developers to cease marketing and offering their test within 15 calendar days. Moreover, if FDA identifies a significant problem or concern with a test, based either on the provided information or external reports, FDA generally would expect the developer to take appropriate steps to address such problems, which could include a recall of the test and/or notification concerning corrected test reports indicating prior test results may not be accurate.
#### (3) Recommendations Regarding Test Reports and Other Information for Tests Offered During FDA Review of EUA Requests
FDA continues to recommend the following:
1. Test reports should prominently disclose that the test has not been reviewed by FDA. Until the test is authorized by FDA, any statements in the test reports and other labeling that expressly state or imply that the test has been authorized by FDA would be false. Similarly, any statements in the test reports and other labeling that state or imply that EUA issuance or FDA authorization are imminent or pending could be misleading.
2. Developers should make publicly available on their website the instructions for use for the test and data about the test’s performance characteristics, including a summary of assay performance.
3. Instructions for use and patient test reports for serology tests should include information that helps users and patients understand the test results, including the following:
- Negative results do not preclude acute SARS-CoV-2 infection. If acute infection is suspected, direct (i.e., diagnostic) testing for SARS-CoV-2 is necessary.
- Results from antibody testing should not be used to diagnose or exclude acute SARS-CoV-2 infection.
- Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.
In addition, as noted in the May 2020 editions of this guidance and earlier in this updated guidance, unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to laboratories certified under CLIA that meet the requirements to perform tests of high-complexity, including testing at the POC when the site is covered by such a laboratory’s CLIA certificate.
#### (4) FDA Review of EUA Requests
For tests described in Sections IV.C.1 and IV.C.2 of this guidance, FDA generally intends not to authorize a test where the EUA request does not demonstrate that the test has been appropriately validated, including validation with clinical specimens using an appropriate comparator as described in Section V of this guidance. FDA’s recommendations for validation, including descriptions of appropriate comparators for different types of tests, can be found in the EUA templates ^31^ for different types of tests.
For tests described in Sections IV.C.1 and IV.C.2 of this guidance, FDA intends to consider the priorities outlined in Section IV.A, as well as other relevant considerations for these currently available tests (e.g., safety concerns), to inform the Agency’s review and prioritization of EUA requests for these tests. Appendix B includes a visual overview of the review policies for tests described in section IV.C.1 and IV.C.2.
### D. Modifications to EUA-Authorized Diagnostic COVID-19 Tests
A developer may request certain modifications to its EUA-authorized test that was authorized in an individual EUA, and such changes shall be implemented as specified in the EUA’s Conditions of Authorization, including having concurrence from FDA prior to modification. ^32^ FDA also has discussed various modification policies in previous editions of the guidance relating to authorized COVID-19 tests. As discussed further below, FDA is updating these policies.
The policies in this section do not apply to at-home testing, including at-home specimen collection.
In addition, as noted in the May 2020 editions of this guidance and earlier in this updated guidance, unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to laboratories certified under CLIA that meet the requirements to perform tests of high-complexity, including testing at the POC when the site is covered by such a laboratory’s CLIA certificate.
In order to provide transparency, when a developer is distributing or offering a test that is a modification of an EUA-authorized diagnostic test prior to or without authorization of the modified test, as discussed in this section, the recommendations in Section IV.C.3 of this updated guidance apply. FDA further recommends that the developer post data about the modified test’s performance characteristics on the developer’s website, and that the instructions for use or test protocol and the test reports accurately reflect the modification and prominently disclose that the test has been modified since authorization by FDA and that the modified test has not been reviewed by FDA.
If FDA identifies a significant problem or concern with a modified test, based either on the provided information or external reports, that cannot be addressed in a timely manner, FDA generally would expect the developer to cease distribution, marketing and offering the modified test.
#### (1) Certain Modifications Made After Issuance of this Updated Guidance
When a commercial manufacturer is modifying its authorized COVID-19 molecular diagnostic test to make modifications that do not change the indication for use set forth in the EUA (e.g., including new/different extraction kits or instruments) and do not change the analyte specific reagents (e.g., PCR primers and/or probes),^33^ where the developer has submitted validation data supporting the modification to FDA in a supplemental EUA request, FDA does not intend to object to implementation of the modification to the diagnostic test while FDA conducts its review.
When a high-complexity CLIA-certified laboratory is modifying an authorized COVID-19 molecular diagnostic test, including one for which such laboratory is not the developer of the original, EUA-authorized test, and the modifications do not change the indication for use set forth in the EUA (e.g., including new/different extraction kits or instruments) and do not change the analyte specific reagents (e.g., PCR primers and/or probes),^34^ FDA does not intend to object to implementation of the modification to the diagnostic test without notification to FDA or a new or amended EUA where the laboratory has validated the modification and confirmed that the performance of the modified test is equivalent to the performance of the authorized test, and use of the test is limited to the high-complexity CLIA-certified laboratory in which the modification was made.^35^
FDA encourages the laboratory to collaborate with the developer of the authorized test so that validation data supporting the modifications can be submitted by the original developer to FDA in a supplemental EUA request. Supplemental EUA requests such as this, which have the potential to increase testing capacity by allowing more laboratories to use the test with additional components, are more likely to meet FDA’s review priorities, discussed in Section IV.A of this guidance.
#### (2) Certain Modifications Made Before Issuance of this Updated Guidance
Under the previous version of the guidance, when a commercial manufacturer made certain modifications to its EUA-authorized COVID-19 diagnostic test, and where validation data supporting the modification had been submitted in a supplemental EUA request, FDA stated that it did not intend to object to implementation of the modification while FDA conducted its review, except for modifications to add specimen types that have not been previously authorized with another test of the same technology. For such modifications made and implemented as discussed in the policies in the previous version of the guidance, FDA does not intend to object to such commercial manufacturers continuing to implement the modification while FDA conducts its review.
Under the previous version of the guidance, when a high-complexity CLIA-certified laboratory modified an EUA-authorized COVID-19 diagnostic test^36^ for use with a new specimen type, where the new specimen type has been previously authorized for another test of the same technology^37^ and where the lab had validated the test for the new specimen type, FDA stated that it did not intend to object to the use of such a modified test without notification to FDA or a new or amended EUA. For all other types of modifications made by a high-complexity CLIA-certified laboratory for an EUA-authorized COVID-19 diagnostic test, in the previous version of the guidance, FDA stated that it did not intend to object to the use of the test by high-complexity CLIA-certified laboratories, without notification to FDA or a new or amended EUA, where the test is a modification of an EUA-authorized diagnostic test and the modified test is validated using a bridging study to the EUA-authorized test.
For such modifications made and implemented by high-complexity CLIA-certified laboratories as discussed in the policies in the previous version of the guidance, FDA does not intend to object to such laboratories continuing to offer any of those modified tests.
In such cases, where the laboratory performing the modified test is not the developer of the original, EUA-authorized test, FDA encourages the laboratory to share its validation data with the developer of the original, EUA-authorized test so that the developer of the original, EUA-authorized test can use the validation data in support of a supplemental EUA request to add the modification. Supplemental EUA requests such as this, which have the potential to increase testing capacity by allowing more laboratories to use the test with additional components, are more likely to meet FDA’s review priorities, discussed in Section IV.A of this guidance.
## V. Validation
All clinical tests should be validated using clinical specimens and an appropriate comparator test prior to use.
In the context of a public health emergency, it is critically important that tests be validated prior to use because false results not only can negatively impact the individual patient but also can have a broad public health impact. FDA has provided recommendations regarding testing that should be performed to ensure analytical and clinical validity, including descriptions of appropriate comparators for different types of tests, in the EUA templates available through download from our website.^38^ Depending on the characteristics of a developer’s test, additional validation studies may be recommended.
Developers can use alternative approaches. FDA encourages developers to discuss any alternative technological approaches to validating their test with FDA through [CDRH-EUA-Templates@FDA.HHS.GOV](mailto:CDRH-EUA-Templates@FDA.HHS.GOV).
Additionally, FDA continues to expect certain serology tests to be independently evaluated by NIH/NCI,^39^ prior to authorization, when requested by the FDA. When performed, this additional testing can assist FDA in determining whether the EUA issuance criteria in section 564 of the FD&C Act have been met and whether FDA should authorize the test.
## VI. Availability of EUA Templates
FDA has made available through download from our website^40^ a series of templates that developers may choose to use to facilitate the preparation and submission of an EUA request for various types of COVID-19 tests. The templates reflect FDA’s current thinking on validation recommendations for SARS-CoV-2 tests and the data and information that developers should submit to facilitate the EUA process. The templates provide information and recommendations, and FDA plans to update them as appropriate as more is learned about COVID-19 and more experience is gained with the EUA process for the various types of COVID-19 tests.
Developers can use alternative approaches. Developers who intend to use alternative approaches should consider seeking FDA’s feedback or recommendations to help them through the EUA process. FDA encourages developers to discuss any alternative technological approaches to validating their test with FDA through [CDRH-EUA-Templates@FDA.HHS.GOV](mailto:CDRH-EUA-Templates@FDA.HHS.GOV).
Members of the public can submit questions about the templates to [CDRH-EUA-Templates@FDA.HHS.GOV](mailto:CDRH-EUA-Templates@FDA.HHS.GOV), or they can submit comments regarding the templates to the public docket established for this guidance.
## Appendix A – FDA Review of EUA Requests for COVID-19 Tests Not Offered Prior to November 15, 2021*
_Flowchart showing the FDA review pathway for EUA requests for molecular, antigen, and serology COVID-19 tests not offered prior to November 15, 2021, illustrating decision points and outcomes for each test type._
*The flowcharts above give a general overview of the policies in Section IV.A of this guidance. Readers should refer to that section for the policies themselves. The flowcharts do not address policies discussed in other sections of this guidance.
## Appendix B – FDA Review of EUA Requests for COVID-19 Tests Offered Prior to November 15, 2021 and Policies for Distribution and Offering of Such Tests During FDA Review*
_Flowchart showing the FDA review pathway and distribution policies for EUA requests for COVID-19 tests that were offered prior to November 15, 2021, during FDA review._
*The flowchart above gives a general overview of the policies in Section IV.C of this guidance. Readers should refer to that section for the policies themselves. The flowchart does not address policies discussed in other sections of this guidance.
---
^1^ Secretary of Health and Human Services, Determination that a Public Health Emergency Exists (originally issued on Jan. 31, 2020, and subsequently renewed), available at [link](https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx).
^2^ Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak (Mar. 13, 2020), available at [link](https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/). On February 24, 2021, there was a Presidential Declaration continuing the national emergency concerning the COVID-19 pandemic beyond March 1, 2021. See Continuation of the National Emergency Concerning the Coronavirus Disease 2019 (COVID-19) Pandemic (February 24, 2021), available at [link](https://www.federalregister.gov/documents/2021/02/26/2021-04173/continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic).
^3^ Throughout this guidance, the term “diagnostic test” is generally used to refer to molecular or antigen tests, both of which can be used to diagnose infection with the SARS-CoV-2 virus. Screening tests, which are used for testing individuals without symptoms or other reasons to suspect COVID-19, are a subset of diagnostic tests. Molecular tests detect the presence of viral RNA and antigen tests detect the presence of viral proteins that are part of the SARS-CoV-2 virus. The terms “serology” or “antibody” tests are generally used to refer to tests that detect antibodies to the SARS-CoV-2 virus. Because the antibodies are part of the body’s immune response to exposure and not the virus itself, such testing cannot be used for diagnosis of acute infection.
^4^ See [FDA Guidance](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities).
^5^ Diagnostic tests, including those for screening, that can be manufactured in high volume and used at the POC or completely at home increase accessibility to tests and results from such tests are typically returned faster than other diagnostic tests. FDA believes that 500,000 tests per week is a reasonable and achievable manufacturing capacity for many manufacturers of POC or at-home tests.
^6^ For the purposes of this guidance, “laboratory-based tests” are tests intended for use in laboratories certified under CLIA that meet the requirements to perform tests of moderate or high complexity. Such tests do not include POC or at-home tests, which are addressed in the first bullet. As a practical matter, only laboratory-based tests are likely to be the type of highly-sensitive, high throughput tests we are seeking to prioritize here.
^7^ To illustrate, we would generally consider tests that support two 384 well thermocycler runs per 8 hours in combination with an automated extraction and liquid handling platform as “high throughput.”
^8^ For the purposes of this guidance, “experienced developers” refers to developers who have interacted with FDA through an EUA request or pre-EUA submission during the current public health emergency or have similar experience. FDA has interacted with over 1,000 test developers through the EUA and pre-EUA processes during the SARS-CoV-2 pandemic. The Agency has found that EUA requests from inexperienced developers are more resource-intensive to review. At this phase of the pandemic, and given our experience to date, we believe that for high or moderate complexity laboratory tests, FDA’s review resources are more impactful when working with experienced developers given the design and validation complexities associated with such tests. As a result, FDA intends to prioritize the review of EUA requests for such high and moderate complexity tests from experienced developers.
^9^ In order for diagnostic tests to significantly increase testing capacity, which has been identified as a US government testing priority, they should be high volume and high throughput and for use on broad patient populations (i.e., not only on symptomatic patients or patients suspected of COVID-19). FDA authorization of high and moderate complexity tests with manufacturing capacities lower than 500,000 tests per week will not sufficiently scale US testing capacity. Furthermore, based on surge manufacturing capacity data received in EUA requests to date, FDA believes that 500,000 tests per week is a reasonable and achievable manufacturing capacity for many manufacturers of high and moderate complexity tests. Similarly, highly manual, low throughput tests will not allow laboratories to scale testing volumes to those needed for large screening programs. With respect to laboratory-based diagnostic tests, FDA intends to prioritize molecular, and not antigen, diagnostic tests that have the other characteristics described since antigen tests are generally not as sensitive as molecular tests, and the primary benefits from antigen tests in this phase of the pandemic come from their ability to scale up for use at POC or completely at home. Reviewing laboratory-based antigen tests would take resources away from reviewing POC and at-home antigen tests. Therefore, FDA intends to focus its resources on the types of antigen tests more likely to provide greater benefit to the nation’s COVID-19 response.
^10^ Home specimen collection kits intended for use with high volume and high throughput laboratory-based tests will support and enable increased testing with such tests by increasing their accessibility.
^11^ Laboratory-based and POC serology tests that are high throughput, can be manufactured in high volume, and that are intended for the quantitative measurement of antibody titers promote an increased understanding of immune responses to SARS-CoV-2.
^12^ Laboratory-based and POC serology tests that can be manufactured in high volume and that are intended for the quantitative detection of neutralizing antibodies promote an increased understanding of immune responses to SARS-CoV-2.
^13^ Prioritization of EUA requests from (or supported by) government stakeholders is discussed in the Guidance for Industry and Other Stakeholders: Emergency Use Authorization of Medical Products and Related Authorities, available at [FDA Guidance](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities).
^14^ FDA has received EUA requests for tests that require a new instrument to perform the test, but the instrument production capacity is such that the test developers would not be able to produce and distribute it in a timely manner enough instruments to perform all the tests they are planning to offer. The addition of an instrument greatly increases the complexity of an EUA review. In addition, laboratories, including POC sites, are unlikely to purchase new instruments that will only be able to run a single test and will potentially not be able to run any tests after the pandemic.
^15^ Developers of tests that are not within these priorities may consider modifications to their test prior to submitting an EUA request to FDA to better align with the current public health needs. Alternatively, they may consider pursuing marketing authorization through a traditional premarket review pathway. If developers of tests that are not within these priorities and are a new type of test where the developer believes the test can help address current public health needs, the developers and/or laboratories are welcome to provide FDA their rationale for the public health need for the individual test and the reasons why FDA review of an EUA request should be considered, by sending an email to CDRH-EUA-Templates@fda.hhs.gov.
^16^ FDA may decline to review or otherwise decide not to authorize a test based on any number of factors, including lack of adequate data to support emergency use authorization, as discussed in Guidance for Industry and Other Stakeholders: Emergency Use Authorization of Medical Products and Related Authorities, available at [FDA Guidance](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities).
^25^ If developers of these serology tests and LDTs submitted an EUA request to FDA prior to issuance of this guidance, the policy discussed in Section IV.C.1 of this guidance applies.
^26^ This policy does not apply to at-home tests or tests with home specimen collection, or any testing outside of a laboratory certified under CLIA that meets the requirements to perform tests of high-complexity.
^27^ When submitting such an EUA request, developers should consider submitting information relating to the priorities outlined in Section IV.A as tests falling under those priorities reflect the public health needs at the current stage of the public health emergency and the tests for which FDA will be focusing its review.
^28^ Available at: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas).
^29^ If sufficient information is not submitted to support authorization, FDA may reach out to laboratories to request additional information.
^30^ If developers are not able to prepare and submit an EUA request within 60 calendar days, but they believe it is of significant public health importance that they continue to offer their unauthorized test beyond that timeframe, the developer is welcome to provide FDA their rationale for the continued public health need for their individual test and the reasons why additional time is needed to prepare and submit an EUA request, by sending an email to [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov).
^31^ Available at: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas).
^32^ We note that modifications to a test authorized under an umbrella EUA are handled differently given the nature of umbrella EUAs. As such, the policy set forth in this subsection regarding modifications does not apply to tests authorized under an umbrella EUA.
^33^ Other modifications, including new claimed specimen types, test settings (e.g., point-of-care, home testing), and new patient populations (e.g., asymptomatic individuals), among others, do not fall under this policy.
^34^ Other modifications, including new claimed specimen types, test settings (e.g., point-of-care, home testing), and new patient populations (e.g., asymptomatic individuals), among others, do not fall under this policy.
^35^ FDA generally considers equivalent performance to be where the LoD of the modified test (using the same validation material used in the LoD study described in the authorized test’s Instructions For Use (IFU)) is within 3x of the LoD established in the authorized test’s IFU or that the LoD of the modified test is within 3x of the LoD of the authorized test in a direct comparison LoD study.
^36^ This applies to modifications to any EUA-authorized diagnostic test, including a laboratory’s own test with an EUA or a purchased kit from a commercial manufacturer with an EUA.
^37^ For the purposes of this guidance, all nucleic acid amplification tests are considered to have the same technology.
^38^ See .
^39^ The FDA is working with the NIH, the Centers for Disease Control and Prevention (CDC), and BARDA to assess the performance of certain commercial manufacturers’ serology tests. As part of this project, the FDA, working with its partnering agencies, has designed a performance assessment protocol that offers a mechanism for an independent evaluation of certain lateral flow and certain enzyme-linked immunosorbent assay (ELISA) or similar technology-based SARS-CoV-2 antibody tests in a laboratory environment. Under this protocol, each test evaluated at the NIH/NCI will be evaluated with a well-characterized sample panel consisting of positive and negative plasma and/or serum samples. The approach represents a balanced attempt to provide a reasonable understanding of the potential performance of a significant number of the tests within a short time period. Performance results are considered during FDA’s review of an EUA request for the test.
^40^ See .
# 24,421 2021-11-15_FDA Letter - EUA Letter of Authorization.md
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summary_short: The FDA “EUA Letter of Authorization” (November 15, 2021) is the legally operative document that authorizes certain laboratory-developed RT-PCR SARS-CoV-2 tests under an Umbrella EUA for Serial Testing. It defines who may use the test (a single CLIA high-complexity laboratory), exactly what indications are authorized (individual and pooled anterior nasal specimens used at least weekly, including asymptomatic screening), and the validation pathways required for each indication (Appendices A–K). The letter also establishes binding Conditions of Authorization, including labeling requirements, post-authorization studies, mutation monitoring, pooling controls, reporting obligations, and limits on modifications. Only tests that meet the nine eligibility criteria and are properly added to Exhibit 1 are considered authorized.
CONTENT
November 15, 2021
To:
Laboratories That Have Developed Certain Molecular-Based Tests for SARS-CoV-2
Authorized Tests:
Certain RT-PCR Molecular-Based Tests for Detection of Nucleic Acid from SARS-CoV-2 from Anterior Nasal Respiratory Specimens for Use as part of a Serial Testing Program
Authorized Laboratories:
Testing is limited to the single laboratory that developed the authorized test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
On February 4, 2020, pursuant to Section 564(b)(1)(C) of the Federal Food, Drug, and Cosmetic Act (the Act) (21 U.S.C. § 360bbb-3(b)(1)(C)), the Secretary of the Department of Health and Human Services (HHS) determined that there is a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad, and that involves the virus that causes COVID-19. Pursuant to Section 564 of the Act, and on the basis of such determination, the Secretary of HHS then declared that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the virus that causes COVID-19 subject to the terms of any authorization issued under Section 564(a) of the Act. ^1^
On November 15, 2021, pursuant to Section 564 of the Act, in response to public health needs to maintain the nation’s testing capacity and adapt to current testing uses, ^2^ FDA is issuing this letter to authorize certain tests that are within the Scope of this Authorization (Section II). Under this Emergency Use Authorization (EUA), authorized tests are authorized for use only in the single laboratory that developed the authorized test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, and meets requirements to perform high complexity tests.
As set forth throughout, this EUA authorizes certain tests that are within the Scope of this Authorization (Section II) for certain specified indications for use. ^3^ This letter authorizes tests (also referred to as products) for multiple indications for use as set forth in the appendices. These indications all contain these essential elements: use with individual or pooled anterior nasal specimens to test individuals, including individuals without symptoms or other epidemiological reasons to suspect COVID-19, when tested at least once per week. This means that tests authorized by this letter may be used with individual or pooled anterior nasal respiratory specimens from individuals with or without known or suspected exposure to COVID-19 when such individuals are tested at least once per week, such as testing at regular intervals as part of a testing program implemented by schools, workplaces, or community groups. The indications in each appendix (A-K) differ in the number of specimens that can be tested or pooled (i.e., 1, up to 3, up to 5, or up to 10), the type of pooling that can be done (i.e., media or swab pooling), and whether the test is authorized for use with home collected specimens. A test is authorized by this EUA if it has been validated in accordance with Appendix A. Appendix A includes the base validation requirements and indication but does not authorize testing of pooled specimens or testing with home collected specimens. Appendices B-K set forth the validation requirements for the pooling and home collection indications. FDA will add tests to Exhibit 1 once it confirms it has received a complete notification as set forth in Section II of this letter. Exhibit 1 will be annotated with the authorized indication(s) for each test and will be maintained on FDA’s webpage. ^4^
FDA’s determination that the tests authorized by this EUA meet the criteria for issuance under Section 564(c) of the Act is based on the available scientific evidence, including recent studies involving antigen tests used in a serial manner, knowledge of recently authorized antigen and molecular tests, our experience with SARS-CoV-2 tests since the start of the emergency, as well as the inclusion of additional risk mitigations, such as limiting the use to serial testing.
Having concluded, based on the available scientific evidence, that the criteria for issuance of this authorization under Section 564(c) of the Act are met, I am authorizing the emergency use of the authorized tests identified in the Scope of this Authorization (Section II) and subject to the Conditions of Authorization (Section IV), for use in the single laboratory that developed the authorized test and that is certified under the CLIA, 42 U.S.C. § 263a and meets the requirements to perform high complexity tests, to detect SARS-CoV-2 in anterior nasal respiratory specimens from individuals.
## I. Criteria for Issuance of Authorization
I have concluded that the emergency use of the authorized tests meets the criteria for issuance of an authorization under Section 564(c) of the Act, because I have concluded that:
1. The SARS-CoV-2 can cause a serious or life-threatening disease or condition, including severe respiratory illness, to humans infected by this virus;
2. Based on the totality of scientific evidence available to FDA, it is reasonable to believe that the authorized tests may be effective in diagnosing infection with SARS-CoV-2 by detecting the presence of SARS-CoV-2 viral material for the indications set forth in the appendices, and that the known and potential benefits of the authorized tests when used for such use, outweigh the known and potential risks of the authorized tests; and
3. There are no adequate, approved, and available alternatives to the emergency use of the authorized tests. ^5^
## II. Scope of this Authorization
I have concluded, pursuant to Section 564(d)(1) of the Act, that the scope of this authorization is limited to the tests described below for the indication in Appendix A and any additional indication(s) for use ^6^ given in the applicable appendix(ces) for which the test is validated consistent with, for use in the single laboratory that developed the authorized test and that is certified under CLIA, 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
### Authorized Tests
Tests that meet all of the following eligibility criteria are authorized consistent with this letter:
1. The test is an RT-PCR test that is *not* already authorized for emergency use as of today’s date for the qualitative detection of SARS-CoV-2 in respiratory specimens collected by anterior nasal swabs;
2. The test is validated in accordance with Appendix A (base validation);
3. The test is validated in accordance with the applicable Appendix B-K if indicated for more than the base indication set forth in Appendix A;
4. The test detects two or more viral targets on the SARS-CoV-2 genome;
5. The test includes a chemical lysis step followed by a nucleic acid isolation step (e.g., silica bead extraction);
6. The test detects only SARS-CoV-2;
7. The test is designed, manufactured, and used within a single CLIA certified laboratory that meets requirements to perform high complexity tests;
8. The test is for prescription (Rx) use only; and
9. The test uses a combination of control materials that control for specimen quality and test system performance. ^7^
Authorized tests are qualitative tests for the detection of nucleic acid from SARS-CoV-2 in anterior nasal respiratory specimens from individuals, including those without symptoms or other reasons to suspect COVID-19, when tested at least once per week, as set forth in Appendix A and any additional appendix(ces) that the test is validated consistent with.
The SARS-CoV-2 nucleic acid is generally detectable in anterior nasal swab specimens during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 nucleic acid; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
Negative results from pooled testing should not be treated as definitive. If a patient’s clinical signs and symptoms are inconsistent with a negative result or results are necessary for patient management, then the patient should be considered for individual testing. Specimens included in pools with a positive or invalid result must be reported as presumptive positive or tested individually prior to reporting a result. Individuals included in a pool that returns a positive or invalid result should be treated as a presumptive positive unless or until they receive a negative result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, they should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result. Specimens with low viral loads may not be detected with pooled testing due to decreased sensitivity or increased interference from pooled testing.
For serial testing programs, additional confirmatory testing for negative results may be necessary, if there is a high likelihood of COVID-19, such as an individual with a close contact with COVID-19 or with suspected exposure to COVID-19 or in communities with high prevalence of infection. Additional confirmatory testing for positive results may also be necessary if there is a low likelihood of COVID-19, such as in individuals without known exposure to COVID-19 or residing in communities with low prevalence of infection.
Authorized tests must be accompanied by labeling that is consistent with this letter. For this EUA, such labeling must include the test procedures, a Fact Sheet for Healthcare Providers, a Fact Sheet for Patients, and a Test Summary. Developers must include, at a minimum, the relevant information in the applicable appendix (see Appendices L–N) and the following statement: This test is authorized under the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing [include link to this letter] for use in [the single laboratory (CLIA certified and meets the requirements to perform high complexity tests) in which it was developed] for [insert indication(s) from applicable appendix(ces)] using the test procedures validated in accordance with the requirements of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing.
In addition, the Fact Sheets are required to be made available to healthcare providers and patients receiving test results.
Authorized tests, when labeled consistent with this letter and subject to the Conditions of Authorization (Section IV) of this letter, are authorized to be used in accordance with the Scope of this Authorization (Section II) and the Conditions of Authorization (Section IV) by the laboratory that developed the authorized test, despite the fact that they do not meet certain requirements otherwise required by applicable federal law.
### Addition to Exhibit 1
A test will be added to Exhibit 1 after FDA confirms that the required documentation set forth below has been submitted via email to FDA. At that time, FDA will notify the developer of the inclusion of its test(s) in Exhibit 1 by replying to the email. Please note that being added to Exhibit 1 does not necessarily mean that FDA has reviewed the underlying validation data submitted or has confirmed that the test is appropriately validated. Instead, being added to Exhibit 1 only means that the developer has submitted complete documentation. However, if FDA determines that a test listed on Exhibit 1 does not meet one or more of the nine eligibility criteria listed above, it will remove the test from Exhibit 1. Tests removed from Exhibit 1 will be included in a list maintained on FDA’s EUA webpage.
To be added to Exhibit 1, developers must notify FDA by sending an email to FDA with the subject line “Addition to Exhibit 1 of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing” to CDRH-EUA-Templates@fda.hhs.gov with the information below:
- Developer (laboratory) name
- Contact individual’s name, address, phone number, email address
- Test name
- The specific indication(s), referenced by noting the applicable appendix
- The required information, including validation data, as set forth in the applicable appendices
- Authorized labeling (i.e., Test Summary, test procedure(s), Fact Sheet for Healthcare Providers, and Fact Sheet for Patients) as set forth above and required by Condition of Authorization A
- The following information on testing capacity:
- i. The number of individual tests that can be run with normal operation in a 24-hour period; and
- ii. The number of individual samples that can be tested in a 24-hour period if all samples are pooled at the maximum ratio authorized pursuant to the applicable appendix of this letter.
- Statement certifying that the nine eligibility criteria listed above are met and that all information submitted is truthful and accurate, for example:
- I certify that, in my capacity as [the position held in laboratory] of [laboratory name], I believe to the best of my knowledge that all nine eligibility criteria described in FDA’s November 15, 2021, letter have been met and that all data and information I am submitting are truthful and accurate and no material fact has been omitted.
Your Fact Sheets and Test Summary will be added to FDA’s webpage when your test is added to Exhibit 1.
### Conclusions
I have concluded, pursuant to Section 564(d)(2) of the Act, that it is reasonable to believe that the known and potential benefits of the authorized tests, when used consistent with the Scope of this Authorization (Section II), outweigh the known and potential risks of such authorized tests.
I have concluded, pursuant to Section 564(d)(3) of the Act, based on the totality of scientific evidence available to FDA, that it is reasonable to believe that the authorized tests may be effective in diagnosing infection with SARS-CoV-2 by detecting the presence of SARS-CoV-2 viral material as set forth in Section I of this letter, when used consistent with the Scope of this Authorization (Section II), pursuant to Section 564(c)(2)(A) of the Act.
FDA has reviewed the scientific information available to FDA, including the information supporting the conclusions described in Section I above, and concludes that the authorized tests (as described in the Scope of this Authorization of this letter (Section II)) meet the criteria set forth in Section 564(c) of the Act concerning safety and potential effectiveness.
The emergency use of the authorized tests under this EUA must be consistent with, and may not exceed the terms of this letter, including the Scope of this Authorization (Section II) and the Conditions of Authorization (Section IV). Subject to the terms of this EUA and under the circumstances set forth in the Secretary of HHS’s determination under Section 564(b)(1)(C) of the Act described above and the Secretary of HHS’s corresponding declaration under Section 564(b)(1) of the Act, the authorized tests are authorized for the indication(s) set forth in Appendix A and any additional appendix for which the test is validated consistent with.
## III. Waiver of Certain Requirements
I am waiving the following requirements for the authorized tests during the duration of this EUA:
- Current good manufacturing practice requirements, including the quality system requirements under 21 CFR Part 820 with respect to the design, manufacture, packaging,labeling, storage, and distribution of your product.
## IV. Conditions of Authorization
Pursuant to Section 564(e) of the Act, I am establishing the following conditions on this authorization:
### Authorized Laboratories (You)
A. Your product’s labeling must be consistent with the information set forth in this letter and must consist of, at a minimum, a Fact Sheet for Healthcare Providers, a Fact Sheet for Patients, a Test Summary, and test procedure(s). Your Fact Sheet for Healthcare Providers and Fact Sheet for Patients must include the relevant information set forth in Appendices L and M, respectively. Your Test Summary must include the relevant information set forth in Appendix N. Additionally, all of your authorized labeling must include the following statement: This test is authorized under the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing [include link to this letter] for use in [the single laboratory (certified under the CLIA and meets requirements to perform high complexity tests) in which it was developed] for [insert indication(s) from applicable appendix(ces)] using the test procedures validated in accordance with the requirements of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing. Your product’s labeling must not include any information that is inconsistent with this authorization.
B. You must evaluate the impact of SARS-CoV-2 viral mutations on your product’s performance. Such evaluations must occur on an ongoing basis and must include any additional data analysis that is requested by FDA in response to any performance concerns you or FDA identify during routine evaluation. Additionally, if requested by FDA, you must submit records of these evaluations for FDA review within 48 hours of the request. If your evaluation identifies viral mutations that affect the stated expected performance of your product, you must notify FDA immediately (via email: CDRH-EUA-Reporting@fda.hhs.gov).
C. If requested by FDA, you must update your labeling within 7 days to include any additional labeling risk mitigations identified by FDA, such as those related to the impact of viral mutations on test performance. Such updates will be made in consultation with, and require concurrence of, DMD/OHT7-OIR/OPEQ/CDRH.
D. Your authorized product must comply with the following labeling requirements under FDA regulations: the intended use statement (21 CFR 809.10(a)(2), (b)(2)); adequate directions for use (21 U.S.C. § 352(f)), (21 CFR 809.10(b)(5), (7), and (8)); appropriate limitations on the use of the device including information required under 21 CFR 809.10(a)(4); and any available information regarding performance of the product, including requirements under 21 CFR 809.10(b)(12).
E. You must make available on your website(s), if applicable, the Fact Sheet for Healthcare Providers and Fact Sheet for Patients.
F. You are authorized to make available additional information relating to the emergency use of your authorized product that is consistent with, and does not exceed, the terms of this letter of authorization.
G. You may make modifications to your authorized product and implement such changes if the test continues to be within the Scope of this Authorization (Section II), and the modifications do not change the indication for use set forth in the applicable appendix(ces) (e.g., including new/different extraction kits or instruments) and do not change the analyte specific reagents (e.g., PCR primers and/or probes).^8^ Prior to implementing modifications under this Condition of Authorization, you must first validate your modified test in accordance with the requirements in the applicable appendix(ces) and notify FDA by submitting any information set forth in Section II that has changed from your prior notification, including updated labeling to reflect the modification(s), to FDA at CDRH-EUA-Templates@fda.hhs.gov using the subject line “Modification to Test on Exhibit 1 of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing”. You must also resubmit the certifying statement required for inclusion in Exhibit 1 as set forth in Section II of this letter. Provided that the modification(s) do not affect whether your product is within the scope of this authorization, the updated labeling will be added to FDA’s website after FDA confirms that the required documentation set forth in Section II has been submitted to FDA. At that time, FDA will notify the developer of the inclusion of its updated labeling on FDA’s website by replying to the email. Please note that adding the updated labeling does not necessarily mean that FDA has reviewed the underlying validation data submitted or has confirmed that the modification(s) is appropriately validated. Instead, being added to FDA’s website only means that the developer has submitted complete documentation as set forth in Section II and consistent with this paragraph.
H. You must inform relevant public health authorities of this EUA, including the terms and conditions herein, and any updates made to your authorized product and authorized labeling.
I. You must notify the relevant public health authorities of your intent to run your product.
J. You must have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
K. You must include with test result reports all authorized Fact Sheets. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
L. You must use your product as outlined in the authorized labeling. Your test procedures must include the use of control materials that control for specimen quality and test system performance, as set forth in Section II of this letter. The test procedures must indicate the expected results for each control that are necessary for a test to be considered valid. Deviations from your authorized test procedures, including the instruments extraction methods, clinical specimen types, control materials, other ancillary reagents and materials required to use your product are not permitted. Any modifications to your authorized product, including the authorized labeling, must be made in accordance with Condition of Authorization G of this letter.
M. All laboratory personnel using your product must be appropriately trained in RT-PCR techniques and use appropriate laboratory and personal protective equipment when handling this product and use your product in accordance with the authorized labeling.
N. Upon request from FDA, you must evaluate the analytical limit of detection and assess traceability^9^ of your product with any FDA-recommended reference material(s). After submission to and concurrence with the data by FDA, you must update your labeling to reflect the additional testing. Such labeling updates will be made in consultation with, and require concurrence of, DMD/OHT7-OIR/OPEQ/CDRH. After concurrence, the updated labeling will be added to FDA’s website.
O. You must collect information on the performance of your product. You must report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of your product of which you become aware.
P. You must have a process in place to track adverse events of your product in accordance with 21 CFR Part 803. Serious adverse events must be immediately reported to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov).
Q. You must ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
R. If your product is used with specimens collected using an authorized home specimen collection kit per Appendix J or K, you must follow any specimen accessioning protocols and other authorized labeling provided with the authorized home specimen collection kit.
S. If your product is used with specimens collected using an authorized home specimen collection kit per Appendix J or K of this letter, you must have a process in place for informing the manufacturer(s) of any authorized home collection kit used with your authorized product of any adverse events that you become aware of related to such kit(s).
T. If testing pooled specimens with your product, you must have and follow a pooling protocol that includes instructions for follow-up for positive and invalid pools, including follow-up instructions to be provided to the organizer of the testing program. For media pooling, the instructions for follow up for positive and invalid pools must include deconvoluting to retest individual samples. For swab pooling, the instructions for follow up for positive and invalid pools must include reporting as “presumed positive” unless or until the individual is re-tested individually and must include instructions to collect a new specimen to be tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, the instructions must indicate that such individuals should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result.
U. You must include with test result reports for specific individuals whose specimen(s) were the subject of pooling, a notice that pooling was used during testing and that “Individual specimens with low viral loads may not be detected due to the decreased sensitivity or increased interference when tested with pooled testing.”
V. If testing pooled specimens with your product, you must include with test result reports for specific individuals whose specimen(s) were the subject of pooling, a notice that their test result is “presumed positive” unless or until they are re-tested individually if the pool in which they were included returns a positive or invalid result. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, the report must include instructions to collect a new specimen to be tested individually and must indicate that such individuals should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result.
W. If testing specimens using pooled testing with your product, you must monitor the positivity rate of the specimens tested using pooled testing by calculating the percent positive results using a moving average (such as a rolling average updated daily using data from the previous 7-10 days).
X. You must keep records of specimen pooling test result data, daily testing totals including number of pooled test results, number of individuals tested and daily running average of percent positive results. For the first 12 months from the date of their creation, such records must be made available to FDA upon request within 48 business hours. After 12 months from the date of their creation, upon FDA request, such records must be made available for inspection within a reasonable time.
Y. You must evaluate the clinical performance of your product by completing the clinical evaluation study for asymptomatic individuals set forth in Appendix A. If this clinical evaluation is not included in the original notification submitted to FDA, then these results must be submitted to FDA at [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov) using the subject line “Post-Authorization Screening Data for Test on Exhibit 1 of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing” within 6 months of submitting the notification required by Section II of this letter (unless otherwise agreed to with DMD/OHT7-OIR/OPEQ/CDRH). If FDA concurs with the data, you must update your authorized labeling to reflect the additional testing. Such labeling updates must be made only after concurrence by DMD/OHT7-OIR/OPEQ/CDRH. If FDA does not concur that the data submitted meets the validation requirements set forth in Appendix A, FDA may determine that your product is not authorized. As described in Section II, FDA will remove any product from Exhibit 1 that it determines is not authorized, e.g., if such product does not meet the validation requirements set forth in Appendix A.
### Conditions Related to Printed Materials, Advertising and Promotion
Z. All descriptive printed matter, advertising, and promotional materials relating to the use of your product shall be consistent with the authorized labeling, as well as the terms set forth in this EUA and meet the requirements set forth in section 502(a), (q)(1), and (r) of the Act, as applicable, and FDA implementing regulations.
AA. No descriptive printed matter, advertising, or promotional materials relating to the use of your product may represent or suggest that this product is safe or effective for the detection of SARS-CoV-2.
BB. All descriptive printed matter, advertising, and promotional materials relating to the use of your test shall clearly and conspicuously state that:
- This product has not been FDA cleared or approved, but has been authorized for emergency use by FDA under an EUA for use by the authorized laboratory;
- This product has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens; and
- The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
The emergency use of your product as described in this letter of authorization must comply with the conditions and all other terms of this authorization.
## V. Duration of Authorization
This EUA will be effective until the declaration that circumstances exist justifying the authorization of the emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 is terminated under Section 564(b)(2) of the Act or the EUA is revoked under Section 564(g) of the Act.
Sincerely,
____________________________
Jacqueline A. O’Shaughnessy, Ph.D.
Acting Chief Scientist
Food and Drug Administration
Enclosure
## Appendix A
### Base Validation for Testing Individual Specimens
As explained in Section II of this letter, all tests must be validated in accordance with this appendix in order to be authorized. After the test is validated, the developer must notify FDA by submitting the information set forth in Section II to FDA at [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov) using the subject line “Addition to Exhibit 1 of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing”. Developers who wish to be authorized for additional indications (e.g., pooling) must also validate their test in accordance with the applicable Appendices B-K.
As noted in Appendices B-K, all tests must validate consistent with this appendix (including all protocols outlined below) in order to be authorized. If no other indication(s) is requested in the notification described in Section II, then the indication noted in this appendix will be the only indication for which the test is authorized under this EUA.
Subject to the terms of this EUA, a test that is otherwise within the Scope of this Authorization (Section II) is authorized for the following indication and may be used for this indication after validation is completed as set forth in this appendix:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swab samples collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
Tests will be added to Exhibit 1 for this indication after FDA determines it has received a complete notification.
Validation specific to this indication, and needed prior to performing validation for any indications set forth in other appendices in this letter, includes the four validation protocols outlined below: (1) Limit of Detection (LoD); (2) Validation for Inclusivity (Analytical Reactivity); (3) Validation for Cross-Reactivity (Analytical Specificity); and (4) Clinical Evaluation.
As part of the notification to FDA, methodology and summary data must be submitted for each validation protocol. This includes line data with the Ct score for each sample tested in the clinical evaluation. If you are leveraging data from another developer’s EUA-authorized test, such as _in silico_ or cross-reactivity data, you must submit a right of reference from that developer as part of your notification or indicate that you intend to leverage the CDC’s general right of reference. ^10^
1. *Limit of Detection (LoD)*
You must determine the LoD of the test utilizing all components of the test system from sample preparation and extraction to detection. Testing quantified live or inactivated virus (i.e., heat treated, chemically modified, or irradiated virus) spiked into real clinical matrix (anterior nasal swab or nasopharyngeal swab samples) for LoD determination is acceptable since this most closely represents a clinical sample. Quantified known positive clinical specimen, as determined by an EUA authorized test, can be used to create dilutions in clinical matrix for LoD determination. Synthetic RNA is not an acceptable test material for the LoD studies. Anterior nasal swab or nasopharyngeal swab samples collected from SARS-CoV-2 negative individuals can be used as clinical matrix. You must determine a preliminary LoD by testing a 2-3 fold dilution series of three replicates per concentration. The lowest concentration that gives positive results 100% of the time is defined as the preliminary LoD. During the preliminary LoD determination at least one concentration that does not yield 100% positive results must be tested. The final LoD concentration must be confirmed by testing 20 individual extraction replicates at the preliminary LoD. For this letter, the LoD is the lowest concentration at which ≥19/20 replicates are positive.
You must determine the LoD of your test for each type of media you intend to use with your test (e.g., saline, PBS, VTM, dry swab reconstituted with PBS).
As part of the notification to FDA, you must provide documentation of the methodology and results of your LoD determination.
2. *Validation for Inclusivity (Analytical Reactivity)*
Genetic variants of SARS-CoV-2 are emerging which may have the potential to impact test performance. This is discussed in the FDA guidance [Policy for Evaluating Impact of Viral Mutations on COVID-19 Tests](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-evaluating-impact-viral-mutations-covid-19-tests), which includes recommendations for evaluating the potential impact of emerging and future viral mutations of SARS-CoV-2 on COVID-19 tests. ^11^
You must perform an _in silico_ inclusivity analysis by conducting sequence alignment of the primer/probe sequences of your test with publicly available SARS-CoV-2 genomes, such as those in the GISAID database.
As part of the notification to FDA, you must provide documentation of the specific primer and probe sequences for your test and the methodology and results of your _in silico_ inclusivity analysis. Include a discussion of your _in silico_ analysis results for the particular SARS-CoV-2 variants that are circulating with high prevalence (i.e., B.1.617.2 and sub-lineages at the time of issuance of this letter). ^12^
Repeat the _in silico_ inclusivity analysis on a regular basis (at least monthly) prior to and after authorization.
Your _in silico_ inclusivity analysis (initial and recurring) must demonstrate, for at least one of the viral targets in your test, 100% homology to at least 95% of sequences (when analyzing at least 2000 sequences within the last 30 days prior to your submission) representing circulating SARS-CoV-2 variants.
3. *Validation for Cross-reactivity (Analytical Specificity)*
You must assess the potential cross-reactivity of your test with the organisms listed in the table below to demonstrate that the test does not react with related pathogens, high prevalence disease agents and normal or pathogenic flora that are reasonably likely to be encountered in a clinical specimen. Specifically, conduct sequence alignment of the primer/probe sequences of your test with publicly available genome sequences for the organisms listed in the table below to determine the extent to which cross-reactivity may impact test performance.
Your validation must demonstrate <80% homology between potential cross-reacting microorganism(s) and your test primers/ probe(s).
As part of the notification to FDA, you must provide documentation of the methodology and results of your cross-reactivity validation.
| High priority pathogens from the same genetic family | High priority organisms likely present in respiratory specimens |
|-----------------------------------------------------|------------------------------------------------------------------|
| Human coronavirus 229E | Adenovirus (e.g., C1 Ad. 71) |
| Human coronavirus OC43 | Human Metapneumovirus (hMPV) |
| Human coronavirus HKU1 | Parainfluenza virus 1-4 |
| Human coronavirus NL63 | Influenza A & B |
| SARS-CoV-1 | Enterovirus (e.g., EV68) |
||
| High priority pathogens from the same genetic family | High priority organisms likely present in respiratory specimens |
|-----------------------------------------------------|---------------------------------------------------------------|
| MERS-coronavirus | Respiratory syncytial virus |
| | Rhinovirus |
| | _Chlamydia pneumoniae_ |
| | _Haemophilus influenzae_ |
| | _Legionella pneumophila_ |
| | _Streptococcus pneumoniae_ |
| | _Streptococcus pyogenes_ |
| | _Bordetella pertussis_ |
| | _Mycoplasma pneumoniae_ |
| | _Candida albicans_ |
| | _Pseudomonas aeruginosa_ |
| | _Staphylococcus epidermis_ |
| | _Streptococcus salivarius_ |
||
4. *Clinical Evaluation*
You must perform a clinical evaluation to determine the clinical sensitivity and specificity of your test using natural clinical specimens. Test a minimum of 30 positive and 30 negative specimens collected from a total of 60 patients suspected of SARS-CoV-2 infection by a healthcare provider in COVID-19 disease endemic region(s).
You must also test an additional 20 positive and 100 negative specimens collected from individuals without symptoms or other reasons to suspect COVID-19 in COVID-19 disease endemic region(s). As explained in Condition of Authorization Y of this letter, this information must be submitted to FDA as part of your initial notification or within 6 months of your notification date.
Acceptable Specimens:^13^
Positive specimens must be individual natural (prospective or retrospective or leftover samples) positive clinical specimens collected in COVID-19 disease endemic region(s).
20-25% of the positive specimens must be “low positive” by the comparator method, meaning the specimen is no more than 3 Ct below the mean Ct of the target with the highest Ct (if there are multiple targets) at the LoD of the comparator test. If collecting specimens prospectively and fewer than 20% of comparator positive specimens representing low positives as per the comparator assay are obtained, supplement the prospective specimens with additional low positive specimens such as archived samples or samples collected from convalescent patients.
The use of frozen samples is acceptable if an analytical study is performed and demonstrates that preservation of samples (e.g., by freezing at ≤-70°C) does not change the sensitivity of your test by more than 3 Ct at LoD when compared to freshly prepared samples.
Samples previously tested positive by another highly sensitive EUA RT-PCR assay (defined below) may be used without additional comparator testing.
Negative specimens must be individual negative samples acquired from the following acceptable sources: (1) prospective samples from individuals suspected of COVID-19 by their healthcare provider, (2) archived/retrospective respiratory samples collected from patients with signs and symptoms of respiratory infection, and (3) other subjects that are expected to be negative for SARS-CoV-2, such as specimens collected prior to COVID-19 pandemic in the U.S.
Comparator Method:
As your comparator method, you must use a highly sensitive EUA (or cleared) RT-PCR assay that uses a chemical lysis step followed by a nucleic acid isolation step (e.g., silica bead extraction), and generates Ct values. An EUA RT-PCR assay is considered highly sensitive when the test’s authorized labeling, posted on FDA’s website, indicates a PPA ≥ 95% based on validation with positive patient specimens. The EUA authorized comparator assay must be used according to authorized labeling (e.g., using only claimed matrices, etc.).
The comparator assay may have the same, or different, targets as your assay.
Validation:
Test clinical specimens in accordance with your proposed diagnostic algorithm (i.e., tested using your proposed test procedure), including retesting when appropriate. The limited volume of natural specimens may preclude retesting. In instances where retesting is indicated per your proposed test procedure but not performed, calculate your test’s performance using the initial results, where equivocal/indeterminate/inconclusive results will count against your final performance.
Test specimens in a blinded fashion (e.g., present positive and negative samples to the end user in a blinded fashion), including blinding the end user to the results of any comparator method testing.
Investigate potential false results using an additional highly sensitive EUA RT-PCR assay and/or Sanger sequencing. The results of the discordant analysis can be footnoted in your final performance table but cannot be used to change the final performance calculations.
Test Performance:
Calculate positive percent agreement (PPA) by comparing the results for each specimen tested with your test compared to the comparator assay.
Calculate negative percent agreement (NPA) by comparing the results for each specimen tested with your test compared to the comparator assay (for prospectively collected samples) or as agreement with expected results if samples were collected from individuals known to be negative for SARS-CoV2 (e.g., collected before December 2019).
Calculate positive and negative percent agreement separately for the two datasets (i.e., specimens collected from patients suspected of SARS-CoV-2 infection by a healthcare provider and specimens collected from individuals without symptoms or other reasons to suspect COVID-19), as well as combined.
Your validation must demonstrate a minimum of 95% positive and negative percent agreement.
Documentation:
Provide documentation of the methodology and results, including line data and Ct scores, of your clinical evaluation. Results from specimens collected from patients suspected of SARS-CoV-2 infection by a healthcare provider must be provided as part of your notification to FDA required by Section II of this letter. Results from specimens collected from individuals without symptoms or other reasons to suspect COVID-19 may be provided either in your notification to FDA or post-authorization as set forth in Condition of Authorization Y of this letter.
## Appendix B
### Swab pooling up to n=3
Subject to the terms of this EUA, a test that is within the Scope of this Authorization (Section II) is authorized for the following indication and may be used for this indication after validation is completed as set forth in Appendix A:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swabs or pooled samples containing up to 3 individual human anterior nasal swabs placed in a single vial after being collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
## Appendix C
### Swab pooling up to n=5
Subject to the terms of this EUA, a test that is otherwise within the Scope of this Authorization (Section II) is authorized for the following indication and may be used for this indication after validation is completed as set forth in this appendix and Appendix A:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swabs or pooled samples containing up to 5 individual human anterior nasal swabs placed in a single vial after being collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
Validation specific to this indication must include both validation protocols outlined below, “Validation of Expected Limit of Detection (LoD)” and “Validation of High Viral Concentrations”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. *Validation of Expected Limit of Detection (LoD)*
Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your procedure for testing 5-swab pools.
To generate a 5-swab pool positive for SARS-CoV-2, prepare a single positive swab by spiking a known amount of inactivated virus or quantified positive patient sample onto the swab prior to immersion in the volume of media you intend to include in your procedure for 5-swab pooling. Add an additional four swabs containing only negative patient clinical matrix. The final viral analyte concentration in the media must be approximately 3x the LoD determined when performing the validation as set forth in Appendix A for testing an individual specimen. To ensure this concentration is achieved, factor in how much volume the swab absorbs, and the SARS-CoV-2 concentration needed on the single positive swab to achieve a final concentration of approximately 3x the LoD in the media. This is the concentration you should use to prepare the positive swabs for your validation study.
Test at least 20 independent extraction replicates of individual swabs in the same volume of buffer used in the LoD study as set forth in Appendix A for validation of individual specimen testing, using the testing protocol in your test’s procedure for testing an individual specimen, validated as set forth in Appendix A. Test 20 paired 5-swab pools in parallel, each containing a single positive swab and 4 individual negative swabs in the volume of media you intend to include in your procedure for testing 5-swab pools, using the testing protocol you intend to include in your procedure for testing 5-swab pools.
Your validation must demonstrate that:
- ≥95% of pooled replicates are detected as positive using the swab pooling protocol;
- The Ct score difference between the pooled and single swab protocols does not exceed 1.7 Ct; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
2. *Validation of High Viral Concentrations*
Prepare three swabs simulating high viral concentrations by spiking 10^6 copies/mL of inactivated virus or quantified positive patient sample. Test 10 replicates of media containing the three spiked positive swabs and 2 individual negative swabs in the volume of media you intend to include in your procedure for testing 5-swab pools, using the testing protocol you intend to include in your procedure for testing 5-swab pools.
Your validation must demonstrate that:
- All 10 replicates are detected as positive; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
## Appendix D
### Swab pooling up to n=10
Subject to the terms of this EUA, a test that is otherwise within the Scope of this Authorization (Section II) is authorized for the following indication and may be used for this indication after validation is completed as set forth in this appendix and Appendix A:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swabs or pooled samples containing up to 10 individual human anterior nasal swabs placed in a single vial after being collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
Validation specific to this indication must include both validation protocols outlined below, “Validation of Expected Limit of Detection (LoD)” and “Validation of High Viral Concentrations”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. *Validation of Expected Limit of Detection (LoD)*
Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your procedure for testing 10-swab pools.
To generate a 10-swab pool positive for SARS-CoV-2, prepare a single positive swab by spiking a known amount of inactivated virus or quantified positive patient sample onto the swab prior to immersion in the volume of media you intend to include in your procedure for 10-swab pooling. Add an additional nine swabs containing only negative patient clinical matrix. The final viral analyte concentration in the media must be approximately 3x the LoD determined when performing the validation as set forth in Appendix A for testing an individual specimen. To ensure this concentration is achieved, factor in how much volume the swab absorbs, and the SARS-CoV-2 concentration needed on the single positive swab to achieve a final concentration of approximately 3x the LoD in the media. This is the concentration you should use to prepare the positive swabs for your validation study.
Test at least 20 independent extraction replicates of individual swabs in the same volume of buffer used in the LoD study as set forth in Appendix A for validation of individual specimen testing, using the testing protocol in your test’s procedure for testing an individual specimen, validated as set forth in Appendix A. Test 20 paired 10-swab pools in parallel, each containing a single positive swab and 9 individual negative swabs in the volume of media you intend to include in your procedure for testing 10-swab pools, using the testing protocol you intend to include in your procedure for testing 10-swab pools.
Your validation must demonstrate that:
- ≥95% of pooled replicates are detected as positive using the swab pooling protocol;
- The Ct score difference between the pooled and single swab protocols does not exceed 1.7 Ct; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
2. *Validation of High Viral Concentrations*
Prepare three swabs simulating high viral concentrations by spiking 10^6 copies/mL of inactivated virus or quantified positive patient sample. Test 10 replicates of media containing the three spiked positive swabs and 7 individual negative swabs in the volume of media you intend to include in your procedure for testing 10-swab pools, using the testing protocol you intend to include in your procedure for testing 10-swab pools.
Your validation must demonstrate that:
- All 10 replicates are detected as positive; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
## Appendix E
### Media pooling up to n=3
Subject to the terms of this EUA, a test that is within the Scope of this Authorization (Section II) is authorized for the following indication and may be used for this indication after validation is completed as set forth in Appendix A:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swabs or pooled samples containing aliquots of media from up to 3 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals, including individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials when tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
## Appendix F
### Media pooling up to n=5 – validation option 1
Subject to the terms of this EUA, a test that is otherwise within the Scope of this Authorization (Section II) is authorized for the following indication and may be used for this indication after validation is completed as set forth in this appendix and Appendix A:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swabs or pooled samples containing aliquots of media from up to 5 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals, including individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials, when tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
Validation specific to this indication must include the validation protocol outlined below, *“Validation of Expected Limit of Detection (LoD)”*. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. *Validation of Expected Limit of Detection (LoD)*
Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your procedure for testing 5-sample pools.
Prepare positive samples for your validation study at 5x the LoD determined when performing the validation as set forth in Appendix A for testing an individual specimen.
Test at least 20 independent extraction replicates of individual samples using the testing protocol in your test’s procedure for testing an individual specimen, validated as set forth in Appendix A. Test 20 paired 5-sample pools in parallel, each containing aliquots from a single positive sample and 4 individual negative samples, using the volumes and testing protocol you intend to include in your procedure for testing 5-sample pools.
Your validation must demonstrate that:
- ≥95% of pooled replicates are detected as positive using the sample pooling protocol;
- The Ct score difference between the pooled and single swab protocols does not exceed 1.7 Ct; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
## Appendix G
### Media pooling up to n=10 – validation option 1
Subject to the terms of this EUA, a test that is otherwise within the Scope of this Authorization (Section II) is authorized for the following indication and may be used for this indication after validation is completed as set forth in this appendix and Appendix A:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swabs or pooled samples containing aliquots of media from up to 10 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals, including individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials, when tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
Validation specific to this indication must include the validation protocol outlined below, **“Validation of Expected Limit of Detection (LoD)”**. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. *Validation of Expected Limit of Detection (LoD)*
Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your procedure for testing 10-sample pools.
Prepare positive samples for your validation study at 10x the LoD determined when performing the validation as set forth in Appendix A for testing an individual specimen.
Test at least 20 independent extraction replicates of individual samples using the testing protocol in your test’s procedure for testing an individual specimen, validated as set forth in Appendix A. Test 20 paired 10-sample pools in parallel, each containing aliquots from a single positive sample and 9 individual negative samples, using the volumes and testing protocol you intend to include in your procedure for testing 10-sample pools.
Your validation must demonstrate that:
- ≥95% of pooled replicates are detected as positive using the sample pooling protocol;
- The Ct score difference between the pooled and single swab protocols does not exceed 1.7 Ct; and
- The invalid rate in the swab pooling protocol does not exceed 5%.
## Appendix H
### Media pooling up to n=5 – validation option 2
Subject to the terms of this EUA, a test that is otherwise within the Scope of this Authorization (Section II) is authorized for the following additional indication and may be used for this indication after validation is completed as set forth in this appendix and Appendix A:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swabs or pooled samples containing aliquots of media from up to 5 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals, including individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials, when tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
Validation specific to this indication must include the validation protocol outlined below, “Validation of the Effect on the Percent Agreement”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. *Validation of the Effect on the Percent Agreement*
Test at least 20 individual positive clinical specimens using the testing protocol in your test’s procedure for testing an individual specimen, validated as set forth in Appendix A. Test 20 paired 5-sample pools in parallel, each containing aliquots from a single positive specimen and 4 randomly selected individual negative clinical specimens (collection of negative anterior nasal specimens from healthy individuals is acceptable), using the testing protocol you intend to include in your procedure for testing 5-sample pools.
20 unique positive specimens and 80 unique negative specimens are needed to comprise twenty 5-sample pools. At least 20% of positive clinical specimens used for this validation study must be low positives, where, for 5-sample pooling, a low positive is within 2.32 Ct of the mean Ct at the LoD determined when performing the validation as set forth in Appendix A for testing an individual specimen.
Archived individual clinical anterior nasal specimens are acceptable for this validation study, if available, given they contain enough volume for both individual and 5-sample pool testing. If archived specimens are used, the original diagnostic results are acceptable in lieu of repeating the individual specimen testing, if the original diagnostic results were acquired according to your test’s procedure for testing an individual specimen, validated as set forth in Appendix A.
If you cannot acquire at least 20% low positive samples as natural clinical specimens, you may dilute positive clinical specimens into pooled negative anterior nasal clinical matrix prepared as described here. Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your procedure for testing 5-sample pools.
Your validation must demonstrate that:
- ≥85% agreement between pooled testing and individual testing; and
- The invalid rate in the pooling protocol does not exceed 5%.
## Appendix I
### Media pooling up to n=10 – validation option 2
Subject to the terms of this EUA, a test that is otherwise within the Scope of this Authorization (Section II) is authorized for the following additional indication and may be used for this indication after validation is completed as set forth in this appendix and Appendix A:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swabs or pooled samples containing aliquots of media from up to 10 individual human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP from individuals, including individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials, when tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
Validation specific to this indication must include the validation protocol outlined below, **“Validation of the Effect on the Percent Agreement”**. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
1. *Validation of the Effect on the Percent Agreement*
Test at least 20 individual positive clinical specimens using the testing protocol in your test’s procedure for testing an individual specimen, validated as set forth in Appendix A. Test 20 paired 10-sample pools in parallel, each containing aliquots from a single positive specimen and 9 randomly selected individual negative clinical specimens (collection of negative anterior nasal specimens from healthy individuals is acceptable), using the testing protocol you intend to include in your procedure for testing 10-sample pools.
20 unique positive specimens and 180 unique negative specimens are needed to comprise twenty 10-sample pools. At least 20% of positive clinical specimens used for this validation study must be low positives, where, for 10-sample pooling, a low positive is within 3.32 Ct of the mean Ct at the LoD determined when performing the validation as set forth in Appendix A for testing an individual specimen.
Archived individual clinical anterior nasal specimens are acceptable for this validation study, if available, given they contain enough volume for both individual and 10-sample pool testing. If archived specimens are used, the original diagnostic results are acceptable in lieu of repeating the individual specimen testing, if the original diagnostic results were acquired according to your test’s procedure for testing an individual specimen, validated as set forth in Appendix A.
If you cannot acquire at least 20% low positive samples as natural clinical specimens, you may dilute positive clinical specimens into pooled negative anterior nasal clinical matrix prepared as described here. Use either diluted positive clinical samples quantified in copies/mL using a standard curve, or inactivated virus of a known quantity represented as copies/mL. Prepare samples using negative anterior nasal clinical matrix (collection from healthy individuals is acceptable) using sample volumes you intend to include in your procedure for testing 10-sample pools.
Your validation must demonstrate that:
- ≥85% agreement between pooled testing and individual testing; and
- The invalid rate in the pooling protocol does not exceed 5%.
## Appendix J
### Individual Home Specimen Collection
Subject to the terms of this EUA, a test that is within the Scope of this Authorization (Section II) is authorized for the following indication and may be used for this indication after validation is completed as set forth in this appendix and Appendix A:
Qualitative detection of RNA from SARS-CoV-2 in individual human anterior nasal swab samples collected by a healthcare provider (HCP), self-collected under the supervision of an HCP, or self-collected at home using the following authorized home collection kit(s): [insert authorized home collection kit with which your test was validated], when used consistent with the home collection kit’s authorization for individuals tested at least once per week.
This test is authorized for use in the single laboratory that developed the test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
A list of authorized home collection kits can be found on FDA’s website, available here: [FDA Authorized Home Collection Kits](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2#individual-molecular).
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
Developers who seek this indication must confirm that the transport media used in the authorized home collection kit is the same transport media used for the validation set forth in Appendix A, or, for specimens collected in dry tubes, that the media used for reconstitution of specimens collected with the authorized home collection kit is the same media used for reconstitution of specimens for the validation set forth in Appendix A. If the validation set forth in Appendix A was completed using a different media than used with the authorized home collection kit, an additional LoD determination, as set forth in Appendix A, must be completed for specimens collected with the authorized home collection kit, with results demonstrated that the LoD is within 3x of the LoD determined with the original validation.
Moreover, developers must clearly include in their test’s authorized labeling that the authorized home collection kit must be used consistent with the home collection kit’s authorization.
## Appendix K
### Pooled Home Specimen Collection
Subject to the terms of this EUA, a test that is within the Scope of this Authorization (Section II) and validated for at least one of the indications set forth in Appendices B-I, is also authorized for use with anterior nasal swab specimens collected using an authorized home collection kit after validation is completed as set forth in this appendix and Appendix A.
The indication of such a test, as set forth in the applicable Appendix B-I, shall include the following clause after “self-collected under the supervision of an HCP”, replacing “from individuals, including individuals without symptoms or other reasons to suspect COVID-19 and placed in individual vials, when tested at least once per week.”:
“or self-collected at home using the following authorized home collection kit(s): [insert authorized home collection kit with which your test was validated] when used consistent with the home collection kit’s authorization for individuals tested at least once per week.”
Such that the portion of the indication discussing specimen collection shall read:
“… human anterior nasal swab specimens that were collected by a healthcare provider (HCP) or self-collected under the supervision of an HCP or self-collected at home using the following authorized home collection kit(s): [insert authorized home collection kit with which your test was validated] when used consistent with the home collection kit’s authorization for individuals tested at least once per week.”
A list of authorized home collection kits can be found on FDA’s website, available here: [FDA Authorized Kits](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2#individual-molecular).
This indication will be added to Exhibit 1 for the relevant test after FDA determines it has received a complete notification.
Developers who seek this indication must confirm that the transport media used in the authorized home collection kit is the same transport media used for the validation set forth in Appendix A, or, for specimens collected in dry tubes, that the media used for reconstitution of specimens collected with the authorized home collection kit is the same media used for reconstitution of specimens for the validation set forth in Appendix A. If the validation set forth in Appendix A was completed using a different media than used with the authorized home collection kit, an additional LoD determination, as set forth in Appendix A, must be completed for specimens collected with the authorized home collection kit, with results demonstrated that the LoD is within 3x of the LoD determined with the original validation.
Moreover, developers must clearly include in their test’s authorized labeling that the authorized home collection kit must be used consistent with the home collection kit’s authorization.
## Appendix L
### Fact Sheet for Healthcare Providers
As set forth in Section II of this letter and required by Condition of Authorization A of this letter, your test’s labeling must include a Fact Sheet for Healthcare Providers that includes the relevant information in this appendix. FDA has provided a template for a Fact Sheet for Healthcare Providers on the FDA website with this letter to facilitate the creation of your test specific fact sheet.
You must include the following in your Fact Sheet for Healthcare Providers:
Fact Sheet for Healthcare Providers
[DATE]
[LABORATORY NAME]
[DEVICE/TEST NAME]
This Fact Sheet informs you of the significant known and potential risks and benefits of the emergency use of the [DEVICE/TEST NAME].
The [DEVICE/TEST NAME] is authorized for use with anterior nasal respiratory specimens from individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.
**All patients whose specimens are tested with this assay will receive the Fact Sheet for Patients: [LABORATORY NAME] - [DEVICE/TEST NAME].**
#### What are the symptoms of COVID-19?
Many patients with COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, dyspnea), although some individuals experience only mild symptoms or no symptoms at all. The current information available to characterize the spectrum of clinical illness associated with COVID-19 suggests that, when present, symptoms include cough, shortness of breath or dyspnea, fever, chills, myalgias, headache, sore throat, new loss of taste or smell, nausea or vomiting or diarrhea. Signs and symptoms may appear any time from 2 to 14 days after exposure to the virus, and the median time to symptom onset is approximately 5 days. For further information on the symptoms of COVID-19 please see the link provided in “Where can I go for updates and more information?” section.
Public health officials have identified cases of COVID-19 throughout the world, including the United States. Please check the CDC COVID-19 webpage (see link provided in “Where can I go for updates and more information?” section at the end of this document) or your local jurisdictions website for the most up to date information.
#### What do I need to know about COVID-19 testing?
Current information on COVID-19 for healthcare providers is available at CDC’s webpage, *Information for Healthcare Professionals* (see links provided in “Where can I go for updates and more information?” section).
**This test is to be performed only using anterior nasal respiratory specimens from individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.**
- The [DEVICE/TEST NAME] can be used to test anterior nasal respiratory specimens.
- The [DEVICE/TEST NAME] should be ordered for the detection of SARS-CoV-2 in individuals, including individuals without symptoms or other reasons to suspect COVID-19, when tested at least once per week.
- **[INCLUDE THE FOLLOWING BULLET IF YOUR TEST INCLUDES USE OF AN AUTHORIZED HOME COLLECTION KIT – MODIFY TO INCLUDE HOME COLLECTION INDICATION BASED ON THE APPENDIX YOU ARE CLAIMING: The [DEVICE/TEST NAME] can also be used to test anterior nasal respiratory specimens collected by a healthcare provider (HCP) or self-collected at home using the following authorized home collection kit(s) [INCLUDE NAME OF AUTHORIZED KIT].]**
- **[INCLUDE THE FOLLOWING BULLET IF YOUR TEST ALLOWS SPECIMEN POOLING – BASED ON THE APPENDIX YOU ARE CLAIMING: The [DEVICE/TEST NAME] can also be used to test up to [INCLUDE POOLING INDICATION BASED ON THE APPENDIX YOU ARE CLAIMING].]**
- The [DEVICE/TEST NAME] is only authorized for use at the [NAME OF LABORATORY] that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
Specimens should be collected with appropriate infection control precautions. Current guidance is available at the CDC’s website (see links provided in “Where can I go for updates and more information?” section).
When collecting and handling specimens from individuals suspected of being infected with the virus that causes COVID-19, appropriate personal protective equipment should be used as outlined in the CDC *Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with Coronavirus Disease 2019 (COVID-19)*. For additional information, refer to CDC *Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons Under Investigation (PUIs) for Coronavirus Disease 2019 (COVID-19)* (see links provided in “Where can I go for updates and more information?” section).
#### What does it mean if the specimen tests positive for the virus that causes COVID-19?
A positive test result for COVID-19 indicates that RNA from SARS-CoV-2 was detected, and therefore the patient is infected with the virus and presumed to be contagious. Laboratory test results should always be considered in the context of clinical observations and epidemiological data (such as local prevalence rates and current outbreak/epicenter locations) in making a final diagnosis and patient management decisions. Patient management should be made by a healthcare provider and follow current CDC guidelines.
The **[DEVICE/TEST NAME]** has been designed to minimize the likelihood of false positive test results. However, it is still possible that this test can give a false positive result, even when used in locations where the prevalence is below 5%. In the event of a false positive result, risks to patients could include the following: a recommendation for isolation of the patient, monitoring of household or other close contacts for symptoms, patient isolation that might limit contact with family or friends and may increase contact with other potentially COVID-19 patients, limits in the ability to work, delayed diagnosis and treatment for the true infection causing the symptoms, unnecessary prescription of a treatment or therapy, or other unintended adverse effects.
**[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: Individuals included in a pool that returns a positive or invalid result should be treated as a presumptive positive unless or until they receive a negative result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, they should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result.]**
All laboratories using this test must follow the standard testing and reporting guidelines according to their appropriate public health authorities.
#### What does it mean if the specimen tests negative for the virus that causes COVID-19?
A negative test result for this test means that SARS-CoV-2 RNA was not present in the specimen above the limit of detection. However, a negative result does not rule out COVID-19 and should not be used as the sole basis for treatment or patient management decisions. It is possible to test a person too early or too late during SARS-CoV-2 infection to make an accurate diagnosis via **[DEVICE/TEST NAME]**.
In addition, asymptomatic people infected with the virus that causes COVID-19 may not shed enough virus to reach the limit of detection of the test, giving a false negative result. In the absence of symptoms, it is difficult to determine if asymptomatic people have been tested too late or too early. Therefore, negative results in asymptomatic individuals may include individuals who were tested too early and may become positive later, individuals who were tested too late and may have serological evidence of infection, or individuals who were never infected.
**[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: Specimens with low viral loads may not be detected in sample pools due to the decreased sensitivity or increased interference of pooled testing. Your interpretation of negative results should take into account clinical and epidemiological risk factors.]**
When diagnostic testing is negative, the possibility of a false negative result should be considered in the context of a patient’s recent exposures and the presence of clinical signs and symptoms consistent with COVID-19. The possibility of a false negative result should especially be considered if the patient’s recent exposures or clinical presentation indicate that COVID-19 is likely, and diagnostic tests for other causes of illness (e.g., other respiratory illness) are negative.
If COVID-19 is suspected based on exposure history together with other clinical findings, re-testing using a new sample with a sensitive method **[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: or without pooling]** should be considered by healthcare providers in consultation with public health authorities. Additional testing may be helpful to ensure testing was not conducted too early.
Risks to a patient of a false negative test result include: delayed or lack of supportive treatment, lack of monitoring of infected individuals and their household or other close contacts for symptoms resulting in increased risk of spread of COVID-19 within the community, or other unintended adverse events.
The performance of this test was established based on the evaluation of a limited number of clinical specimens. The clinical performance has not been established in all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation.
Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2 and their prevalence, which change over time.
#### What is an EUA?
The United States FDA has made this test available under an emergency access mechanism called an Emergency Use Authorization (EUA). The EUA is supported by the Secretary of Health and Human Service’s (HHS’s) declaration that circumstances exist to justify the emergency use of in vitro diagnostics (IVDs) for the detection and/or diagnosis of the virus that causes COVID-19. An IVD made available under an EUA has not undergone the same type of review as an FDA-approved or cleared IVD. FDA may issue an EUA when certain criteria are met, which includes that there are no adequate, approved, available alternatives, and based on the totality of scientific evidence available, it is reasonable to believe that this IVD may be effective in diagnosing COVID-19.
This test is authorized under the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing \[include link to this letter\] for use in \[the specific laboratory, that is certified under CLIA and meets requirements to perform high complexity tests, in which it was developed\] for \[insert indication(s) from applicable appendix(ces)\] using the test procedures validated in accordance with the requirements of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing.
The EUA for this test is in effect for the duration of the COVID-19 declaration justifying emergency use of IVDs, unless terminated or revoked (after which the test may no longer be used).
#### What are the approved available alternatives?
Any tests that have received full marketing status (e.g., cleared, approved), as opposed to an EUA, by FDA can be found by searching the medical device databases here: [https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases](https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases). A cleared or approved test should be used instead of a test made available under an EUA, when appropriate and available. FDA has issued EUAs for other tests that can be found at:
[https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization).
#### Where can I go for updates and more information?
**CDC webpages:**
**General:** [https://www.cdc.gov/coronavirus/2019-ncov/index.html](https://www.cdc.gov/coronavirus/2019-ncov/index.html)
**Symptoms:** [https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html](https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html)
**Healthcare Professionals:** [https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html](https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html)
**Information for Laboratories:** [https://www.cdc.gov/coronavirus/2019-nCoV/lab/index.html](https://www.cdc.gov/coronavirus/2019-nCoV/lab/index.html)
**Laboratory Biosafety:** [https://www.cdc.gov/coronavirus/2019-nCoV/lab-biosafety-guidelines.html](https://www.cdc.gov/coronavirus/2019-nCoV/lab-biosafety-guidelines.html)
**Isolation Precautions in Healthcare Settings:** [https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.ht](https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html) [ml](https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html)
**Specimen Collection:** [https://www.cdc.gov/coronavirus/2019-nCoV/guidelines-clinical-specimens.html](https://www.cdc.gov/coronavirus/2019-nCoV/guidelines-clinical-specimens.html)
**Infection Control:** [https://www.cdc.gov/coronavirus/2019-ncov/php/infection-control.html](https://www.cdc.gov/coronavirus/2019-ncov/php/infection-control.html)
**FDA webpages:**
**General:** [www.fda.gov/novelcoronavirus](http://www.fda.gov/novelcoronavirus)
**EUAs:**(includes links to fact sheet for individuals and manufacturer’s instructions)
**LABORATORY NAME:**
ADDRESS LINE 1
ADDRESS LINE 2
**Customer Support:**
+1 800 XXX-XXXX
customersupportemail@company.com
**Technical Support:**
+1 800 XXX-XXXX
techsupportemail@company.com
**Report Adverse events,** including problems with test performance or results, to MedWatch by submitting the online FDA Form 3500 ([https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.home](https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.home)) or by calling **1-800-FDA-1088**
## Appendix M
### Fact Sheet for Patients
As set forth in Section II of this letter and required by Condition of Authorization A of this letter, your test’s labeling must include a Fact Sheet for Patients that includes the relevant information in this appendix. FDA has provided a template for a Fact Sheet for Patients on the FDA website with this letter to facilitate the creation of your test-specific fact sheet.
You must include the following in your Fact Sheet for Patients:
Fact Sheet for Patients
[DATE]
[LABORATORY NAME]
[DEVICE/TEST NAME]
You are being given this Fact Sheet because your sample(s) was tested for the Coronavirus Disease 2019 (COVID-19) using the [DEVICE/TEST NAME].
This Fact Sheet contains information to help you understand the risks and benefits of using this test for the diagnosis of COVID-19. After reading this Fact Sheet, if you have questions or would like to discuss the information provided, please talk to your healthcare provider.
For the most up to date information on COVID-19 please visit the CDC Coronavirus Disease 2019 (COVID-19) webpage:
[https://www.cdc.gov/COVID19](https://www.cdc.gov/COVID19)
#### What is COVID-19?
COVID-19 is caused by the SARS-CoV-2 virus which is a new virus in humans causing a contagious respiratory illness. COVID-19 can present with a mild to severe illness, although some people infected with COVID-19 may have no symptoms at all. Older adults and people of any age who have underlying medical conditions have a higher risk of severe illness from COVID-19. Serious outcomes of COVID-19 include hospitalization and death. The SARS-CoV-2 virus can be spread to others not just while one is sick, but even before a person shows signs or symptoms of being sick (e.g., fever, coughing, difficulty breathing, etc.). A full list of symptoms of COVID-19 can be found at the following link:
[https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html](https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html).
#### What is the [DEVICE/TEST NAME]?
The test is designed to detect the virus that causes COVID-19 in anterior nasal swabs.
#### Why was my sample tested?
You were tested because your healthcare provider believes you may have been exposed to the virus that causes COVID-19 based on your signs and symptoms (e.g., fever, cough, difficulty breathing), and/or because:
- You are being tested at regular intervals (serial testing) even though you do not have symptoms or risk factors for COVID-19; or
- You live in or have recently traveled to a place where transmission of COVID-19 is known to occur; or
- You have been in close contact with an individual suspected of or confirmed to have COVID-19; or
- You and your healthcare provider believe there is another reason to investigate your COVID-19 status.
Testing of the samples will help find out if you may have COVID-19.
[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: Laboratories may use pooling when testing your specimen, which means they combine your sample with other individuals' samples prior to testing and test them as a "pool". The laboratory may return a result for the entire pool together or may return individual results.]
#### What are the known and potential risks and benefits of the test?
Potential risks include:
- Possible discomfort or other complications that can happen during sample collection.
- Possible incorrect test result (see below for more information).
Potential benefits include:
- The results, along with other information, can help your healthcare provider make informed recommendations about your care.
- The results of this test may help limit the spread of COVID-19 to your family and those you come in contact with.
#### What does it mean if I have a positive test result?
If you have a positive test result, it is very likely that you have COVID-19. Therefore, it is also likely that you may be placed in isolation to avoid spreading the virus to others. You should follow CDC guidance to reduce the potential transmission of disease.
[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: If you were tested as part of a pool that returned a positive or invalid test result, you may have COVID-19 and should consider yourself to have a positive test result unless or until you receive a negative test result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, you should isolate until receiving a negative result when re-tested individually and should not be grouped with other individuals who have received a positive or presumptive positive result.]
There is a smaller possibility that this test can give a positive result that is wrong (a false positive result) particularly when used in a population without many cases of COVID-19 infection. Your healthcare provider will work with you to determine how best to care for you based on the test results along with medical history, and your symptoms.
#### What does it mean if I have a negative test result?
A negative test result means that the virus that causes COVID-19 was not found in your sample.
However, it is possible for this test to give a negative result that is incorrect (false negative) in some people with COVID-19. You might test negative if the sample was collected early during your infection. You could also be exposed to COVID-19 after your sample was collected and then have become infected.
In particular, people infected with COVID-19 but who have no symptoms may not shed enough virus to trigger a positive test. This means that you could possibly still have COVID-19 even though the test result is negative. If your test is negative, your healthcare provider will consider the test result together with all other aspects of your medical history (such as symptoms, possible exposures, and geographical location of places you have recently traveled) in deciding how to care for you.
[INCLUDE THIS TEXT IF YOUR INDICATION INCLUDES POOLING: If your test result indicates your specimen was pooled and you have a negative test result there is a small chance that your result is incorrect. You should talk with your healthcare provider if you are concerned.]
If you have no symptoms but have been tested because your healthcare provider thought you may have been exposed to COVID-19, you should continue to monitor your health and let your healthcare provider know if you develop any symptoms of COVID-19. If you develop symptoms you may need another test to determine if you have contracted the virus causing COVID-19.
If you develop symptoms or your symptoms get worse you should seek medical care. If you have the following symptoms you should seek immediate medical care at the closest emergency room:
- Trouble breathing
- Persistent pain or pressure in the chest
- New confusion
- Inability to wake up or stay awake
- Bluish lips or face
It is important that you work with your healthcare provider to help you understand the next steps you should take.
#### Is this test FDA-approved or cleared?
No. This test is not yet approved or cleared by the United States FDA. FDA may issue an Emergency Use Authorization (EUA) when certain criteria are met, which includes that there are no adequate, approved, available alternatives. The EUA for this test is supported by the Secretary of Health and Human Service’s (HHS’s) declaration that circumstances exist to justify the emergency use of in vitro diagnostics for the detection and/or diagnosis of the virus that causes COVID-19. This EUA will remain in effect (meaning this test can be used) for the duration of the COVID-19 declaration justifying the emergency use of in vitro diagnostics, unless it is terminated or revoked by FDA (after which the test may no longer be used).
This test is authorized under the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing [include link to this letter] for use in [the specific laboratory, that is certified under CLIA and meets requirements to perform high complexity tests, in which it was developed] for [insert indication(s) from applicable appendix(ces)] using the test procedures validated in accordance with the requirements of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing.
#### What are the approved alternatives?
Any tests that have received full marketing status (e.g., cleared, approved), as opposed to an EUA, by FDA can be found by searching the medical device databases here:
[https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases](https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/medical-device-databases). A cleared or approved test should be used instead of a test made available under an EUA, when appropriate and available. FDA has issued EUAs for other tests that can be found at:
[https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization)
#### Where can I go for updates and more information?
The most up-to-date information on COVID-19 is available at the CDC General webpage:
[https://www.cdc.gov/COVID19](https://www.cdc.gov/COVID19). In addition, please also contact your healthcare provider with any questions/concerns.
## Appendix N
### Authorized Test Summary
As set forth in Section II of this letter and required by Condition of Authorization A, your test’s labeling must include a Test Summary that includes the relevant information in this appendix. FDA has provided a template for a Test Summary on the FDA website with this letter to facilitate the creation of your test specific summary.
You must include the following information in your Test Summary, replacing text highlighted in yellow **[Text]** with information applicable to your specific test:
### TEST SUMMARY
For **In vitro** Diagnostic Use
Rx Only
For use under Emergency Use Authorization (EUA) only
The **[test name]** will be performed at the **[laboratory name]** located at **[laboratory address]**, which is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets the requirements to perform high complexity tests.
#### INTENDED USE
The **[test name]** is intended for the **in vitro [insert indication(s) from applicable appendix(ces)]**. Testing is limited to **[laboratory name]** laboratory located at **[laboratory address]**, which is certified under Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets the requirements to perform high-complexity testing.
The **[test name]** is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of real-time PCR and in vitro diagnostic procedures. The **[test name]** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
Results are for the detection and identification of SARS-CoV-2 RNA. The SARS-CoV-2 nucleic acid is generally detectable in anterior nasal swab specimens during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
Laboratories within the United States and its territories are required to report all results to the appropriate public health authorities.
**[INCLUDE THIS PARAGRAPH IF YOUR INDICATION INCLUDES POOLING:]** Negative results from pooled testing should not be treated as definitive. If a patient’s clinical signs and symptoms are inconsistent with a negative result or results are necessary for patient management, then the patient should be considered for individual testing. Specimens included in pools with a positive or invalid result must be reported as presumptive positive or tested individually prior to reporting a result. Individuals included in a pool that returns a positive or invalid result should be treated as a presumptive positive unless or until they receive a negative result when re-tested individually. However, as most individuals in a positive pool will likely receive a negative result when re-tested individually, they should isolate until receiving a negative result when re-tested individually and should not be cohorted with other individuals who have received a positive or presumptive positive result. Specimens with low viral loads may not be detected with pooled testing due to decreased sensitivity or increased interference from pooled testing.
For serial testing programs, additional confirmatory testing for negative results may be necessary, if there is a high likelihood of COVID-19, such as an individual with a close contact with COVID-19 or with suspected exposure to COVID-19 or in communities with high prevalence of infection. Additional confirmatory testing for positive results may also be necessary, if there is a low likelihood of COVID-19, such as in individuals without known exposure to COVID-19 or testing in communities with low prevalence of infection.
1) **Special Conditions for Use Statements:**
- For use under Emergency Use Authorization (EUA) only
- For prescription use only
- For **in vitro** diagnostic use only
**[INCLUDE THIS PARAGRAPH IF YOUR INDICATION INCLUDES HOME COLLECTION:]** Testing of specimens self-collected at home is limited to specimens collected with the **[name of authorized home collection kit with which your test is validated]** by **[the patient population authorized in the home collection kit EUA]**.
This test is authorized under the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing **[include link to this letter]** for use in **[the specific laboratory, that is certified under CLIA and meets requirements to perform high complexity tests, in which it was developed]** for **[insert indication(s) from applicable appendix(ces)]** using the test procedures validated in accordance with the requirements of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing.
#### DEVICE DESCRIPTION AND TEST PRINCIPLE
The **[Test Name]** assay is a reverse transcription polymerase chain reaction (RT-PCR) test. The SARS-CoV-2 primer and probe set(s) is designed to detect RNA from the SARS-CoV-2 **[genes/regions]** in anterior nasal swab specimens that were collected from individuals, including individuals without symptoms or other reasons to suspect COVID-19.
*[Describe the processes used to perform the test, including, as applicable, 1) nucleic acid extraction, 2) reverse transcription of target RNA to cDNA, 3) PCR amplification of target and internal control, and 4) simultaneous detection of PCR amplicons by fluorescent dye labeled probes. Include key parameters such as input volumes, reverse transcription (RT) time and temperature, PCR cycling parameters including dwell temperature and dwell times.]*
#### INSTRUMENTS USED WITH TEST
Instruments
The **[test name]**, a real-time RT-PCR test, is to be used with the **[list extraction kit(s)]** and the **[list RT-PCR Instrument(s)]** and **[RT-PCR Instrument Software]**.
Collection Kits (if applicable)
This assay can be used with the **[list EUA authorized Home Collection Kit(s)]**.
Reagents
The primary reagents used in **[test name]** assay:
| Kits and Reagents | Manufacturer | Catalog # |
|-------------------|--------------|-----------|
| | | |
| | | |
||
### CONTROL MATERIAL(s) TO BE USED WITH [test name]
*[List all control materials used with the test and describe what they are, how they are expected to work, where in the testing process they are used, and the frequency of use. If a control is commercially available, provide supplier’s name and catalog number or other identifier; if your device relies on external controls that are manufactured by a third party please note that these controls must also be validated within your analytical and clinical studies.]*
Controls that are used with the test include:
a) A “no template” (negative) control is needed to *[describe need]* and is used *[describe use – please also specify frequency of use]*
b) A positive template control is needed to *[describe need]* and is used *[describe use – please specify the concentration of the positive control relative to the LoD of your test (note that ideally the positive control concentration should be such that it is close to the LoD of your test) and also specify frequency of use]*
c) An extraction control *[describe control]* is needed to *[describe need]* and is used *[describe use – please also specify frequency of use]*. Please note that if the no template control and positive control, are taken through the entire sample processing procedure, including the extraction, then a separate extraction control is not required.
d) An internal control *[describe control]* is needed to *[describe need]* and is used *[describe use]*.
### INTERPRETATION OF RESULTS
All test controls must be examined prior to interpretation of patient results. If the controls are not valid, the patient results cannot be interpreted. Appropriate control interpretation criteria and result interpretation criteria are described here. You must describe if a Ct cutoff is used as part of your testing algorithm and/or if the end user is required to review curves before final result interpretation. Although not typical for molecular-based tests, if the test result involves the use of an algorithm/calculation, for example a ratio value, when determining the final patient test result, include a detailed description and any additional calibration materials that may be required.
1. **Examination and Interpretation of Control Results**
*[Describe in detail the expected results generated, including acceptance criteria, for all the controls used in test. Describe the measured values (if applicable) for valid and invalid controls and outline the actions to take in the event of an invalid control result.]*
2. **Examination and Interpretation of Patient Specimen Results**
Assessment of clinical specimen test results must be performed after the controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
*[Describe when clinical specimen test results should be assessed and outline the criteria for test validity. Clearly indicate how to interpret numeric test values (if applicable) as positive or negative for presence of SARS-CoV-2. Indicate if the end user is required to review curves before final result interpretation and, if applicable, how to identify indeterminate/inconclusive/equivocal results. When applicable, we recommend providing a table clearly describing the possible combinations of test result values for each primer/probe set. Describe how they should be combined into a final interpretation of the result for your test. If the test produces an equivocal or indeterminate result, please indicate what follow-up testing/process should be conducted, if applicable.]*
*[If your test is indicated for pooling, also include a pooling results interpretation table, indicating how to interpret each possible result, including when samples should be retested individually.]*
### PERFORMANCE EVALUATION
1) **Limit of Detection (LoD) - Analytical Sensitivity:**
The LoD for *[test name]* was evaluated and verified using *[validation material, e.g., SARS-CoV-2 inactivated virus (e.g., heat treated or irradiated)]* per the validation required by Appendix A of the Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing. Nucleic acid was extracted from the swabs using *[specify nucleic acid extraction]* and the reverse transcription RT-PCR was performed using the *[specify RT-PCR Instrument and, if applicable, interpretive software version]*. Preliminary and Confirmation LoD results are included in the tables below.
| Virus Concentration | Target 1 Ct Value | Target 2 Ct Value | Internal Control Ct Value | # of Replicates |
|---------------------|-------------------|-------------------|---------------------------|-----------------|
| | | | | |
||
| Targets | Target 1 | Target 2 |
|---------------------|----------|----------|
| Analyte Concentration | | |
| Positives/Total | | |
| % Detected | | |
| Mean Ct | | |
| Mean SD | | |
| CV | | |
||
The data confirmed the assay analytical sensitivity is *[specify LoD represented as genome copies or equivalents/mL]*.
2) **Inclusivity (Analytical Reactivity):**
An alignment was performed with the oligonucleotide primer and probe sequences of the *[test name]* with *[number of sequences]* publicly available SARS-CoV-2 sequences (including mutation variants of high prevalence, i.e., B.1.617.2 and sub-lineages at the time of issuance of this letter) from *[specify sequence data base, e.g., GISAID]* to demonstrate the predicted inclusivity of the assay.
*[Insert summary of results of inclusivity analysis.]*
3) **Cross-reactivity (Analytical Specificity):**
Analytical specificity of the primer/probe combination for *[test name]* was evaluated by conducting sequence alignment of the primer/probe sequences of the test with publicly available genome sequences for potential cross-reacting microorganisms. The following organisms were tested with *[test name]* primer probe set.
| Organism | Strain | Target 1 | Target 2 |
|----------|--------|----------|----------|
| | | | |
||
4) **Clinical Evaluation:**
Clinical evaluation of the *[test name]* was conducted with 30 individual natural positive and 30 negative anterior nasal swab clinical specimens collected from patients suspected of SARS-CoV-2 infection by a healthcare provider in COVID-19 disease endemic region(s). These specimens were *[prospective, retrospective, or leftover samples]*. Nucleic acid was extracted from the swabs using *[specify nucleic acid extraction]* and the reverse transcription RT-PCR was performed using the *[specify RT-PCR Instrument and, if applicable, interpretive software version]*.
Data is summarized in the Table below:
**Table: Summary Performance on individual anterior nasal swab specimens in comparison to an FDA-authorized method for specimens collected from individuals suspected of COVID-19 by a healthcare provider**
| [Test Name] | FDA EUA RT-PCR Assay | Total | % Performance Agreement | 95% CI |
|-------------|----------------------|-------|-------------------------|--------|
| | Detected | Not Detected | | | |
| Detected | A | B | A+B | PPA= 100% x A/(A+C) | |
| Not Detected| C | D | C+D | NPA= 100% x D/(B+D) | |
| Total | A+C | B+D | | | |
||
[IF VALIDATION WAS ALSO COMPLETED WITH SPECIMENS COLLECTED FROM INDIVIDUALS WITHOUT SYMPTOMS OR OTHER REASONS TO SUSPECT COVID-19, ALSO INCLUDE THOSE RESULTS:] Clinical evaluation of the [test name] was conducted with 20 positive and 100 negative specimens collected from individuals without symptoms or other reasons to suspect COVID-19 in COVID-19 disease endemic region(s). These specimens were [prospective, retrospective, or leftover samples]. Nucleic acid was extracted from the swabs using [specify nucleic acid extraction] and the reverse transcription RT-PCR was performed using the [specify RT-PCR Instrument and, if applicable, interpretive software version].
Data is summarized in the Table below:
**Table: Summary Performance on individual anterior nasal swab specimens in comparison to an FDA-authorized method for specimens collected from individuals without symptoms or other reasons to suspect COVID-19**
| [Test Name] | FDA EUA RT-PCR Assay | Total | % Performance Agreement | 95% CI |
|-------------|----------------------|-------|-------------------------|--------|
| | Detected | Not Detected | | | |
| Detected | A | B | A+B | PPA= 100% x A/(A+C) | |
| Not Detected| C | D | C+D | NPA= 100% x D/(B+D) | |
| Total | A+C | B+D | | | |
||
5) **Additional Validation for [indication provided by appendix(ces) B -K, e.g., Media Pooling up to n=10 with validation option 2]**
[For each additional indication, include a section with the required validation and documentation from the applicable appendix.]
### LIMITATIONS
- The performance of this test was established based on the evaluation of a limited number of clinical specimens collected between [include collection window dates between MONTH, YEAR AND MONTH, YEAR and the location(s) of clinical evaluation (Country(ies)– identify if it was multiple sites in the country or limited locations – if known)]. The clinical performance of this test has not been established in all circulating variants but is anticipated to be reflective of the variants in circulation at the time and location(s) of the clinical evaluation. As such, performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2, and their prevalence, which change over time.
- [IF EVALUATION OF SPECIMENS COLLECTED FROM INDIVIDUALS WITHOUT SYMPTOMS OR OTHER REASONS TO SUSPECT COVID-19 HAVE NOT YET BEEN EVALUATED, INCLUDE THIS STATEMENT:] Clinical performance has been established in specimens collected from subjects suspected of COVID-19 by a healthcare provider. Performance of specimens collected from individuals without symptoms or other reasons to suspect COVID-19 has not been established. A study to determine the performance in individuals without symptoms or other reasons to suspect COVID-19 will be completed.
### WARNINGS:
- This product has not been FDA cleared or approved, but has been authorized by FDA under an Emergency Use Authorization (EUA) for use by the laboratory that developed the test and which is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets the requirements to perform high complexity tests.
- This product has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens; and
- The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
---
^1^ U.S. Department of Health and Human Services, *Determination of a Public Health Emergency and Declaration that Circumstances Exist Justifying Authorizations Pursuant to Section 564(b) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3*. 85 FR 7316 (February 7, 2020)
^2^ Many laboratories have been providing SARS-CoV-2 testing with tests that are not FDA authorized for emergency use, including as discussed in FDA policies in place earlier in the public health emergency. This authorization is intended to provide an efficient mechanism by which some of these tests can become authorized.
^3^ For ease of reference, this letter uses the phrase “authorized tests” to refer to molecular-based tests that are developed and used by the single laboratory, that is certified under CLIA and meets requirements to perform high complexity tests, that developed the test and that are within the Scope of Authorization (Section II).
^4^ CDRH IVD EUA webpage [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas)
^5^ No other criteria of issuance have been prescribed by regulation under Section 564(c)(4) of the Act.
^6^ The indications for use for tests authorized by this EUA are limited to anterior nasal swab specimens in dry tubes or tubes containing viral transport media (VTM), saline, or phosphate-buffered saline (PBS) and do not include any indications for other specimen types, such as saliva. The indications for use for tests authorized by this EUA also do not include specimens in tubes containing inactivating transport media (ITM), such as those containing guanidine thiocyanate or similar chemicals.
^8^ Other modifications, including new claimed specimen types or test settings (e.g., point-of-care, home testing), or any other modifications that change the indication for use, are not authorized under this EUA and must be authorized under an individual EUA prior to use.
^9^ Traceability refers to tracing analytical sensitivity/reactivity back to an FDA-recommended reference material.
^10^ The Centers for Disease Control and Prevention (CDC) has granted a right of reference to the performance data contained in the CDC’s EUA request for the [CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel (CDC)](https://www.cdc.gov/coronavirus/2019-ncov/lab/testing.html) (FDA submission number EUA200001) to any entity seeking authorization for a COVID-19 diagnostic device. The CDC has also granted a right of reference to the performance data contained in the CDC’s EUA request for their [Influenza SARS-CoV-2 (Flu SC2) Multiplex Assay](https://www.cdc.gov/coronavirus/2019-ncov/lab/testing.html) (FDA submission number EUA201781) to any entity seeking authorization for a multi-analyte respiratory panel that includes SARS-CoV-2. CDC has published the primer and probe sequences for the Influenza SARS-CoV-2 Multiplex Assay on the [CDC website](https://www.cdc.gov/coronavirus/2019-ncov/lab/testing.html).
^11^ Available at: [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-evaluating-impact-viral-mutations-covid-19-tests](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-evaluating-impact-viral-mutations-covid-19-tests).
^12^ For additional information on the estimated proportions of SARS-CoV-2 lineages, see: [https://covid.cdc.gov/covid-data-tracker/#variant-proportions](https://covid.cdc.gov/covid-data-tracker/#variant-proportions).
# 3,586 2021-11-15_FDA Letter - Laboratories Who Have Developed a Molecular-Based Test.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-11-15_FDA Letter - Laboratories Who Have Developed a Molecular-Based Test.md
file_date: 2021-11-15
title: FDA Letter - Laboratories Who Have Developed a Molecular-Based Test
category: regulatory
subcategory: fda-policy
tags:
source_file_type: pdf
xfile_type: NA
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summary_short: The FDA “Laboratories Who Have Developed a Molecular-Based Test” letter (Nov 15, 2021) reissues and narrows an EUA for certain molecular laboratory-developed tests listed in Appendix A, authorizing them only for qualitative SARS-CoV-2 detection in respiratory specimens from individuals suspected of COVID-19 by a healthcare provider. It explains that no additional tests will be added under this EUA and updates conditions and fact sheets to reflect the current phase of the pandemic and FDA’s shift toward separate serial screening/pooling pathways. It also sets enforceable conditions for authorized single-lab use (CLIA high complexity), reporting, labeling, adverse event tracking, and ongoing evaluation of viral mutation impacts.
CONTENT
November 15, 2021
To:
Laboratories with tests listed in Appendix A.
Authorized Tests:
Tests listed in Appendix A.^1^
Indication:
Qualitative detection of nucleic acid from SARS-CoV-2 in respiratory specimens collected from individuals suspected of COVID-19^2^ by their healthcare provider. Use of the test is limited to the authorized laboratory.
Authorized Laboratories:
Testing is limited to the single laboratory that developed the authorized test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets the requirements to perform tests of high complexity. The authorized laboratory for each authorized test is listed in Appendix A.
On February 4, 2020, pursuant to Section 564(b)(1)(C) of the Federal Food, Drug, and Cosmetic Act (the Act), the Secretary of the Department of Health and Human Services (HHS) determined that there is a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad, and that involves the virus that causes COVID-19. Pursuant to Section 564 of the Act, and on the basis of such determination, the Secretary of HHS then declared that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the virus that causes COVID-19 subject to the terms of any authorization issued under Section 564(a) of the Act.^3^
On March 31, 2020, in response to this evolving public health emergency and continued concerns about the availability of sufficient in vitro diagnostic tests, FDA issued this EUA for certain molecular-based laboratory developed tests (LDTs) for use by the single developing laboratory (as described in the Scope of Authorization (Section II)) under Section 564 of the Act (21 U.S.C. § 360bbb-3). Under this EUA, authorized tests are authorized for use only in the single laboratory that developed the authorized test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets the requirements to perform tests of high complexity.
FDA has continued to periodically review the circumstances and the appropriateness of authorizing the emergency use of tests under this EUA as required by Section 564(g)(1) of the Act since it was issued on March 31, 2020. Based on this review and all available information, FDA has concluded that the criteria for issuance under Section 564(c) of the Act are met with respect to the authorized tests and has also determined that it is no longer appropriate to include any additional authorized tests under this EUA. As described below, FDA’s decision to reissue this EUA pursuant to Section 564(c) of the Act is based in part on the changing circumstances of this pandemic. This includes a significant shift towards tests that can be used with pooled specimens that are collected as part of a serial testing program for screening. Such tests are outside the scope of this EUA. Given this, FDA is reissuing this EUA such that only tests that are listed in Appendix A are authorized for use as described in Section II of this letter when used consistent with the Conditions of Authorization (Section IV). FDA has updated the Conditions of Authorization and also updated the fact sheets to reflect the most up-to-date information as part of this reissuance.
FDA may authorize additional tests, as appropriate, either in individual EUAs or under a new umbrella EUA. At this stage of the pandemic, FDA intends to focus its review on the types of tests needed to meet the current public health needs, including tests intended for use as part of serial screening testing programs. Serial screening testing programs are expected to be a cornerstone of the current phase of the country’s pandemic response as many schools, workplaces, communities, and other entities are setting up testing programs to rapidly screen for COVID-19, and FDA is providing streamlined approaches for authorization of tests intended for use in these programs. FDA will review individual EUA requests for tests based on a number of factors and may issue an EUA when the statutory criteria for issuance are met.
Having concluded that the criteria for issuance under Section 564(c) of the Act are met with respect to the tests listed in Appendix A of this letter, I am authorizing the emergency use of the tests listed in Appendix A as described in the Scope of Authorization (Section II) and pursuant to the Conditions of Authorization (Section IV) to detect SARS-CoV-2 in respiratory specimens from individuals suspected of COVID-19 by their healthcare provider for use in the single laboratory that developed the authorized test and that is certified under the CLIA, 42 U.S.C. § 263a, and meets the requirements to perform tests of high complexity.
## I. Criteria for Issuance of Authorization
I have concluded that the emergency use of the authorized tests listed in Appendix A of this reissued letter of authorization meet the criteria for issuance of an authorization under Section 564(c) of the Act, because I have concluded that:
1. The SARS-CoV-2 can cause a serious or life-threatening disease or condition, including severe respiratory illness, to humans infected by this virus;
2. Based on the totality of scientific evidence available to FDA, it is reasonable to believe that the authorized tests may be effective in diagnosing COVID-19, and that the known and potential benefits of the authorized tests when used for diagnosing COVID-19, outweigh the known and potential risks of the authorized tests; and
3. There is no adequate, approved, and available alternative to the emergency use of the authorized tests.^4^
## II. Scope of Authorization
I have concluded, pursuant to Section 564(d)(1) of the Act, that the scope of this authorization is limited to the authorized tests listed in Appendix A for the indication above.
Authorized Tests
Tests listed in Appendix A, when labeled consistent with the authorized test procedures and as described in the authorized test’s EUA summary (available at [FDA EUA Summary](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2)), are authorized to be used by the single laboratory that developed the authorized test, despite the fact that they do not meet certain requirements otherwise required by applicable federal law.
Authorized tests must be accompanied by the following product information pertaining to their emergency use, which is required to be made available to healthcare providers and patients:
- Fact Sheet for Healthcare Providers: Molecular LDT COVID-19 Authorized Test
- Fact Sheet for Patients: Molecular LDT COVID-19 Authorized Test
These facts sheets, the authorized test procedures, and the authorized test’s EUA summary are collectively referred to below as the “authorized labeling” for each authorized test.
I have concluded, pursuant to Section 564(d)(2) of the Act, that it is reasonable to believe that the known and potential benefits of the authorized tests outweigh the known and potential risks of such authorized tests.
I have concluded, pursuant to Section 564(d)(3) of the Act, based on the totality of scientific evidence available to FDA, that it is reasonable to believe that the authorized tests listed in Appendix A may be effective for the indication above, when used consistently with the Scope of Authorization of this letter (Section II), pursuant to Section 564(c)(2)(A) of the Act.
FDA has reviewed the scientific information available to FDA, including the information supporting the conclusions described in Section I above, and concludes that the authorized tests (as described in the Scope of Authorization of this letter (Section II)) meet the criteria set forth in Section 564(c) of the Act concerning safety and potential effectiveness.
The emergency use of the authorized tests under this EUA must be consistent with, and may not exceed the terms of this letter, including the Scope of Authorization (Section II) and the Conditions of Authorization (Section IV).
Conditions of Authorization (Section IV). Subject to the terms of this EUA and under the circumstances set forth in the Secretary of HHS's determination under Section 564(b)(1)(C) of the Act described above and the Secretary of HHS’s corresponding declaration under Section 564(b)(1) of the Act, the tests are authorized for the indication above.
This EUA will cease to be effective when the HHS declaration that circumstances exist to justify the EUA is terminated under Section 564(b)(2) of the Act or when the EUA is revoked under Section 564(g) of the Act.
## III. Waiver of Certain Requirements
I am waiving the following requirements for the product during the duration of this EUA:
- Current good manufacturing practice requirements, including the quality system requirements under 21 CFR Part 820 with respect to the design, manufacture, packaging, labeling, storage, and distribution of your product.
## IV. Conditions of Authorization
Pursuant to Section 564(e) of the Act, I am establishing the following conditions on this authorization:
### Authorized Laboratories (You)
A. Your authorized product must comply with the following labeling requirements under FDA regulations: the intended use statement (21 CFR 809.10(a)(2), (b)(2)); adequate directions for use (21 U.S.C. 352(f)), (21 CFR 809.10(b)(5), (7), and (8)); appropriate limitations on the use of the device including information required under 21 CFR 809.10(a)(4); and any available information regarding performance of the product, including requirements under 21 CFR 809.10(b)(12).
B. You must inform relevant public health authorities of this EUA, including the terms and conditions herein, and any updates made to your authorized product or authorized labeling.
C. You must notify the relevant public health authorities of your intent to run your authorized product.
D. You must have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
E. You must include with test results, all authorized Fact Sheets. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
F. You must make available on your website(s), if applicable, the Fact Sheet for Healthcare Providers and the Fact Sheet for Patients.
G. You are authorized to make available additional information relating to the emergency use of your authorized product that is consistent with, and does not exceed, the terms of this letter of authorization.
H. You must use your authorized product as outlined in the authorized test procedures. Deviations from the authorized test procedures, including the authorized instruments, authorized extraction methods, authorized clinical specimen types, authorized control materials, authorized other ancillary reagents and/or authorized materials required to use your product are not permitted.
I. You must collect information on the performance of your authorized product. You must report to DMD/OHT7-OIR/OPEQ/CDRH (via email: [CDRH-EUA-Reporting@fda.hhs.gov](mailto:CDRH-EUA-Reporting@fda.hhs.gov)) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of your authorized product of which you become aware.
J. You may request changes to the authorized labeling. Any request for changes to the authorized labeling must be submitted to the Division of Microbiology (DMD)/Office of Health Technology 7 (OHT7)-Office of In Vitro Diagnostics and Radiological Health (OIR)/Office of Product Evaluation and Quality (OPEQ)/Center for Devices and Radiological Health (CDRH) and require appropriate authorization from FDA prior to implementation.
K. You must evaluate the analytical limit of detection and assess traceability of your authorized product with any FDA-recommended reference material(s), if requested by FDA. After submission to FDA and DMD/OHT7-OIR/CDRH’s review and concurrence with the data, FDA will update the EUA summary to reflect the additional testing. Such updates will be made in consultation with, and require concurrence of, DMD/OHT7-OIR/OPEQ/CDRH.
L. You must track adverse events, including any occurrence of false results with your authorized product and report any such events to FDA pursuant to 21 CFR Part 803.
M. All laboratory personnel using your authorized product must be appropriately trained in molecular techniques and use appropriate laboratory and personal protective equipment when handling this product, and use your authorized product in accordance with the authorized test procedure.
N. You must ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
O. You must evaluate the impact of SARS-CoV-2 viral mutations on your product’s performance. Such evaluations must occur on an ongoing basis and must include any additional data analysis that is requested by FDA in response to any performance concerns you or FDA identify during routine evaluation. Additionally, if requested by FDA, you must submit records of these evaluations for FDA review within 48 hours of the request. If your evaluation identifies viral mutations that affect the stated expected performance of your product, you must notify FDA immediately via email to [CDRH-EUA-Reporting@fda.hhs.gov](mailto:CDRH-EUA-Reporting@fda.hhs.gov).
P. If requested by FDA, you must update your labeling within 7 calendar days to include any additional labeling risk mitigations identified by FDA regarding the impact of viral mutations on test performance. Such updates will be made in consultation with, and require concurrence of, DMD/OHT7-OIR/OPEQ/CDRH.
### Conditions Related to Printed Materials, Advertising and Promotion
Q. All descriptive printed matter, advertising, and promotional materials, relating to the use of your authorized product shall be consistent with the authorized labeling, as well as the terms set forth in this EUA, and meet the requirements set forth in section 502(q)(1) and (r) of the Act, as applicable, and FDA implementing regulations.
R. No descriptive printed matter, advertising, or promotional materials relating to the use of your authorized product may represent or suggest that such test is safe or effective when used for detection SARS-CoV-2.
S. All descriptive printed matter, advertising, and promotional material relating to the use of your authorized product shall clearly and conspicuously state that:
- This product has not been FDA cleared or approved by FDA, but has been authorized by FDA under an EUA for use by authorized laboratories;
- This product has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens; and
- The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or the authorization is revoked sooner.
The emergency use of your product as described in this letter of authorization must comply with the conditions and all other terms of this authorization.
## V. Duration of Authorization
This EUA will be effective until the declaration that circumstances exist justifying the authorization of the emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 is terminated under Section 564(b)(2) of the Act or the EUA is revoked under Section 564(g) of the Act.
Sincerely,
Jacqueline A. O’Shaughnessy, Ph.D.
Acting Chief Scientist
Food and Drug Administration
Enclosure
---
^1^ For ease of reference, this letter will refer to the tests listed in Appendix A as the “authorized tests.” Appendix A is included on the FDA website at: [FDA EUA](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2)
^2^ On February 11, 2020, the virus tentatively named 2019-nCoV was formally designated as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Also on February 11, 2020, the disease caused by SARS-CoV-2 was formally designated as Coronavirus Disease 2019 (COVID-19). This document uses the updated names.
^3^ U.S. Department of Health and Human Services, _Determination of a Public Health Emergency and Declaration that Circumstances Exist Justifying Authorizations Pursuant to Section 564(b) of the Federal Food, Drug, and Cosmetic Act_, 21 U.S.C. § 360bbb-3, 85 FR 716 (February 7, 2020).
^4^ No other criteria of issuance have been prescribed by regulation under Section 564(c)(4) of the Act.
^5^ Traceability refers to tracing analytical sensitivity/reactivity back to an FDA-recommended reference material. FDA may request, for example, that you perform this study in the event that we receive reports of adverse events concerning your authorized test.
# 507 2021-11-15_FDA Website - Umbrella EUA.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2021-11-15_FDA Website - Umbrella EUA.md
file_date: 2021-11-15
title: FDA Website - Umbrella EUA
category: regulatory
subcategory: fda-policy
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notes: date converted 2024-03-27
web_url: https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2#umbrella-eua
summary_short: The Umbrella EUA describes FDA’s November 15, 2021 authorization for certain laboratory-developed RT-PCR SARS-CoV-2 tests using anterior nasal specimens for serial testing programs, including optional pooled testing and screening of asymptomatic individuals at least weekly. It specifies eligibility criteria, pooling parameters that vary by appendix (pool sizes up to 10, media vs. swab pooling, and possible home collection), and limits use to the single CLIA-certified high-complexity laboratory that developed the test. It also explains the notification/self-certification process for being added to Exhibit 1 and notes that listing does not necessarily mean FDA reviewed the underlying validation data.
CONTENT
On November 15, 2021, the FDA issued an umbrella EUA for certain RT-PCR molecular-based tests, developed by laboratories, for detection of nucleic acid from SARS-CoV-2 from anterior nasal respiratory specimens for use as part of a serial testing program, that meet certain criteria for eligibility specified in the EUA. Under this EUA, authorized tests can be used with individual or pooled anterior nasal specimens for testing individuals, including individuals without symptoms or other epidemiological reasons to suspect COVID-19, when tested at least once per week. This means that tests authorized by this EUA may be used with individual or pooled anterior nasal respiratory specimens from individuals with or without known or suspected exposure to COVID-19 when such individuals are tested at least once per week, such as testing at regular intervals as part of a testing program implemented by schools, workplaces, or community groups. The indications in each appendix (A-K) differ in the number of specimens that can be pooled (1, up to 3, up to 5, or up to 10), the type of pooling that can be done (media pooling or swab pooling), and whether the test can be used with home collected specimens.
Use of tests authorized by this EUA is limited to use in the single laboratory that developed the authorized test and that is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high complexity tests.
Tests will be added to Exhibit 1 of this EUA following submission of a complete notification to the FDA with the information required by the EUA, including self-certifying that the applicable validation has been completed, and confirmation by the FDA that the required documentation has been submitted. Being added to Exhibit 1 does not necessarily mean that the FDA has reviewed the underlying validation data submitted or confirmed that the test is appropriately validated.
[EUA Letter of Authorization - Umbrella EUA for SARS-CoV-2 Molecular Diagnostic Tests for Serial Testing](https://www.fda.gov/media/154111/download?attachment)
[Appendix L - Fact Sheet for Health Care Providers (Template)](https://www.fda.gov/media/154112/download?attachment)
[Appendix M - Fact Sheet for Patients (Template)](https://www.fda.gov/media/154114/download?attachment)
[Appendix N - Test Summary (Template)](https://www.fda.gov/media/154113/download?attachment)
# 8,418 2022-09-27_FDA Guidance - COVID IVD Test Developers v6.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2022-09-27_FDA Guidance - COVID IVD Test Developers v6.md
file_date: 2022-09-27
title: FDA Guidance - COVID IVD Test Developers v6
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summary_short: The FDA “Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)” (v6, Sept 27, 2022) updates FDA’s review priorities and enforcement policies for COVID-19 diagnostic and serology IVDs, superseding the November 15, 2021 version. It narrows EUA review to a smaller set of tests and supplemental requests from experienced developers that address unmet needs (e.g., variants or innovative technologies), while encouraging most developers to pursue traditional premarket pathways. It also clarifies ongoing policies for tests previously offered during FDA review, state-authorized single-lab testing, permitted modifications to authorized molecular tests, and baseline expectations for validation and reporting.
CONTENT
***INTERNAL TITLE:*** Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised)*
Guidance for Developers and Food and Drug Administration Staff
Document issued on the web on September 27, 2022.
This document supersedes “Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised): Guidance for Developers and Food and Drug Administration Staff” issued November 15, 2021.
_U.S. Department of Health and Human Services_
_Food and Drug Administration_
_Center for Devices and Radiological Health_
*This is the sixth edition of this guidance, which originally issued February 29, 2020, and was subsequently revised on March 16, May 4, May 11, 2020, and November 15, 2021.*
## Preface
### Public Comment
This guidance is being issued to address the Coronavirus Disease 2019 (COVID-19) public health emergency. This guidance is being implemented without prior public comment because the Food and Drug Administration (FDA or Agency) has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is being implemented immediately, but it remains subject to comment in accordance with the Agency’s good guidance practices.
Comments may be submitted at any time for Agency consideration. Submit written comments to the Dockets Management Staff (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. Submit electronic comments to [https://www.regulations.gov](https://www.regulations.gov). All comments should be identified with the docket number FDA-2020-D-0987 and complete title of the guidance in the request.
### Additional Copies
Additional copies are available from the FDA webpage titled “COVID-19-Related Guidance Documents for Industry, FDA Staff, and Other Stakeholders,” available at [https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders](https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders), and the FDA webpage titled “Search for FDA Guidance Documents,” available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents](https://www.fda.gov/regulatory-information/search-fda-guidance-documents). You may also send an e-mail request to [CDRH-Guidance@fda.hhs.gov](mailto:CDRH-Guidance@fda.hhs.gov) to receive an additional copy of the guidance. Please include the document number 20010-R5 and complete title of the guidance in the request.
### Questions
For questions about this document, contact [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov).
## Table of Contents
I. Introduction .......................................................................................................................... 4
II. Background .......................................................................................................................... 5
III. Scope ................................................................................................................................. 6
IV. Policy ................................................................................................................................. 7
A. Review of EUA Requests for COVID-19 Tests ................................................................. 7
B. State Authorization of High-Complexity CLIA-Certified Laboratories ............................ 8
C. Distribution and Offering of SARS-CoV-2 Diagnostic and Serology Tests During FDA Review ................................................................................................................................. 10
(1) FDA Review of EUA Requests ........................................................................................ 10
(2) Recommendations Regarding Test Reports and Other Information for Tests Offered During FDA Review of EUA Requests .......................................................................... 11
D. Modifications to EUA-Authorized Diagnostic COVID-19 Tests ....................................... 11
(1) Modifications Made After Issuance of this Updated Guidance .................................... 12
(2) Certain Modifications Made Before Issuance of this Updated Guidance .................... 12
V. Validation .......................................................................................................................... 14
VI. Availability of EUA Templates and Inquiries Regarding Validation ............................ 15
## I. Introduction
FDA plays a critical role in protecting the United States from threats such as emerging infectious diseases, including the Coronavirus Disease 2019 (COVID-19) pandemic. FDA is committed to providing timely guidance to support response efforts to this pandemic.
FDA is issuing this guidance to provide FDA’s review priorities and enforcement policies regarding novel coronavirus (COVID-19) tests for the duration of the public health emergency. Rapid detection of COVID-19 cases in the United States requires wide availability of testing to control the spread of this highly contagious infection. This document supersedes “Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised): Guidance for Developers and Food and Drug Administration Staff” issued November 15, 2021.
The policies in this guidance are intended to remain in effect only for the duration of the public health emergency related to COVID-19 declared by the Secretary of Health and Human Services (HHS) on January 31, 2020, effective January 27, 2020, including any renewals made by the HHS Secretary in accordance with section 319(a)(2) of the Public Health Service Act (PHS Act). FDA continues to assess the evolving situation and intends to update this guidance as appropriate.
Given this public health emergency, and as discussed in the Notice in the _Federal Register_ of March 25, 2020, titled “Process for Making Available Guidance Documents Related to Coronavirus Disease 2019,” available at [https://www.govinfo.gov/content/pkg/FR-2020-03-25/pdf/2020-06222.pdf](https://www.govinfo.gov/content/pkg/FR-2020-03-25/pdf/2020-06222.pdf), this guidance is being implemented without prior public comment because FDA has determined that prior public participation for this guidance is not feasible or appropriate (see section 701(h)(1)(C) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) and 21 CFR 10.115(g)(2)). This guidance document is being implemented immediately, but it remains subject to comment in accordance with the Agency’s good guidance practices.
In general, FDA’s guidance documents do not establish legally enforceable responsibilities. Instead, guidances describe the Agency’s current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word _should_ in Agency guidance means that something is suggested or recommended, but not required.
## II. Background
There is currently a pandemic of respiratory disease caused by a novel coronavirus. The virus has been named “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2) and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). On January 31, 2020, HHS issued a declaration of a public health emergency related to COVID-19 and mobilized the Operating Divisions of HHS. [^1] In addition, on March 13, 2020, the President declared a national emergency in response to COVID-19. [^2]
Under section 564 of the FD&C Act, the FDA Commissioner may authorize the use of unapproved medical products, or unapproved uses of approved medical products, in certain emergency circumstances, after the HHS Secretary has made a declaration of emergency or threat justifying authorization of emergency use, to diagnose, treat, or prevent serious or life-threatening diseases or conditions caused by chemical, biological, radiological, and nuclear (CBRN) agents when certain criteria are met. The Emergency Use Authorization (EUA) authorities allow FDA to help strengthen the nation’s public health protections against CBRN threats by facilitating the availability and use of medical countermeasures needed during certain public health emergencies.
As of August 15, 2022, FDA has issued EUAs for more than 439 tests for COVID-19, including more than 354 diagnostic and 85 serology or other immune response tests. Further, two molecular diagnostic COVID-19 tests have been granted marketing authorization through the traditional device premarket review pathways. In the context of a public health emergency involving pandemic infectious disease, it is critically important that tests are validated because false results not only can negatively impact the individual patient but also can have a broad public health impact. False positive results for diagnostic tests, for example, can lead to unnecessary quarantine and potential further spread when presumed positive individuals are quarantined together, wasted contact tracing and testing resources, and delay in accurate diagnosis and appropriate treatment for the individual. False negative results can lead to lack of appropriate treatment for the individual and further spread of the disease.
Previous versions of this guidance described policies regarding the distribution and offering of certain tests for clinical use prior to or without an EUA. These policies were issued to help quickly increase availability of tests in the early stages of the pandemic. Unless and until an EUA is issued that authorizes additional testing environments for a specific test, under the Clinical Laboratory Improvement Amendments (CLIA), section 353 of the Public Health Service Act (42 USC 263a), use of that test is limited to laboratories that are certified under CLIA, and meet the requirements to perform tests of high complexity, and at the point-of-care (POC) when covered by such a laboratory’s CLIA certificate. Throughout this guidance, references to “high-complexity CLIA-certified laboratories” are referring to laboratories that are certified under CLIA and meet the requirements to perform tests of high complexity. These policies did not apply to at-home tests or tests with home specimen collection.
FDA has updated these policies when appropriate in response to the changing landscape of this pandemic. The previous update on November 15, 2021, explained FDA’s intent to review EUA requests for certain types of tests that FDA believed would be most beneficial at that stage of the pandemic. In addition, in the November 15, 2021, version, FDA revised the previous enforcement policies to reflect that, at that stage of the pandemic, the Agency generally expected COVID-19 tests to have been issued an EUA prior to the tests being distributed or offered.
FDA has continued to closely monitor the COVID-19 testing landscape and believes it is again appropriate to update its policies to reflect the current needs of the pandemic. As explained throughout this updated guidance, FDA intends to review the EUA requests for a smaller subset of tests based on the review priorities described in section IV.A. Traditional marketing pathways remain available to all developers and FDA encourages developers of tests that fall outside the scope of the priorities outlined in this updated guidance to pursue those routes. In sum, FDA has revised this guidance to update the types of COVID-19 tests for which the Agency intends to review EUA requests, to discuss the use of the traditional premarket review pathways for other types of COVID-19 tests for which the Agency does not intend to review EUA requests, and to make minor updates to the enforcement policies.
## III. Scope
This guidance applies to diagnostic and serology tests for COVID-19. [^3] The policies and recommendations described in this guidance are intended to facilitate availability of tests for COVID-19 that FDA believes will be most beneficial at the current stage of the public health emergency.
FDA notes that the enforcement policies in this guidance do not address medical device reporting (MDR) under 21 CFR Part 803 for tests offered prior to authorization as described in the guidance. Developers offering such tests are expected to comply with applicable MDR requirements, including reporting of medical device events that reasonably suggest that their device may have caused or contributed to a death or serious injury, and malfunctions that would be likely to cause or contribute to a death or serious injury if they were to recur. Moreover, unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to high-complexity CLIA-certified laboratories, including testing at the point-of-care when the site is covered by the laboratory’s CLIA certificate for high complexity testing.
## IV. Policy
### A. Review of EUA Requests for COVID-19 Tests
The issuance of an EUA is discretionary. FDA’s decision to review and process an EUA request, and ultimately issue an EUA if the relevant statutory criteria are met, is based on a determination, on a case-by-case basis, that such action is necessary to protect the public health in an emergency. It is an authorization that the government “may” issue when necessary to protect the public health in an emergency (see section 564(a)(1) of the FD&C Act (21 U.S.C. 360bbb-3(a)(1)), which states, in relevant part, “subject to the provisions of this section, the Secretary may authorize the introduction into interstate commerce…a drug, device, or biological product intended for use in an actual or potential emergency”). FDA’s January 2017 guidance, *Emergency Use Authorization of Medical Products and Related Authorities*, describes factors that FDA intends to use in its prioritization of EUA requests, such as the public health need for the product, the availability of the product, the availability and adequacy of the information concerning the likelihood that the product may be safe and effective in preventing, treating, or diagnosing the condition, and whether the product is included in government stakeholder stockpiles.
Given the need to address urgent public health priorities, FDA has and continues to prioritize reviewing the EUA requests it receives for COVID-19 tests.
At this stage of the pandemic, FDA intends to prioritize its review of EUA requests and supplemental EUA requests from experienced developers for diagnostic tests that are likely to have a significant public health benefit (e.g., employ innovative technology) or are likely to fulfill an unmet need (e.g., diagnosing infection with a new variant or subvariant).
FDA generally intends to focus its review on EUA requests and supplemental EUA requests for tests that are within these priorities. In addition to the above priorities, FDA also intends to focus its review on EUA requests that are from or supported by a U.S. government stakeholder, such as tests funded by the Biomedical Advanced Research and Development Authority (BARDA) or the National Institutes of Health’s Rapid Acceleration of Diagnostics (RADx). FDA intends to notify test developers of its intent by email if FDA declines to review or otherwise decides not to authorize a test/modification in an EUA request or supplemental EUA request.
In general, FDA believes these priorities are appropriate to address the public health needs at the current stage of the public health emergency based on the available information and may adjust these priorities as public health needs change. Specifically, there is generally sufficient availability of authorized high-throughput laboratory-based diagnostic tests intended for use with pooled samples and authorized home-use antigen tests that are available for over-the-counter (OTC) or prescription use.
FDA believes that the number of EUA requests that fall within FDA’s current review priorities described in this guidance are likely limited and generally encourages developers to submit COVID-19 tests through traditional premarket review pathways. If you are unsure whether your test may be prioritized for review, we encourage you to reach out to CDRH-EUA-Templates@fda.hhs.gov; however, at this stage, FDA strongly encourages developers of new tests and existing tests for which modifications are sought to pursue traditional pre-market pathways.
### B. State Authorization of High-Complexity CLIA-Certified Laboratories
Versions of this guidance prior to November 15, 2021, described a policy regarding States and territories that authorize laboratories within their State or territory to develop their own COVID-19 tests and perform specimen testing, where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA.
Under such policy, a State or territory choosing to authorize laboratories within that State or territory to develop and perform a test for COVID-19 would do so under authority of its own State law, and under a process that it established, and FDA did not intend to object to the use of such tests for specimen testing where the notification of SARS-CoV-2 test validation was not submitted to FDA and the laboratory did not submit an EUA request to FDA, and where instead the State or territory took responsibility for COVID-19 testing by laboratories in its State during the COVID-19 outbreak. This policy applied only to tests designed, developed, and used within a single, high-complexity, CLIA-certified laboratory. The policy did not apply to at-home tests or tests with home specimen collection, or any testing outside of a high-complexity CLIA-certified laboratory.
In versions of this guidance prior to November 15, 2021, FDA requested that the State or territory notify us if it chose to use this flexibility to expedite COVID-19 testing. FDA indicated that it would not be reviewing the process adopted by the State or territory. FDA expected that such States and territories as part of their oversight process would require laboratories developing SARS-CoV-2 tests to validate those tests prior to use. FDA encouraged laboratories that developed and performed a test for COVID-19 that was authorized by a State or territory to notify FDA that they have started clinical testing by sending an email to that effect to CDRH-EUA-Templates@fda.hhs.gov, and provide information on testing capacity.
In the November 15, 2021, version of this guidance, FDA revised this policy such that FDA no longer intended to apply the policy to additional States or territories going forward. The FDA is maintaining the policy in Section IV.B. of the November 15, 2021, policy, without further revision. For the States and territories listed on the notification list on FDA’s website prior to November 15, 2021, that are continuing to authorize laboratories within their State or territory to develop and perform a test for COVID-19, FDA does not intend to object to the use of such tests for specimen testing where notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA and the State or territory takes responsibility. This policy applies only to tests designed, developed, and used within a single, high-complexity CLIA-certified laboratory. This policy does not apply to at-home tests or tests with home specimen collection, or any testing outside of a high-complexity CLIA-certified laboratory.
FDA notes that laboratories should be aware of requirements to report test results to appropriate federal, state, and local public health agencies in accordance with applicable federal, state, and local laws.[^12]
### C. Distribution and Offering of SARS-CoV-2 Diagnostic and Serology Tests During FDA Review
Previous versions of this guidance document described enforcement policies where FDA generally did not intend to object to developers distributing and offering certain tests prior to FDA authorization, as described in the policies. Those policies were updated in the November 15, 2021, version of the guidance, and FDA is generally continuing those updated policies and clarifying them, as discussed below.
#### (1) FDA Review of EUA Requests
For the following tests, FDA does not intend to object to the continued distribution or offering of the test while FDA reviews the EUA request for the test:
- Tests on one of the [notification lists](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/notifications-and-emergency-use-authorizations-faqs-testing-sars-cov-2)[^13] on FDA’s website at the time of issuance of this updated guidance; and,
- Laboratory developed tests (LDTs)[^14] offered following the HHS August 2020 Web Statement entitled, “Rescission of Guidances and Other Informal Issuances Concerning Premarket Review of Laboratory Developed Tests” (“August 2020 HHS Announcement”) and prior to November 15, 2021, where an EUA request was submitted to FDA as described in Section IV.C.2 of the November 15, 2021 version of this guidance document.[^15]
For tests described in this section, FDA intends to notify test developers by email if FDA declines to review, declines to issue, or otherwise decides not to authorize the test for any reason, including lack of response or a determination that there is a lack of adequate data to support authorization. If so notified, FDA generally expects developers to cease distributing, marketing, and offering their tests within 15 calendar days. Moreover, if FDA identifies a significant problem or concern with a test, based either on the provided information or external reports, FDA generally would expect the developer to take appropriate steps to address such problems, which could include conducting a recall of the test and/or notification concerning corrected test reports indicating prior test results may not be accurate.
#### (2) Recommendations Regarding Test Reports and Other Information for Tests Offered During FDA Review of EUA Requests
FDA continues to recommend the following:
1. Test reports should prominently disclose that the test has not been reviewed by FDA. Until the test is authorized by FDA, any statements in the test reports and other labeling that expressly state or imply that the test has been authorized by FDA would be false. Similarly, any statements in the test reports and other labeling that state or imply that EUA issuance or FDA authorization are imminent or pending could be misleading.
2. Developers should make publicly available on their website the instructions for use of the test and data about the test’s performance characteristics, including a summary of assay performance.
3. Instructions for use and patient test reports for serology tests should include information that helps users and patients understand the test results, including the following:
- Negative results do not preclude acute SARS-CoV-2 infection. If acute infection is suspected, direct (i.e., diagnostic) testing for SARS-CoV-2 is necessary.
- Results from antibody testing should not be used to diagnose or exclude acute SARS-CoV-2 infection.
- Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.
In addition, as noted in previous versions of this guidance and earlier in this updated guidance, unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to high-complexity CLIA-certified laboratories, including testing at the POC when the site is covered by such a laboratory’s CLIA certificate.
### D. Modifications to EUA-Authorized Diagnostic COVID-19 Tests
Throughout the course of the pandemic FDA has issued various policies with respect to modifications and as discussed further below, FDA is updating these policies. The policies in this section do not apply to at-home tests or tests with at-home specimen collection.
In order to provide transparency, when a developer is distributing or offering a test that is a modification of an EUA-authorized diagnostic test prior to or without authorization of the modified test, as discussed in this section, the recommendations in Section IV.C.2 of this updated guidance apply. FDA further recommends that the developer post data about the modified test’s performance characteristics on the developer’s website, and that the instructions for use or test protocol and the test reports accurately reflect the modification and prominently disclose that the test has been modified since authorization by FDA and that the modified test has not been reviewed by FDA.
If FDA identifies a significant problem or concern with a modified test, based either on the provided information or external reports, that cannot be addressed in a timely manner, FDA generally would expect the developer to cease distribution, marketing and offering the modified test and address such problem, which could include conducting a recall of the modified test and/or notification concerning corrected test reports indicating prior test results may not be accurate.
#### (1) Modifications Made After Issuance of this Updated Guidance
In addition to the priorities above, FDA intends to review supplemental EUA requests that fulfill a condition of an EUA. For other supplemental requests, such as those that are beyond the priorities outlined above, FDA encourages developers to consider including the modification in a submission through a traditional premarket review pathway. In general, FDA expects such modified tests to be authorized under an EUA or pursuant to a traditional premarket review pathway before being distributed or offered.
When a high-complexity CLIA-certified laboratory is modifying an authorized COVID-19 molecular diagnostic test, including one for which such laboratory is not the developer of the original, EUA-authorized test, and the modifications do not change the indication for use set forth in the EUA (e.g., including new/different extraction kits or instruments that would not be expected to change the indication for use) and do not change the analyte specific reagents (e.g., the modifications do not change the PCR primers and/or probes),[^16] FDA does not intend to object to implementation of the modification to the diagnostic test without notification to FDA or a new or amended EUA where the laboratory has validated the modification and confirmed that the performance of the modified test is equivalent to the performance of the authorized test, and use of the test is limited to the high-complexity CLIA-certified laboratory in which the modification was made.[^17]
In such cases, where the laboratory modifying and performing the test is not the developer of the original, EUA-authorized test, FDA encourages the laboratory to collaborate with the developer of the authorized test so that validation data supporting the modifications can be submitted by the original developer to FDA in a supplemental EUA request or incorporated into a future submission through the traditional premarket review pathways.
#### (2) Certain Modifications Made Before Issuance of this Updated Guidance
Under previous versions of this guidance, when a commercial manufacturer made certain modifications to its EUA-authorized COVID-19 diagnostic test, and where validation data supporting the modification had been submitted in a supplemental EUA request, FDA stated that it did not intend to object to implementation of the modification while FDA conducted its review, except for modifications to add specimen types that have not been previously authorized with another test of the same technology. For such modifications made and implemented as discussed in the policies in the previous version of the guidance, FDA does not intend to object to such commercial manufacturers continuing to implement the modification while FDA conducts its review.
Under the previous version of the guidance, when a high-complexity CLIA-certified laboratory modified an EUA-authorized COVID-19 diagnostic test[^18] prior to November 15, 2021, for use with a new specimen type, where the new specimen type has been previously authorized for another test of the same technology[^19] and where the laboratory had validated the test for the new specimen type, FDA stated that it did not intend to object to the use of such a modified test without notification to FDA or a new or amended EUA. For all other types of modifications made by the high-complexity CLIA-certified laboratory prior to November 15, 2021, for an EUA-authorized COVID-19 diagnostic test, in the previous version of the guidance, FDA stated that it did not intend to object to the use of the test by high-complexity CLIA-certified laboratories, without notification to FDA or a new or amended EUA, where the modified test is validated using a bridging study to the EUA-authorized test.
For high-complexity CLIA-certified laboratories that modified an authorized COVID-19 molecular diagnostic test after November 15, 2021, but before issuance of this updated guidance, including one for which such laboratory is not the developer of the original, EUA-authorized test, and the modifications do not change the indication for use set forth in the EUA (e.g., including new/different extraction kits or instruments that would not be expected to change the indication for use) and do not change the analyte specific reagents (e.g., the modifications do not change the PCR primers and/or probes),[^20] FDA stated that it did not intend to object to implementation of the modification to the diagnostic test without notification to FDA or a new or amended EUA where the laboratory has validated the modification and confirmed that the performance of the modified test is equivalent to the performance of the authorized test, and use of the test is limited to the high-complexity CLIA-certified laboratory in which the modification was made.[^21]
For such modifications made and implemented by high-complexity CLIA-certified laboratories as discussed in the policies in the previous versions of the guidance, FDA does not intend to object to such laboratories continuing to offer any of those modified tests.
In such cases, where the laboratory performing the modified test is not the developer of the original, EUA-authorized test, FDA encourages the laboratory to share its validation data with the developer of the original, EUA-authorized test so that the developer of the original, EUA-authorized test can use the validation data in support of a supplemental EUA request to add the modification or can incorporate it into a future submission through the traditional premarket review pathways.
## V. Validation
All clinical tests should be validated using clinical specimens and an appropriate comparator test prior to use.
In the context of a public health emergency, it is critically important that tests be validated prior to use because false results not only can negatively impact the individual patient but also can have a broad public health impact. However, FDA also generally accepts a lower level of evidence of validation for an EUA than for traditional premarket review pathways. FDA has provided recommendations regarding testing that should be performed to ensure analytical and clinical validity to the level of evidence expected for an EUA, including descriptions of appropriate comparators for different types of tests, in the EUA templates available through download from our website.[^22] Depending on the characteristics of a developer’s test, additional validation studies may be recommended.
Because the level of evidence required for authorization under traditional premarket review pathways is higher than that required for an EUA, the recommendations in the EUA templates may not be sufficient for developers seeking marketing authorization of their tests through traditional premarket review pathways. FDA can provide recommendations specific to a test developer’s situation through inquiries to [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov) or through pre-submission interactions.[^23]
Developers can use alternative approaches. FDA encourages developers to discuss any alternative technological approaches to validating their test with FDA through [CDRH-EUA-Templates@FDA.HHS.GOV](mailto:CDRH-EUA-Templates@FDA.HHS.GOV).
Additionally, FDA continues to expect certain serology tests to be independently evaluated by NIH/NCI,[^24] prior to authorization, when requested by the FDA. When performed, this additional testing can assist FDA in determining whether the EUA issuance criteria in section 564 of the FD&C Act have been met and whether FDA should authorize the test. This independent evaluation may also be used to assist FDA in determining whether the criteria for marketing authorization have been met for tests submitted through traditional premarket review pathways.
## VI. Availability of EUA Templates and Inquiries Regarding Validation
FDA has made available through download from our website[^25] a series of templates that developers may choose to use to facilitate the preparation and submission of an EUA request for various types of COVID-19 tests. The templates reflect FDA’s current thinking on validation recommendations for SARS-CoV-2 tests and the data and information that developers should submit to facilitate the EUA process. The templates provide information and recommendations, and FDA plans to update them as appropriate as more is learned about COVID-19 and more experience is gained with the EUA process for the various types of COVID-19 tests. Developers may use alternative approaches. Developers who are considering alternative approaches should consider seeking FDA’s feedback.
FDA can provide validation recommendations specific to a test developer’s situation both for those seeking EUA and for those seeking marketing authorization through traditional review pathways. Developers can send simple inquiries to [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov) or submit a pre-EUA or pre-submission for more complex inquiries.[^26] For tests seeking marketing authorization through traditional premarket review pathways, FDA may recommend validation studies or supportive evidence in addition to the recommendations in the EUA templates.
Members of the public can submit questions about the templates to [CDRH-EUA-Templates@FDA.HHS.GOV](mailto:CDRH-EUA-Templates@FDA.HHS.GOV), or they can submit comments regarding the templates to the public docket established for this guidance.
---
[^1]: Secretary of Health and Human Services, Determination that a Public Health Emergency Exists (originally issued on Jan. 31, 2020, and subsequently renewed), available at [https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx](https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx).
[^2]: Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak (Mar. 13, 2020), available at [https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/](https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/). On February 24, 2021, there was a Presidential Declaration continuing the national emergency concerning the COVID-19 pandemic beyond March 1, 2021. See Continuation of the National Emergency Concerning the Coronavirus Disease 2019 (COVID-19) Pandemic (February 24, 2021), available at [https://www.federalregister.gov/documents/2021/02/26/2021-04173/continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic](https://www.federalregister.gov/documents/2021/02/26/2021-04173/continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic).
[^3]: Throughout this guidance, the term “diagnostic test” is generally used to refer to molecular or antigen tests, both of which can be used to diagnose infection with the SARS-CoV-2 virus. Diagnostic tests may be designed for use in various settings, such as in a CLIA-certified laboratory, at the point of care at a site covered by a laboratory’s CLIA certificate, or at home. Screening tests, which are used for testing individuals without symptoms or other reasons to suspect COVID-19, are a subset of diagnostic tests. Molecular tests detect the presence of viral RNA and antigen tests detect the presence of viral proteins that are part of the SARS-CoV-2 virus. There may also be diagnostic tests that incorporate different technologies, such as breath tests, that have a reasonable expectation of technical and clinical success. While the principles in this guidance are generally still applicable to such tests, there are fewer available, so different approaches may be appropriate. Therefore, FDA recommends that developers of such tests
[^12]: Under section 18115 of the CARES Act (Public Law 116-136), laboratories, including those in patient care settings operating under a CLIA Certificate of Waiver, Certificate of Compliance or Certificate of Accreditation, must report the results of COVID-19 tests to HHS or its designee, in such form and manner as the Secretary may prescribe, during the declared public health emergency. For additional information on the laboratory data reporting guidance and FAQs from HHS, please see: [HHS Guidance](https://www.hhs.gov/coronavirus/testing/covid-19-diagnostic-data-reporting/index.html).
[^13]: [FDA Notification Lists](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/notifications-and-emergency-use-authorizations-faqs-testing-sars-cov-2)
[^14]: LDTs are typically considered tests that are designed, manufactured, and used within a single laboratory that is certified under CLIA and meets the requirements to perform tests of high complexity.
[^15]: This does not apply to EUA requests for which FDA has already notified the test developer by email that FDA declines to review, declines to issue, or otherwise decides not to authorize the test for any reason, including lack of response or a determination that there is a lack of adequate data to support authorization. Developers of such tests were generally expected to cease distributing, marketing, and offering their tests within 15 calendar days of receiving such an email.
[^16]: Other modifications, including new specimen types, test settings (e.g., point-of-care, home testing), and new patient populations (e.g., asymptomatic individuals), among others, do not fall under this policy.
[^17]: FDA generally considers equivalent performance to be where the LoD of the modified test (using the same validation material used in the LoD study described in the authorized test’s Instructions For Use (IFU)) is within 3x of the LoD established in the authorized test’s IFU or that the LoD of the modified test is within 3x of the LoD of the authorized test in a direct comparison LoD study.
[^18]: This applies to modifications to any EUA-authorized diagnostic test, including a laboratory’s own test with an EUA or a purchased kit from a commercial manufacturer with an EUA, but does not apply to modifications of authorized home collection kits.
[^19]: For the purposes of this guidance, all nucleic acid amplification tests are considered to have the same technology.
[^20]: Other modifications, including new specimen types, test settings (e.g., point-of-care, home testing), and new patient populations (e.g., asymptomatic individuals), among others, do not fall under this policy.
[^21]: FDA generally considers equivalent performance to be where the LoD of the modified test (using the same validation material used in the LoD study described in the authorized test’s Instructions For Use (IFU)) is within 3x of the LoD established in the authorized test’s IFU or that the LoD of the modified test is within 3x of the LoD of the authorized test in a direct comparison LoD study.
[^22]: See [FDA EUA Guidance](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas).
[^23]: See FDA Guidance document “Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program,” available at: [FDA Guidance](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program).
[^24]: The FDA is working with the NIH, the Centers for Disease Control and Prevention (CDC), and BARDA to assess the performance of certain commercial manufacturers’ serology tests. As part of this project, the FDA, working with partnering agencies, has designed a performance assessment protocol that offers a mechanism for an independent evaluation of certain lateral flow and certain enzyme-linked immunosorbent assay (ELISA) or similar technology-based SARS-CoV-2 antibody tests in a laboratory environment. Under this protocol, each test evaluated at the NIH/NCI will be evaluated with a well-characterized sample panel consisting of positive and negative plasma and/or serum samples. The approach represents a balanced attempt to provide a reasonable understanding of the potential performance of a significant number of the tests within a short time period. Performance results are considered during FDA’s review of an EUA request for the test.
[^25]: See [FDA EUA Guidance](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas).
[^26]: See FDA Guidance document “Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program,” available at: [FDA Guidance](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program).
# 9,097 2022-11-01_FDA Letter - Repeat Testing Revision Letter.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2022-11-01_FDA Letter - Repeat Testing Revision Letter.md
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summary_short: The FDA “Repeat Testing Revision Letter” (November 1, 2022) revises all EUA-authorized SARS-CoV-2 antigen tests to require updated serial testing frequencies based on new clinical evidence. It mandates labeling changes specifying at least two tests over three days for symptomatic individuals and at least three tests over five days for asymptomatic individuals, while removing prior post-authorization study requirements. It standardizes consumer, healthcare provider, and digital app instructions to emphasize that negative antigen results are presumptive and that repeat testing is essential for accuracy.
CONTENT
November 1, 2022
To:
Developers of Antigen In Vitro Diagnostics (IVDs) Authorized for Emergency Use for Coronavirus Disease 2019 (COVID-19) as of Today’s Date
Re:
Revisions Related to Serial (Repeat) Testing for the EUAs of Antigen IVDs
On February 4, 2020, pursuant to Section 564(b)(1)(C) of the Federal Food, Drug, and Cosmetic Act (the Act) (21 U.S.C. § 360bbb-3(b)(1)(C)), the Secretary of the Department of Health and Human Services (HHS) determined that there is a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad, and that involves the virus that causes COVID-19. Pursuant to Section 564 of the Act, and on the basis of such determination, the Secretary of HHS then declared that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the virus that causes COVID-19 subject to the terms of any authorization issued under Section 564(a) of the Act. [^1] FDA subsequently authorized the emergency use of numerous in vitro diagnostics (IVDs) for detection and/or diagnosis of SARS-CoV-2, the virus that causes COVID-19. [^2]
Pursuant to Section 564 of the Act, and in response to new data regarding performance of antigen tests from a study assessing at-home COVID-19 antigen test performance (“the antigen study”), [^3] FDA is revising the authorized uses [^4] and requiring updates to product labeling of all tests that are within the scope of this letter. This revision also establishes one additional Condition of Authorization, and eliminates one Condition of Authorization, on EUAs that are within the scope of this revision (Section I).
The additional condition of authorization established by this revision concerns updates to the authorized labeling [^5] to reflect the revised authorized use for tests that are within the scope of this revision. FDA’s determination that the Condition of Authorization established by this revision is necessary or appropriate to protect the public health is based on the available scientific evidence and FDA’s continuing efforts to evaluate the performance of authorized antigen IVDs with respect to the use of serial testing. The eliminated condition of authorization concerns the collection of additional data to evaluate the performance of authorized antigen IVDs with respect to the use of serial testing. FDA’s determination that the Condition of Authorization eliminated by this revision is no longer necessary or appropriate to protect the public health in light of the antigen study.
Having concluded that the revisions to the EUAs of tests that are within the scope of this letter (section I) are appropriate to protect the public health or safety, I am hereby revising all such EUAs pursuant to Section 564(g)(2)(C), including to revise the authorized use and to establish the additional condition set forth in this letter as permitted by Section 564(e) of the Act. This action is based on the available scientific evidence [^6] on the impact of serial testing on the performance of SARS-CoV-2 antigen tests.
## I. Scope of this Revision
This letter revises all current EUAs for antigen SARS-CoV-2 IVD devices [^7] as of today’s date by:
1. Revising the authorized use to be for serial testing at least twice over three days for individuals with symptoms of COVID-19 and, for tests previously authorized for testing individuals without symptoms, revising the authorized use to be for serial testing at least three times over five days for individuals without symptoms of COVID-19, as set forth in Appendix A of this letter.
2. Establishing a new condition of authorization, as set forth in Section III of this letter, on such authorizations, and
3. Eliminating a condition of authorization, as set forth in Section III of this letter, on such authorizations.
This revision does not apply to EUAs for non-antigen based authorized assays (e.g., molecular, serology), EUAs for authorized IL-6 assays, EUAs for standalone specimen collection devices, or EUAs for standalone home collection kits.
All updated labeling will be added to FDA’s webpage and posted with the EUA after it is submitted to FDA as required by Condition of Authorization (1) of this letter.
## II. Waiver of Certain Requirements
This revision does not change the waiver of any requirements included in the EUAs being revised.
## III. Revisions to Conditions of Authorization
A. Pursuant to Section 564(e) of the Act, I am establishing the additional condition below with respect to repeat testing on all authorized tests within this letter’s scope.
**Developer (You)**
1. You must update your authorized labeling to reflect the revised authorized use in Appendix A and as set forth in Appendix B of this letter by submitting your proposed updated labeling to FDA as a supplement to your EUA within 10 business days of today’s date, unless otherwise agreed to by the Division of Microbiology (DMD)/Office of Health Technology 7 (OHT7)-Office of In Vitro Diagnostics/Office of Product Evaluation and Quality (OPEQ)/Center for Devices and Radiological Health (CDRH). Following FDA’s concurrence with the supplement, you must update your electronic labeling and electronic/mobile applications (apps) within 20 business days. You must update your paper labeling within 30 business days of FDA’s concurrence and all tests distributed subsequently must be accompanied by the updated paper labeling.
B. Pursuant to section 564(g)(2)(C) of the Act, and in consideration of the establishment of Condition of Authorization (1) above, I am eliminating the following condition (or similar condition) from EUAs within the scope (section I above):
**Developer (You)**
You must evaluate the clinical performance of your product to support the serial screening claim in an FDA agreed upon post authorization clinical evaluation study within 4 months of the date of this letter (unless otherwise agreed to with DMD/OHT7/OPEQ/CDRH). After submission to and concurrence with the data by FDA, you must update the authorized labeling to reflect the additional testing. Such labeling updates will be made in consultation with, and require concurrence of, DMD/OHT7/OPEQ/CDRH.
Sincerely,
____________________
Namandjé N. Bumpus, Ph.D.
Chief Scientist
Food and Drug Administration
Enclosure
## Appendix A
### Revised Authorized Uses
The authorized uses for tests that are within the scope (Section I) of this letter are revised as follows:
1. Where a test was previously authorized for testing of symptomatic individuals (e.g., within the first [number specific to each test] days of symptom onset), the test is now authorized for use at least twice over three days with at least 48 hours between tests.
2. Where a test was previously authorized for testing of asymptomatic individuals (e.g., individuals without symptoms or other epidemiological reasons to suspect COVID-19), the test is now authorized for use at least three times over five days with at least 48 hours between tests.
## Appendix B
### Required Changes to Authorized Labeling
As required by Condition of Authorization (1), you must update your authorized labeling to include the labeling elements, sections, and statements below:
#### 1. Intended Use:[^8]
In addition to name, technology, analyte specific information and other validated claims, the Intended Use must include the updated frequency of testing for symptomatic and asymptomatic individuals (as applicable).
- For tests referenced in Appendix A, #1, this means including language that the test is for serial testing for use at least twice over three days with at least 48 hours between tests;
- For tests referenced in Appendix A, #2, this means including language that the test is for serial testing for use at least three times over five days with at least 48 hours between tests and removing language regarding testing at least twice over two or three days with at least 24 and no more than 36 hours between tests.
In addition, the Intended Use must include the following statements:
- “negative results are presumptive”
- “The [Test Name] is only for in vitro diagnostic use under the Food and Drug Administration’s Emergency Use Authorization. This product has not been FDA cleared or approved.”
#### 2. Outer Box and Subassembly Labeling (as applicable):
- Expiration date (sticker): Based on component of kit with the earliest expiration date
- Summary of box contents
- Items necessary to use the test but not provided in the test kit: [e.g., access to computer/smartphone, internet, email account]
- Storage temperature
- Summary of how the kit works
Statements that must be present on the outer box:
- For Emergency Use Authorization (EUA) only
- For in vitro diagnostic use
- In the USA, this product has not been FDA cleared or approved, but has been authorized by FDA under an EUA.
- This product has been authorized only for the detection of proteins from SARS-CoV-2 [for multi-analyte tests please insert the additional on-panel analytes, e.g., influenza A/B], not for any other viruses or pathogens.
- The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
- Determining a negative result requires multiple tests. You may need to purchase additional tests to perform serial (repeat) testing. This test is more likely to give you a false negative result when you have COVID-19 than a lab-based molecular test.
#### 3. Instructions for Use
##### a. Lay User Labeling (applicable only to tests authorized for home use)
**i.Test Interpretation**
Repeat testing is needed to improve test accuracy. Please follow the table below when interpreting test results for COVID-19.
| Status on First Day of Testing | First Result Day 1 | Second Result Day 3 | Third Result Day 5 | Interpretation |
|-------------------------------|-------------------|-------------------|------------------|----------------|
| With Symptoms | Positive | N/A | N/A | Positive for COVID-19 |
| With Symptoms | Negative | Positive | N/A | Positive for COVID-19 |
| With Symptoms | Negative | Negative | N/A | Negative for COVID-19 |
| Without Symptoms | Positive | N/A | N/A | Positive for COVID-19 |
| Without Symptoms | Negative | Positive | N/A | Positive for COVID-19 |
| Without Symptoms | Negative | Negative | Positive | Positive for COVID-19 |
| Without Symptoms | Negative | Negative | Negative | Negative for COVID-19 |
||
Results should be considered in the context of an individual’s recent exposures, history, and the presence of clinical signs and symptoms consistent with COVID-19.
***COVID-19 Positive (+)***
If the Control (C) line and the Test (T) line are visible, the test is positive. Any faint visible \[*color*\] test (T) line with the control line (C) should be read as positive.
**You do not need to perform repeat testing if you have a positive result at any time.**
A positive test result means that the virus that causes COVID-19 was detected in your sample and it is very likely you have COVID-19 and are contagious. Please contact your doctor/primary care physician or your local health authority immediately and adhere to the local guidelines regarding self-isolation. There is a very small chance that this test can give a positive result that is incorrect (a false positive).
***COVID-19 Negative (-)***
If the Control (C) line is visible, but the Test (T) line is not visible, the test is negative.
**To increase the chance that the negative result for COVID-19 is accurate, you should:**
- **Test again in 48 hours if you have symptoms on the first day of testing.**
- **Test 2 more times at least 48 hours apart if you do not have symptoms on the first day of testing.**
A negative test result indicates that the virus that causes COVID-19 was not detected in yoursample. Anegativeresultispresumptive, meaning itisnotcertain thatyou do nothave COVID-19. You may still have COVID-19 and you may still be contagious. There is a higherchanceoffalsenegativeresultswith antigen testscompared to laboratory-based tests such as PCR. If you test negative and continue to experience COVID-19-like symptoms, (e.g., fever, cough, and/or shortness of breath) you should seek follow up care with your health care provider.
***Invalid***
If the control (C) line is not visible, the test is invalid. Re-test with a new swab and new test device.
**ii. How to Use This Test**
The Lay User labeling must include a specific section “How to Use this Test” with the following information:
- Serial testing should be performed in all individuals with negative results; individuals with symptoms of COVID-19 and initial negative results should be tested again after 48 hours. Individuals without symptoms of COVID-19, and with initial negative results, should be tested again after 48 hours and, if the 2nd test is also negative, a 3rd time after an additional 48 hours. You may need to purchase additional tests to perform this serial (repeat) testing.
- If you test negative but continue to have symptoms of COVID-19, and both your first and second tests are negative, you may not have COVID-19, however you should follow-up with your healthcare provider.
- If your test is positive, then proteins from the virus that causes COVID-19 have been found in your sample and you likely have COVID-19.
**iii. Warnings, Precautions, and Safety Information**
The Lay User labeling must include the following warnings, precautions and/or safety information:
- Read all instructions carefully before performing the test. Failure to follow the instructions may result in inaccurate test results.
- In the USA, this product has not been FDA cleared or approved, but has been authorized by FDA under an Emergency Use Authorization. This product has been authorized only for the detection of proteins from SARS-CoV-2, not for any other viruses or pathogens. The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
- Serial testing should be performed in individuals with negative results at least twice over three days (with 48 hours between tests) for symptomatic individuals and three times over five days (with at least 48 hours between tests) for asymptomatic individuals. You may need to purchase additional tests to perform this serial (repeat) testing.
- An anterior nasal swab sample can be self-collected by an individual age \[*X*\] years and older. Children age 2 to \[*X*\] years should be tested by an adult.
- Do not use on anyone under 2 years of age.
- Wear a safety mask or other face-covering when collecting a specimen from a child or another individual.
- Do not use if any of the test kit contents or packaging is damaged.
- Test components are single-use. Do not re-use.
- Do not use kit past its expiration date.
- Do not touch the swab tip.
- Once opened, the test card should be used within \[*X*\] minutes.
- Do not read test results before \[*X*\] minutes or after \[*Y*\] minutes. Results read before \[*X*\] minutes or after \[*Y*\] minutes may lead to a false positive, false negative, or invalid result.
- If applicable: Keep testing kit and kit components away from children and pets before and after use. Avoid contact with your \[e.g., *skin, eyes, nose, or mouth*\]. Do not ingest any kit components. The reagent solution contains harmful chemicals (see table below). If the solution contacts your \[e.g., *e.g., skin, eyes, nose, or mouth\]*, flush with large amounts of water.
**If irritation persists, seek medical advice:** [**https://www.poisonhelp.org**](https://www.poisonhelp.org/) **or1-800-222-1222**. *\[Note: Please do not use the following website in your labeling:https://www.poison.org/contact-us](https://www.poison.org/contact-us). Also, please populate the following table as appropriate for your device and per FDA toxicological assessment of your device:*\]
| Chemical Name | GHS Code for each Ingredient | Concentrations |
|--------------|----------------------------|----------------|
| e.g., Microcide III | H315, skin irritation | 0.2% |
||
|
- For more information on EUAs please visit: [https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization)
- For the most up to date information on COVID-19, please visit: [www.cdc.gov/COVID19](https://www.cdc.gov/COVID19)
**iv. Limitations**
- There is a higher chance of false negative results with antigen tests than with laboratory-based molecular tests due to the sensitivity of the test technology. This means that there is a higher chance this test will give a false negative result in an individual with COVID-19 as compared to a molecular test, especially in samples with low viral load.
- The performance of this test was established based on the evaluation of a limited number of clinical specimens collected between [month, year and month, year]. The clinical performance has not been established for all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation. Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2 and their prevalence, which change over time.
- All COVID-19 antigen test negative results are presumptive and confirmation with a molecular assay may be necessary. If you continue to have symptoms of COVID-19, and both your first and second tests are negative, you may not have COVID-19, however you should follow-up with a healthcare provider.
- If the test is positive, then proteins from the virus that causes COVID-19 have been found in the sample and you likely have COVID-19.
- This test is read visually and has not been validated for use by those with impaired vision or color-impaired vision.
- Incorrect test results may occur if a specimen is incorrectly collected or handled.
**v. Frequently Asked Questions (FAQ):**
The following FAQ section should be added to the Lay User IFU (and, if applicable, the QRI) for those Lay User IFUs that also contain the information typically found in a Patient Fact Sheet for OTC tests:
WHAT ARE THE KNOWN AND POTENTIAL RISKS AND BENEFITS OF THE TEST?
Potential risks include:
- Possible discomfort during sample collection.
- Possible incorrect test result (see Warnings and Result Interpretation sections for more information).
Potential benefits include:
- The results, along with other information, can help you and your healthcare provider make informed recommendations about your care.
- The results of this test may help limit the potential spread of COVID-19 to your family and others in your community.
For more information on EUAs go here: [https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization)
**WHAT IS THE DIFFERENCE BETWEEN AN ANTIGEN AND MOLECULAR TEST?**
There are different kinds of tests for the SARS-CoV-2 virus that causes COVID-19. Molecular tests detect genetic material from the virus. Antigen tests, such as the [Test Name], detect proteins from the virus. Due to the lower sensitivity of antigen tests, there is a higher chance this test will give you a false negative result when you have COVID-19 than a molecular test would.
**HOW ACCURATE IS THIS TEST?**
Clinical studies have shown that antigen tests more accurately determine whether you are infected with the virus that causes COVID-19 when taken multiple times across several days. Repeat testing improves test accuracy. This serial testing approach is recommended to minimize the risk of incorrect results. For more information on the performance of the test and how the performance may apply to you, please refer to the performance data in the Healthcare Provider Instructions for Use (IFU), available at [insert developer’s website’s address].
**WHAT IF I HAVE A POSITIVE TEST RESULT?**
A positive result means that it is very likely you have COVID-19 because proteins from the virus that causes COVID-19 were found in your sample. You should self-isolate from others and contact a healthcare provider for medical advice about your positive result.
**WHAT IF I HAVE A NEGATIVE TEST RESULT?**
A negative test result indicates that antigens from the virus that causes COVID-19 were not detected in your sample. However, if you have symptoms of COVID-19, and your first test is negative, you should test again in 48 hours since antigen tests are not as sensitive as molecular tests. If you do not have symptoms and received a negative result, you should test at least two more times with 48 hours in between tests for a total of three tests. If you have a negative result, it does not rule out SARS-CoV-2 infection; you may still be infected and you may still infect others. It is important that you work with your healthcare provider to help you understand the next steps you should take.
**WHAT DOES AN INVALID TEST RESULT MEAN?**
An invalid result means the test was not able to tell if you have COVID-19 or not. If the test is invalid, a new swab should be used to collect a new nasal specimen and you should test again with a new test.
**IMPORTANT**
Do not use this test as the only guide to manage your illness. Consult your healthcare provider if your symptoms persist or become more severe.
Individuals should provide all results obtained with this product to their healthcare provider.
##### b. HCP Labeling
**i. Test Interpretation**
Repeat testing is needed to improve test accuracy. Please follow the table below when interpreting test results.
| Status on first day of Testing | First Result Day 1 | Second Result Day 3 | Third Result Day 5 | Interpretation |
|-------------------------------|--------------------|---------------------|-------------------|-----------------------------|
| With Symptoms | Positive | N/A | N/A | Positive for COVID-19 |
| With Symptoms | Negative | Positive | N/A | Positive for COVID-19 |
| With Symptoms | Negative | Negative | N/A | Negative for COVID-19 |
| Without Symptoms | Positive | N/A | N/A | Positive for COVID-19 |
| Without Symptoms | Negative | Positive | N/A | Positive for COVID-19 |
| Without Symptoms | Negative | Negative | Positive | Positive for COVID-19 |
| Without Symptoms | Negative | Negative | Negative | Negative for COVID-19 |
||
Results should be considered in the context of an individual’s recent exposures, history, and the presence of clinical signs and symptoms consistent with COVID-19.
**COVID-19 Positive (+)**
If the Control (C) line and the Test (T) line are visible, the test is positive. Any faint visible [color] test (T) line with the control line (C) should be read as positive.
**Repeat testing does not need to be performed if patients have a positive result at any time.**
A positive test result means that the virus that causes COVID-19 was detected in the sample, and it is very likely the individual has COVID-19 and is contagious. Please contact the patient’s doctor/primary care physician (if applicable) and the local health authority immediately and instruct your patient to adhere to the local guidelines regarding self-care.
Isolation. There is a very small chance that this test can give a positive result that is incorrect (a false positive).
Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Individuals who test positive with the [Test Name] should self-isolate and seek follow up care with their physician or healthcare provider as additional confirmatory testing with a molecular test for positive results may also be necessary, if there is a low likelihood of COVID-19, such as in individuals without known exposures to COVID-19 or residing in communities with low prevalence of infection.
**COVID-19 Negative (-)**
If the Control (C) line is visible, but the Test (T) line is not visible, the test is negative.
**To increase the chance that the negative result for COVID-19 is accurate, you should:**
- **Test again in 48 hours if the individual has symptoms on the first day of testing.**
- **Test 2 more times at least 48 hours apart if the individual does not have symptoms on the first day of testing.**
A negative test result indicates that the virus that causes COVID-19 was not detected in the sample. A negative result does not rule out COVID-19. There is a higher chance of false negative results with antigen tests compared to laboratory-based tests such as PCR tests. If the test is negative but COVID-19-like symptoms, e.g., fever, cough, and/or shortness of breath continue, follow up testing for SARS-CoV-2 with a molecular test or testing for other respiratory disease should be considered. If applicable, seek follow up care with the primary health care provider.
All negative results should be treated as presumptive and confirmation with a molecular assay may be necessary if there is a high likelihood of SARS-CoV-2 infection, such as in an individual with a close contact with COVID-19 or with suspected exposure to COVID-19 or in communities with high prevalence of infection. Negative results do not rule out SARS-CoV-2 infection and should not be used as the sole basis for treatment or patient management decisions, including infection control decisions.
***Invalid***
If the control (C) line is not visible, the test is invalid. Re-test with a new swab and new test device.
**ii. Warnings, Precautions, and Safety Information**
The following Warnings, Precautions, and Safety Information should be included in the full HCP IFU; in addition, the warning statements of the first three bullet points below should also be included in the Quick Reference Guide (QRI) of all tests authorized for point-of-care (PoC) use.
- Read all instructions carefully before performing the test. Failure to follow the instructions may result in inaccurate test results.
- In the USA, this product has not been FDA cleared or approved, but has been authorized by FDA under an Emergency Use Authorization. This product has been authorized only for the detection of proteins from SARS-CoV-2\[*for multi-analyte tests please insert the additional on-panel analytes, e.g., influenza A/B*\], not for any other viruses or pathogens. The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
- **Serial testing should be performed in individuals with negative results at least twice over three days (with 48 hours between tests) for symptomatic individuals and three times over five days (with at least 48 hours between tests) for asymptomatic individuals. You may need to purchase additional tests to perform this serial (repeat) testing**.
- An anterior nasal swab sample can be self-collected by an individual age \[*X*\] years and older. Children age 2 to \[*X*\] years should be tested by an adult.
- Do not use on anyone under 2 years of age.
- Wear a safety mask or other face-covering when collecting a specimen from a child or another individual.
- Do not use if any of the test kit contents or packaging is damaged.
- Test components are single-use. Do not re-use.
- Do not use kit past its expiration date.
- Do not touch the swab tip.
- Once opened, the test card should be used within \[*X*\] minutes.
- **Do not read test results before \[*X*\] minutes or after \[*Y*\] minutes. Results read before \[*X*\] minutes or after \[*Y*\] minutes may lead to a false positive, false negative, or invalid result.**
- **Keep testing kit and kit components away from children and pets before and after use. Avoid contact with your \[*e.g., skin, eyes, nose, or mouth\]*. Do not ingest any kit components. The reagent solution contains harmful chemicals (see table below). If the solution contacts your \[e.g., *skin, eyes, nose, or mouth\]*, flush with large amounts of water. If irritation persists, seek medical advice:** [**https://www.poisonhelp.org**](https://www.poisonhelp.org/) **or 1-800-222-1222**.
*\[Note: Please do not use the following website in your labeling:. Also, please populate the following table as appropriate for your device and per FDA toxicological assessment of your device:*\]
| Chemical Name | GHS Code for each Ingredient | Concentrations |
|--------------|----------------------------|----------------|
| e.g., Microcide III | H315, skin irritation | 0.2% |
||
- For more information on EUAs please visit: [https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization)
- For the most up to date information on COVID-19, please visit: [www.cdc.gov/COVID19](http://www.cdc.gov/COVID19)
**iii. Limitations**
- The performance of this test was established based on the evaluation of a limited number of clinical specimens collected between \[*month, year and month, year*\]. The clinical performance has not been established for all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation. Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of SARS-CoV-2 and their prevalence, which change over time.
- There is a higher chance of false negative results with antigen tests than with laboratory-based molecular tests due to the sensitivity of the test technology. This means that there is a higher chance this test will give a false negative result in an individual with COVID-19 as compared to a molecular test, especially in samples with low viral load.
- All COVID-19 antigen test negative results are presumptive and confirmation with a molecular assay may be necessary.
- If the patient continues to have symptoms of COVID-19, and both the patient’s first and second tests are negative, the patient may not have COVID-19, however additional follow-up may be needed.
- If the test is positive, then proteins from the virus that causes COVID-19 have been found in the sample and the individual likely has COVID-19.
- This test is read visually and has not been validated for use by those with impaired vision or color-impaired vision.
- Incorrect test results may occur if a specimen is incorrectly collected or handled.
- This test detects both viable (live) and nonviable SARS-CoV-2. Test performance
depends on the amount of virus (antigens) in the sample and may or may not correlate with viral culture results performed on the same sample.
**iv. Performance Section of HCP labeling**
A prospective clinical study was conducted between January 2021 and May 2022 as a component of the Rapid Acceleration of Diagnostics (RADx) initiative from the National Institutes of Health (NIH). A total of 7,361 individuals were enrolled via a decentralized clinical study design, with a broad geographical representation of the United States. Per inclusion criteria, all individuals were asymptomatic upon enrollment in the study and at least 14 days prior to it and did not have a SARS-CoV-2 infection in the three months prior to enrollment. Participants were assigned to one of three EUA authorized SARS-CoV-2 OTC rapid antigen tests to conduct serial testing (every 48 hours) for 15 days. If an antigen test was positive, the serial-antigen testing result is considered positive.
At each rapid antigen testing time point, study subjects also collected a nasal swab for comparator testing using a home collection kit (using a 15-minute normalization window between swabs). SARS-CoV-2 infection status was determined by a composite comparator method on the day of the first antigen test, using at least two highly sensitive EUA RT-PCRs. If results of the first two molecular test were discordant a third highly sensitive EUA RT-PCR test was performed, and the final test result was based upon the majority rule.
Study participants reported symptom status throughout the study using the MyDataHelps app. Two-day serial antigen testing is defined as performing two antigen tests 36 - 48 hours apart. Three-day serial antigen testing is defined as performing three antigen tests over five days with at least 48 hours between each test.
Out of the 7,361 participants enrolled in the study, 5,609 were eligible for analysis. Among eligible participants, 154 tested positive for SARS-CoV-2 infection based on RT-PCR, of which 97 (62%) were asymptomatic on the first day of their infection, whereas 57 (39%) reported symptoms on the first day of infection. Pre-symptomatic subjects were included in the positive percent agreement (PPA) of asymptomatic individuals, if they were asymptomatic on the first day of antigen testing, regardless of whether they developed symptoms at any time after the first day of testing.
Performance of the antigen test with serial testing in individuals is described in Table YYY.
**Table YYY:** Data establishing PPA of COVID-19 antigen serial testing compared to the molecular comparator single day testing throughout the course of infection with serial testing. Data is from all antigen tests in study combined.
| DAYS AFTER FIRST PCR POSITIVE TEST RESULT | ASYMPTOMATIC ON FIRST DAY OF TESTING | | | SYMPTOMATIC ON FIRST DAY OF TESTING | | |
|------------------------------------------|---------------------------------------|---------------------------------------|---------------------------------------|---------------------------------------|---------------------------------------|---------------------------------------|
| | Ag Positive / PCR Positive (Antigen Test Performance % PPA) | | | | | |
| | 1 Test | 2 Tests | 3 Tests | 1 Test | 2 Tests | 3 Tests |
| 0 | 9/97 (9.3%) | 35/89 (39.3%) | 44/78 (56.4%) | 34/57 (59.6%) | 47/51 (92.2%) | 44/47 (93.6%) |
| 2 | 17/34 (50.0%) | 23/34 (67.6%) | 25/32 (78.1%) | 58/62 (93.5%) | 59/60 (98.3%) | 43/43 (100%) |
| 4 | 16/21 (76.2%) | 15/20 (75.0%) | 13/15 (86.7%) | 55/58 (94.8%) | 53/54 (98.1%) | 39/40 (97.5%) |
| 6 | 20/28 (71.4%) | 21/27 (77.8%) | 16/18 (88.9%) | 27/34 (79.4%) | 26/33 (78.8%) | 22/27 (81.5%) |
| 8 | 13/23 (56.5%) | 13/22 (59.1%) | 4/11 (36.4%) | 12/17 (70.6%) | 12/17 (70.6%) | 7/11 (63.6%) |
| 10 | 5/9 (55.6%) | 5/8 (62.5%) | - | 4/9 (44.4%) | 3/7 (42.9%) | - |
||
1 Test = one (1) test performed on the noted days after first PCR positive test result. Day 0 is the first day of documented infection with SARS-CoV-2.
2 Tests = two (2) tests performed an average of 48 hours apart. The first test performed on the indicated day and the second test performed 48 hours later.
3 Tests = three (3) tests performance an average of 48 hours apart. The first test performed on the indicated day, the second test performed 48 hours later, and a final test performed 48 hours after the second test.
#### 4. Fact Sheets
The Fact Sheet for Healthcare Providers (HCPs) and Fact Sheet for Patients and Fact Sheet for Individuals will be updated by FDA consistent with this revision, and FDA will provide them to you.
#### 5. Electronic Applications (e.g., Cell Phone Apps)
Electronic applications (apps) should include a prominently placed warning for the requirement of repeat testing after a negative test result. App related software should be updated to accommodate the following minimal information:
- Test interpretation as outlined in section 3. a. i. above.
- How to Use This Test as outlined in section 3. a. ii. above
- Warning Statements:
- In the USA, this product has not been FDA cleared or approved, but has been authorized by FDA under an Emergency Use Authorization. This product has been authorized only for the detection of proteins from SARS-CoV-2, not for any other viruses or pathogens. The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
- **Serial testing should be performed in individuals with negative results at least twice over three days (with 48 hours between tests) for symptomatic individuals and three times over five days (with at least 48 hours between tests) for asymptomatic individuals. You may need to purchase additional tests to perform this serial (repeat) testing.**
- There is a higher chance of false negative results with antigen tests than with laboratory-based molecular tests due to the sensitivity of the test technology. This means that there is a higher chance this test will give a false negative result in an individual with COVID-19 as compared to a molecular test, especially in samples with low viral load.
- All COVID-19 antigen test negative results are presumptive and confirmation with a molecular assay may be necessary. If you continue to have symptoms of COVID-19, and both your first and second tests are negative, you may not have COVID-19, however you should follow-up with a healthcare provider.
- This test is read visually and has not been validated for use by those with impaired vision or color-impaired vision.
- A link to an FAQ document as described in section 3. a. v. above.
---
[^1]: U.S. Department of Health and Human Services, *Determination of a Public Health Emergency and Declaration that Circumstances Exist Justifying Authorizations Pursuant to Section 564(b) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3*. 85 FR 7316 (February 7, 2020)
[^2]: In Vitro Diagnostics EUAs: [FDA](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas)
[^3]: [Performance of Screening for SARS-CoV-2 Using Rapid Antigen Tests to Detect Incidence of Symptomatic and Asymptomatic SARS-CoV-2 Infection: findings from the Test Us at Home prospective cohort study](https://www.medrxiv.org/content/10.1101/2022.08.05.22278466v1)
[^4]: Generally, the authorized uses of antigen tests are described in, among other locations, the “indication” discussion and “authorized product detail” section in the letters of authorization, and in an “intended use” section in the authorized labeling.
[^5]: Authorized labeling impacted by the additional condition of authorization established by this letter includes some combination of the following documents: Instructions for Use (IFU), Quick Reference Instructions (QRI), laboratory Standard Operating Procedures (SOPs), electronic labeling and applications, and Fact Sheets. Note that the Fact Sheets are generated by FDA who will update these documents after it receives the supplement request to update the test’s other labeling consistent with this revision.
[^6]: [Performance of Screening for SARS-CoV-2 using Rapid Antigen Tests to Detect Incidence of Symptomatic and Asymptomatic SARS-CoV-2 Infection: findings from the Test Us at Home prospective cohort study](https://www.medrxiv.org/content/10.1101/2022.08.05.22278466v1)
[^7]: [Please see the following link for currently authorized Antigen IVD devices for SARS-CoV-2](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-antigen-diagnostic-tests-sars-cov-2)
[^8]: As discussed in footnote 4, generally the authorized uses of antigen tests are described in, among other locations, an “intended use” section in the authorized labeling. If such uses are discussed elsewhere in the authorized labeling, you must also make appropriate updates to that labeling to reflect the revised authorized uses.
# 394 2022-11-01_FDA Website - Antigen EUA Revisions for Serial Repeat Testing.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2022-11-01_FDA Website - Antigen EUA Revisions for Serial Repeat Testing.md
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title: FDA Website - Antigen EUA Revisions for Serial Repeat Testing
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web_url: https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-antigen-diagnostic-tests-sars-cov-2#SerialTesting
summary_short: The Antigen EUA Revisions for Serial Repeat Testing summarizes FDA’s November 1, 2022 revision updating authorized uses and labeling for all authorized SARS-CoV-2 antigen tests to emphasize repeat testing after a negative result. It sets new serial-testing instructions—at least twice over three days for symptomatic use and at least three times over five days for asymptomatic use, with 48 hours between tests—and requires EUA holders to submit supplemental requests with updated labeling. The revision also adds one new Condition of Authorization and removes one that FDA determined was no longer needed.
CONTENT
On November 1, 2022, the FDA revised the authorized uses and required updates to product labeling regarding repeat, or serial, testing, for all currently authorized SARS-CoV-2 antigen tests. The revised Letter of Authorization establishes one additional Condition of Authorization and also eliminates one Condition of Authorization that is no longer needed.
This action is in response to available data about the performance of COVID-19 antigen tests showing that repeat testing after a negative COVID-19 antigen test result increases the chance of an accurate result in people with and without symptoms and could help prevent people from unknowingly spreading the SARS-CoV-2 virus to others. The FDA communicated recommendations consistent with this revision in the August 11, 2022, Safety Communication: [At-Home COVID-19 Antigen Tests-Take Steps to Reduce Your Risk of False Negative](https://www.fda.gov/medical-devices/safety-communications/home-covid-19-antigen-tests-take-steps-reduce-your-risk-false-negative-results-fda-safety).
The November 1, 2022 revision requires test developers in the scope of the revision to take certain actions, including submitting a supplemental EUA request to the FDA with updated labeling to reflect the revised authorized uses, as follows:
Where a test was previously authorized for testing of symptomatic individuals (for example, within the first [number specific to each test] days of symptom onset), the test is now authorized for use at least twice over three days with at least 48 hours between tests.
Where a test was previously authorized for testing of asymptomatic individuals (for example, individuals without symptoms or other epidemiological reasons to suspect COVID-19), the test is now authorized for use at least three times over five days with at least 48 hours between tests.
[Repeat Testing Revision Letter - November 1, 2022](https://www.fda.gov/media/162799/download?attachment)
# 2,432 2022-11-17_FDA Website - At Home COVID-19 Antigen Tests-Take Steps.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2022-11-17_FDA Website - At Home COVID-19 Antigen Tests-Take Steps.md
file_date: 2022-11-17
title: FDA Website - At Home COVID-19 Antigen Tests-Take Steps
category: regulatory
subcategory: fda-policy
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web_url: https://www.fda.gov/medical-devices/safety-communications/home-covid-19-antigen-tests-take-steps-reduce-your-risk-false-negative-results-fda-safety
summary_short: The FDA safety communication on at-home COVID-19 antigen tests explains that negative results can miss infections—especially early or in asymptomatic people—and recommends serial (repeat) testing 48 hours apart to reduce false negatives. It outlines practical testing schedules (two tests if symptomatic; three tests if exposed without symptoms), notes antigen tests are generally less sensitive than molecular PCR, and cites FDA-required follow-up studies and NIH-supported data that informed EUA labeling revisions on November 1, 2022.
CONTENT
November 17, 2022, Update: The FDA took an additional action related to the need for repeat testing following a negative COVID-19 test result on COVID-19 antigen tests -- revising the emergency use authorizations (EUAs) of all authorized COVID-19 antigen tests on November 1, 2022. For details, see [FDA Actions](https://www.fda.gov/medical-devices/safety-communications/home-covid-19-antigen-tests-take-steps-reduce-your-risk-false-negative-results-fda-safety#actions) below.
Date Issued: August 11, 2022 (Updated November 17, 2022)
The U.S. Food and Drug Administration (FDA) is advising people to perform repeat testing, also called serial testing, following a negative result on any at-home COVID-19 antigen test, to reduce the risk an infection may be missed (false negative result) and to help prevent people from unknowingly spreading the SARS-CoV-2 virus to others. The FDA recommends repeat testing following a negative result whether or not you have COVID-19 symptoms.
At-home COVID-19 antigen tests detect proteins, called antigens, from the SARS-CoV-2, the virus that causes COVID-19. At-home COVID-19 antigen tests are less likely to detect the SARS-CoV-2 virus than molecular tests, such as polymerase chain reaction (PCR) tests. This is especially true early in an infection or in people who do not have COVID-19 symptoms. Currently, all at-home COVID-19 antigen tests are FDA-authorized for repeat use. This means people should use multiple tests over a certain time period, such as 2-3 days, especially when the people using the tests don't have COVID-19 symptoms. Today, the FDA is highlighting the continued need for repeat testing when people get a negative result with an at-home COVID-19 antigen test, including recommending additional testing over a longer period of time.
Over the course of the COVID-19 pandemic, public health scientists have continued to learn about the SARS-CoV-2 virus and the impact of variants on diagnostic tests that detect SARS-CoV-2. Today's recommendations are based on the latest study results from people with likely omicron infection showing that repeat testing after a negative at-home COVID-19 antigen test result increases the chance of an accurate result. COVID-19 diagnostic testing remains a cornerstone of our nation's fight against COVID-19. At-home COVID-19 antigen tests, while not perfect, provide a fast and convenient COVID-19 testing option.
Recommendations:
Before you use a COVID-19 antigen test:
Be aware that at-home COVID-19 antigen tests are less accurate than molecular tests. COVID-19 antigen tests may not detect the SARS-CoV-2 virus early in an infection, meaning testing soon after you were exposed to someone with COVID-19 could lead to a false-negative result, especially if you don't have symptoms. This is the reason why repeat testing is important.
If you plan to use at-home COVID-19 antigen tests, have several tests on hand so you can test more than once. You do not need to use the same brand of test each time for repeat testing. Visit [At-Home OTC COVID-19 Diagnostic Tests](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/home-otc-covid-19-diagnostic-tests) for a list of all FDA-authorized home tests and for more information about who can use a test and for what ages.
Be aware the FDA expects similar performance with Point of Care (POC) COVID-19 antigen tests performed at a clinic or doctor's office. A negative POC COVID-19 antigen test result should also be followed up with repeat testing and an at-home test could be used.
When you use an at-home COVID-19 antigen test:
Follow the test's step by step instructions exactly to perform the test and to read the test's results.
After you use an at-home COVID-19 antigen test:
If you receive a positive result initially or after a repeat test, this means the test detected the SARS-CoV-2 virus and you most likely have COVID-19.
Follow the [Centers for Disease Control and Prevention (CDC) guidance](https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/index.html) for people with COVID-19, including to stay home, isolate from others, and seek follow-up care with a health care provider to determine the next steps.
If you receive a negative result, the test did not detect the SARS-CoV-2 virus at the time of that test.
If you have [COVID-19 symptoms](https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html), test again 48 hours after the first negative test, for a total of at least two tests.
If you get a negative result on the second test and you are concerned that you could have COVID-19, you may choose to test again 48 hours after the second test, consider getting a laboratory molecular-based test, or call your health care provider.
If you do not have COVID-19 symptoms and believe you have been exposed to COVID-19, test again 48 hours after the first negative test, then 48 hours after the second negative test, for a total of at least three tests.
If you get a negative result on the second test, test again 48 hours after the second test.
If you get a negative result on the third test and you are concerned that you could have COVID-19, you may choose to test again using an antigen test, consider getting a laboratory molecular-based test, or call your health care provider.
If you get a positive result on any repeat test with an at-home COVID-19 antigen test, you most likely have COVID-19 and should follow the CDC guidance for people with COVID-19.
Background
[COVID-19 diagnostic tests](https://www.fda.gov/consumers/consumer-updates/covid-19-test-basics) detect the SARS-CoV-2 virus. There are at-home COVID-19 diagnostic tests that are [FDA-authorized](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization) for self-testing at home, or anywhere. The FDA has authorized both molecular and antigen COVID-19 diagnostic tests for home use.
Overall performance of at-home COVID-19 antigen tests
Most at-home COVID-19 tests are antigen tests and do not detect the SARS-CoV-2 virus as well as molecular tests, most of which are laboratory-based such as polymerase chain reaction (PCR) tests. Molecular COVID-19 tests are generally expected to detect the SARS-CoV-2 virus at least 95% of the time when someone is infected. However, at-home COVID-19 antigen tests are generally expected to detect the SARS-CoV-2 virus at least 80% of the time when someone is infected.
When you perform an at-home COVID-19 antigen test, and you get a positive result, the results are usually accurate. However, if you perform an at-home COVID-19 antigen test, you could get a false negative result. This means that the test may not detect the SARS-CoV-2 virus that is in your nasal swab sample. This could happen if you test soon after you get an infection, especially if you don't have [COVID-19 symptoms](https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html). If you receive a false negative test result, you may unknowingly spread the SARS-CoV-2 virus to others.
Studies to better understand at-home COVID-19 antigen test performance
When at-home COVID-19 antigen tests were initially FDA-authorized, the FDA knew that for people to get accurate results, test instructions would need to include directions for repeat testing. The FDA believed the best way to better understand COVID-19 infections and evaluate test accuracy was to require test developers to perform follow up studies with their tests. The studies would need to assess how well COVID-19 antigen tests could detect the SARS-CoV-2 virus, especially in people without COVID-19 symptoms. Therefore, the FDA required each at-home COVID-19 antigen test manufacturer to assess how well their test works when used by people with and without COVID-19 symptoms following repeat testing instructions.
In parallel, the FDA collaborated with the National Institutes for Health (NIH) and the University of Massachusetts Chan Medical School and together they designed a [comprehensive study](https://www.medrxiv.org/content/10.1101/2022.08.04.22278274v1) to assess at-home COVID-19 antigen test performance. The study was funded by the NIH's Rapid Acceleration Diagnostics (RADx) Program and included more than 7,000 participants. The results of the study would be available as a resource to all at-home COVID-19 antigen test manufacturers.
The study participants collected their nasal sample and performed an at-home COVID-19 antigen test. Participants who got a negative test result performed repeat testing every 48 hours, over 14 days. All participants also collected their nasal sample using a home collection kit and then sent the sample to a clinical laboratory for testing with an FDA-authorized molecular test. The study compared the performance of at-home COVID-19 antigen tests to performance of a laboratory-based molecular test. [Results from this study](https://www.medrxiv.org/content/10.1101/2022.08.05.22278466v1) show that repeat testing over a longer timeframe improves test performance and increases the likelihood that an at-home COVID-19 antigen test will detect an infection. These results have further guided the FDA's thinking that repeat testing after a negative result with an at-home COVID-19 antigen test reduces the risk of a false negative result.
FDA Actions
On November 1, 2022, based on the data discussed in this safety communication, the FDA revised the authorized uses and required updates to the labeling for all currently authorized COVID-19 antigen tests regarding repeat testing after a negative COVID-19 test result.
For additional information about the EUA revision, visit: [Antigen EUA Revisions for Serial (Repeat) Testing](https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-antigen-diagnostic-tests-sars-cov-2#SerialTesting)
For additional information about at-home tests, visit: [At-Home OTC COVID-19 Diagnostic Tests](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/home-otc-covid-19-diagnostic-tests)
The FDA is committed to assuring appropriately accurate and reliable at-home COVID-19 diagnostic tests for all Americans and will keep the public informed if significant new information about COVID-19 antigen test performance becomes available.
Reporting Problems with Your Device
If you think you had a problem with your COVID-19 test, the FDA encourages you to report the problem through the [MedWatch Voluntary Reporting Form](https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.home).
Health care personnel employed by facilities that are subject to the FDA's user facility reporting requirements should follow the reporting procedures established by their facilities.
Questions?
If you have questions, email the Division of Industry and Consumer Education (DICE) at DICE@FDA.HHS.GOV or call 800-638-2041 or 301-796-7100.
# 8,029 2023-01-12_FDA Guidance - COVID IVD Test Developers v7.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2023-01-12_FDA Guidance - COVID IVD Test Developers v7.md
file_date: 2023-01-12
title: FDA Guidance - COVID IVD Test Developers v7
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summary_short: The FDA “Policy for Coronavirus Disease-2019 Tests (Revised)” (7th edition, January 12, 2023) outlines FDA’s EUA review priorities and enforcement policies for COVID-19 diagnostic and serology tests during the section 564 emergency declaration. It explains when tests may be distributed or offered during FDA review, what disclosures and performance information should accompany non-authorized tests, and how high-complexity CLIA labs can make certain modifications to EUA-authorized molecular tests without a new EUA if validated and limited to that lab.
CONTENT
***INTERNAL TITLE:*** Policy for Coronavirus Disease-2019 Tests (Revised)*
Guidance for Developers and Food and Drug Administration Staff
Document issued January 12, 2023.
This document supersedes “Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised): Guidance for Developers and Food and Drug Administration Staff” issued September 27, 2022.
U.S. Department of Health and Human Services
Food and Drug Administration
Center for Devices and Radiological Health
*This is the seventh edition of this guidance, which originally issued February 29, 2020, and was subsequently revised on March 16, May 4, May 11, 2020, November 15, 2021, and September 27, 2022.*
## Preface
### Public Comment
Comments may be submitted at any time for Agency consideration. Submit written comments to the Dockets Management Staff (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. Submit electronic comments to [https://www.regulations.gov](https://www.regulations.gov). All comments should be identified with the docket number FDA-2020-D-0987 and complete title of the guidance in the request.
### Additional Copies
Additional copies are available from the FDA webpage titled “COVID-19-Related Guidance Documents for Industry, FDA Staff, and Other Stakeholders,” available at [https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders](https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders), and the FDA webpage titled “Search for FDA Guidance Documents,” available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents](https://www.fda.gov/regulatory-information/search-fda-guidance-documents). You may also send an e-mail request to [CDRH-Guidance@fda.hhs.gov](mailto:CDRH-Guidance@fda.hhs.gov) to receive an additional copy of the guidance. Please include the document number GUI00020010 and complete title of the guidance in the request.
### Questions
For questions about this document, contact [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov).
## Table of Contents
I. Introduction ............................................................................................................................. 4
II. Background ............................................................................................................................ 5
III. Scope ..................................................................................................................................... 6
IV. Policy .................................................................................................................................... 7
A. Review of EUA Requests for COVID-19 Tests ............................................................... 7
B. State Authorization of High-Complexity CLIA-Certified Laboratories ......................... 8
C. Distribution and Offering of SARS-CoV-2 Diagnostic and Serology Tests During FDA Review .......................................................................................................................... 10
1. FDA Review of EUA Requests .................................................................................. 10
2. Recommendations Regarding Test Reports and Other Information for Tests Offered During FDA Review of EUA Requests .................................................................... 11
D. Modifications to EUA-Authorized Diagnostic COVID-19 Tests .................................. 11
1. Modifications Made After Issuance of this Updated Guidance ................................. 12
2. Certain Modifications Made Before Issuance of this Updated Guidance .................. 13
V. Validation ............................................................................................................................. 14
VI. Availability of EUA Templates and Inquiries Regarding Validation .................................. 15
## I. Introduction
FDA plays a critical role in protecting the United States from threats such as emerging infectious diseases, including the Coronavirus Disease 2019 (COVID-19) pandemic. FDA is committed to providing timely guidance to support response efforts to this pandemic.
FDA is issuing this guidance to provide FDA’s review priorities and enforcement policies regarding novel coronavirus (COVID-19) tests. Rapid detection of COVID-19 cases in the United States requires wide availability of testing to control the spread of this highly contagious infection.
The policies in this guidance are intended to remain in effect only for the duration of the declaration under section 564 of the Federal Food, Drug, and Cosmetic Act (FD&C Act) by the Secretary of Health and Human Services (HHS) on February 4, 2020, declaring that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the novel coronavirus (2019-nCoV).[^1] FDA continues to assess the evolving situation and intends to update this guidance as appropriate.
In general, FDA’s guidance documents do not establish legally enforceable responsibilities. Instead, guidances describe the Agency’s current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word _should_ in Agency guidance means that something is suggested or recommended, but not required.
## II. Background
There is currently a pandemic of respiratory disease caused by a novel coronavirus. The virus has been named “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2) and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). On January 31, 2020, the Secretary of HHS issued a declaration of a public health emergency under section 319 of the Public Health Services Act related to COVID-19 and mobilized the Operating Divisions of HHS.[^2] On February 4, 2020, the Secretary of HHS issued a declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of SARS-CoV-2 based on the HHS Secretary’s public health emergency determination under section 564(b)(1)(C) of the FD&C Act.[^3] In addition, on March 13, 2020, the President declared a national emergency in response to COVID-19.[^4]
Under section 564 of the FD&C Act, the FDA Commissioner may authorize the use of unapproved medical products, or unapproved uses of approved medical products, in certain emergency circumstances, after the HHS Secretary has made a declaration of emergency or threat justifying authorization of emergency use, to diagnose, treat, or prevent serious or life-threatening diseases or conditions caused by chemical, biological, radiological, and nuclear (CBRN) threat agents when certain criteria are met. The Emergency Use Authorization (EUA) authorities allow FDA to help strengthen the nation’s public health protections against CBRN threats by facilitating the availability and use of medical countermeasures needed during certain public health emergencies.
As of August 15, 2022, FDA has issued EUAs for more than 439 tests for COVID-19, including more than 354 diagnostic and 85 serology or other immune response tests. Further, two molecular diagnostic COVID-19 tests have been granted marketing authorization through the traditional device premarket review pathways. In the context of a public health emergency involving pandemic infectious disease, it is critically important that tests are validated because false results not only can negatively impact the individual patient but also can have a broad public health impact. False positive results for diagnostic tests, for example, can lead to unnecessary quarantine and potential further spread when presumed positive individuals are quarantined together, wasted contact tracing and testing resources, and delay in accurate diagnosis and appropriate treatment for the individual. False negative results can lead to lack of appropriate treatment for the individual and further spread of the disease.
Previous versions of this guidance described policies regarding the distribution and offering of certain tests for clinical use prior to or without an EUA. These policies were issued to help quickly increase availability of tests in the early stages of the pandemic. Unless and until an EUA is issued that authorizes additional testing environments for a specific test, under the Clinical Laboratory Improvement Amendments (CLIA), section 353 of the Public Health Service Act (42 USC 263a), use of that test is limited to laboratories that are certified under CLIA, and meet the requirements to perform tests of high complexity, and at the point-of-care (POC) when covered by such a laboratory’s CLIA certificate. Throughout this guidance, references to “high-complexity CLIA-certified laboratories” are referring to laboratories that are certified under CLIA and meet the requirements to perform tests of high complexity. These policies did not apply to at-home tests or tests with home specimen collection.
FDA has updated these policies when appropriate in response to the changing landscape of this pandemic. The previous update on November 15, 2021, explained FDA’s intent to review EUA requests for certain types of tests that FDA believed would be most beneficial at that stage of the pandemic. In addition, in the November 15, 2021, version, FDA revised the previous enforcement policies to reflect that, at that stage of the pandemic, the Agency generally expected COVID-19 tests to have been issued an EUA prior to the tests being distributed or offered.
FDA has continued to closely monitor the COVID-19 testing landscape and believes it is again appropriate to update its policies to reflect the current needs of the pandemic. As explained throughout this guidance, FDA intends to review the EUA requests for a small subset of tests based on the review priorities described in Section IV. A. Traditional marketing pathways remain available to all developers and FDA encourages developers of tests that fall outside the scope of the priorities outlined in this guidance to pursue those routes. In sum, in the September 27, 2022, update, FDA revised this guidance to update the types of COVID-19 tests for which the Agency intends to review EUA requests, to discuss the use of the traditional premarket review pathways for other types of COVID-19 tests for which the Agency does not intend to review EUA requests, and to make minor updates to the enforcement policies. In the current version of this guidance, FDA has revised the duration for which the policies in this guidance are intended to remain in effect.
## III. Scope
This guidance applies to diagnostic and serology tests for COVID-19.[^5] The policies and recommendations described in this guidance are intended to facilitate availability of tests for COVID-19 that FDA believes will be most beneficial at the current stage of the public health emergency.
FDA notes that the enforcement policies in this guidance do not address medical device reporting (MDR) under 21 CFR Part 803 for tests offered prior to authorization as described in the guidance. Developers offering such tests are expected to comply with applicable MDR requirements, including reporting of medical device events that reasonably suggest that their device may have caused or contributed to a death or serious injury, and malfunctions that would be likely to cause or contribute to a death or serious injury if they were to recur. Moreover, unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to high-complexity CLIA-certified laboratories, including testing at the point-of-care when the site is covered by the laboratory’s CLIA certificate for high complexity testing.
## IV. Policy
### A. Review of EUA Requests for COVID-19 Tests
The issuance of an EUA is discretionary. FDA’s decision to review and process an EUA request, and ultimately issue an EUA if the relevant statutory criteria are met, is based on a determination, on a case-by-case basis, that such action is necessary to protect the public health in an emergency. It is an authorization that the government “may” issue when necessary to protect the public health in an emergency (see section 564(a)(1) of the FD&C Act (21 U.S.C. 360bbb-3(a)(1)), which states, in relevant part, “subject to the provisions of this section, the Secretary may authorize the introduction into interstate commerce…a drug, device, or biological product intended for use in an actual or potential emergency”). FDA’s January 2017 guidance, *Emergency Use Authorization of Medical Products and Related Authorities,* describes factors that FDA intends to use in its prioritization of EUA requests, such as the public health need for the product, the availability of the product, the availability and adequacy of the information concerning the likelihood that the product may be safe and effective in preventing, treating, or diagnosing the condition, and whether the product is included in government stakeholder stockpiles.
Given the need to address urgent public health priorities, FDA has and continues to prioritize among the EUA requests it receives for COVID-19 tests.
At this stage of the pandemic, FDA intends to prioritize its review of EUA requests and supplemental EUA requests from experienced developers for diagnostic tests that are likely to have a significant public health benefit (e.g., employ innovative technology) or are likely to fulfill an unmet need (e.g., diagnosing infection with a new variant or subvariant).
FDA generally intends to focus its review on EUA requests and supplemental EUA requests for tests that are within these priorities. In addition to the above priorities, FDA also intends to focus its review on EUA requests that are from or supported by a U.S. government stakeholder, such as tests funded by the Biomedical Advanced Research and Development Authority (BARDA) or the National Institutes of Health’s Rapid Acceleration of Diagnostics (RADx). FDA intends to notify test developers of its intent by email if FDA declines to review or otherwise decides not to authorize a test/modification in an EUA request or supplemental EUA request.
In general, FDA believes these priorities are appropriate to address the public health needs at the current stage of the public health emergency based on the available information and may adjust these priorities as public health needs change. Specifically, there is generally sufficient availability of authorized high-throughput laboratory-based diagnostic tests intended for use with pooled samples and authorized home-use antigen tests that are available for over-the-counter (OTC) or prescription use.
FDA believes that the number of EUA requests that fall within FDA’s current review priorities described in this guidance are likely limited and generally encourages developers to submit COVID-19 tests through traditional premarket review pathways. If you are unsure whether your test may be prioritized for review, we encourage you to reach out to CDRH-EUA-Templates@fda.hhs.gov; however, at this stage, FDA strongly encourages developers of new tests and existing tests for which modifications are sought to pursue traditional pre-market pathways.
### B. State Authorization of High-Complexity CLIA-Certified Laboratories
Versions of this guidance prior to November 15, 2021, described a policy regarding States and territories that authorize laboratories within their State or territory to develop their own COVID-19 tests and perform specimen testing, where the notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request to FDA.
Under such policy, a State or territory choosing to authorize laboratories within that State or territory to develop and perform a test for COVID-19 would do so under authority of its own State law, and under a process that it established, and FDA did not intend to object to the use of such tests for specimen testing where the notification of SARS-CoV-2 test validation was not submitted to FDA and the laboratory did not submit an EUA request to FDA, and where instead the State or territory took responsibility for COVID-19 testing by laboratories in its State during the COVID-19 outbreak. This policy applied only to tests designed, developed, and used within a single, high-complexity, CLIA-certified laboratory. The policy did not apply to at-home tests or tests with home specimen collection, or any testing outside of a high-complexity CLIA-certified laboratory.
In versions of this guidance prior to November 15, 2021, FDA requested that the State or territory notify us if it chose to use this flexibility to expedite COVID-19 testing. FDA indicated that it would not be reviewing the process adopted by the State or territory. FDA expected that such States and territories as part of their oversight process would require laboratories developing SARS-CoV-2 tests to validate those tests prior to use. FDA encouraged laboratories that developed and performed a test for COVID-19 that was authorized by a State or territory to notify FDA that they have started clinical testing by sending an email to that effect to CDRH-EUA-Templates@FDA.HHS.GOV, and provide information on testing capacity.
In the November 15, 2021, version of this guidance, FDA revised this policy such that FDA no longer intended to apply the policy to any additional States or territories going forward. The FDA is maintaining the policy in Section IV.B. of the November 15, 2021, policy, without further revision. For the States and territories listed on the notification list on FDA’s website prior to November 15, 2021, that are continuing to authorize laboratories within their State or territory to develop and perform a test for COVID-19, FDA does not intend to object to the use of such tests for specimen testing where notification of SARS-CoV-2 test validation is not submitted to FDA and the laboratory does not submit an EUA request, and where instead the State or territory takes responsibility. This policy applies only to tests designed, developed, and used within a single, high-complexity CLIA-certified laboratory. This policy does not apply to at-home tests or tests with home specimen collection, or any testing outside of a high-complexity CLIA-certified laboratory.
FDA notes that laboratories should be aware of requirements to report test results to appropriate federal, state, and local public health agencies in accordance with applicable federal, state, and local laws.
### C. Distribution and Offering of SARS-CoV-2 Diagnostic and Serology Tests During FDA Review
Previous versions of this guidance document described enforcement policies where FDA generally did not intend to object to developers distributing and offering certain tests prior to FDA authorization, as described in the policies. Those policies were updated in the November 15, 2021, version of the guidance, and FDA is generally continuing those updated policies and clarifying them, as discussed below.
#### (1) FDA Review of EUA Requests
For the following tests, FDA does not intend to object to the continued distribution or offering of the test while FDA reviews the EUA request for the test:
- Tests on one of the [notification lists](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/notifications-and-emergency-use-authorizations-faqs-testing-sars-cov-2) on FDA’s website at the time of issuance of this updated guidance; and,
- Laboratory developed tests (LDTs) offered following the HHS August 2020 Web Statement entitled, “Rescission of Guidances and Other Informal Issuances Concerning Premarket Review of Laboratory Developed Tests” (“August 2020 HHS Announcement”) and prior to November 15, 2021, where an EUA request was submitted to FDA as described in Section IV.C.2 of the November 15, 2021 version of this guidance document.
For tests described in this section, FDA intends to notify test developers by email if FDA declines to review, declines to issue, or otherwise decides not to authorize the test for any reason, including lack of response or a determination that there is a lack of adequate data to support authorization. If so notified, FDA generally expects developers to cease distributing, marketing, and offering their tests within 15 calendar days. Moreover, if FDA identifies a significant problem or concern with a test, based either on the provided information or external reports, FDA generally would expect the developer to take appropriate steps to address such problems, which could include conducting a recall of the test and/or notification concerning corrected test reports indicating prior test results may not be accurate.
#### (2) Recommendations Regarding Test Reports and Other Information for Tests Offered During FDA Review of EUA Requests
FDA continues to recommend the following:
1. Test reports should prominently disclose that the test has not been reviewed by FDA. Until the test is authorized by FDA, any statements in the test reports and other labeling that expressly state or imply that the test has been authorized by FDA would be false. Similarly, any statements in the test reports and other labeling that state or imply that EUA issuance or FDA authorization are imminent or pending could be misleading.
2. Developers should make publicly available on their website the instructions for use for the test and data about the test’s performance characteristics, including a summary of assay performance.
3. Instructions for use and patient test reports for serology tests should include information that helps users and patients understand the test results, including the following:
- Negative results do not preclude acute SARS-CoV-2 infection. If acute infection is suspected, direct (i.e., diagnostic) testing for SARS-CoV-2 is necessary.
- Results from antibody testing should not be used to diagnose or exclude acute SARS-CoV-2 infection.
- Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.
In addition, as noted in previous versions of this guidance and earlier in this updated guidance, unless and until an EUA is issued that authorizes additional testing environments for a specific test, under CLIA, use of that test is limited to high-complexity CLIA-certified laboratories, including testing at the POC when the site is covered by such a laboratory’s CLIA certificate.
### D. Modifications to EUA-Authorized Diagnostic COVID-19 Tests
Throughout the course of the pandemic, FDA has issued various policies with respect to modifications and, as discussed further below, FDA is updating these policies. The policies in this section do not apply to at-home tests or tests with at-home specimen collection.
In order to provide transparency, when a developer is distributing or offering a test that is a modification of an EUA-authorized diagnostic test prior to or without authorization of the modified test, as discussed in this section, the recommendations in Section IV.C.2 of this updated guidance apply. FDA further recommends that the developer post data about the modified test’s performance characteristics on the developer’s website, and that the instructions for use or test protocol and the test reports accurately reflect the modification and prominently disclose that the test has been modified since authorization by FDA and that the modified test has not been reviewed by FDA.
If FDA identifies a significant problem or concern with a modified test, based either on the provided information or external reports, that cannot be addressed in a timely manner, FDA generally would expect the developer to cease distribution, marketing and offering the modified test and address such problem, which could include conducting a recall of the modified test and/or notification concerning corrected test reports indicating prior test results may not be accurate.
#### (1) Modifications Made After Issuance of this Updated Guidance
In addition to the priorities above, FDA intends to review supplemental EUA requests that fulfill a condition of an EUA. For other supplemental requests, such as those that are beyond the priorities outlined above, FDA encourages developers to consider including the modification in a submission through a traditional premarket review pathway. In general, FDA expects such modified tests to be authorized under an EUA or pursuant to a traditional premarket review pathway before being distributed or offered.
When a high-complexity CLIA-certified laboratory is modifying an authorized COVID-19 molecular diagnostic test, including one for which such laboratory is not the developer of the original, EUA-authorized test, and the modifications do not change the indication for use set forth in the EUA (e.g., including new/different extraction kits or instruments that would not be expected to change the indication for use) and do not change the analyte specific reagents (e.g., the modifications do not change the PCR primers and/or probes), FDA does not intend to object to implementation of the modification to the diagnostic test without notification to FDA or a new or amended EUA where the laboratory has validated the modification and confirmed that the performance of the modified test is equivalent to the performance of the authorized test, and use of the test is limited to the high-complexity CLIA-certified laboratory in which the modification was made.
In such cases, where the laboratory modifying and performing the test is not the developer of the original, EUA-authorized test, FDA encourages the laboratory to collaborate with the developer of the authorized test so that validation data supporting the modifications can be submitted by the original developer to FDA in a supplemental EUA request or incorporated into a future submission through the traditional premarket review pathways.
#### (2) Certain Modifications Made Before Issuance of this Updated Guidance
Under previous versions of this guidance, when a commercial manufacturer made certain modifications to its EUA-authorized COVID-19 diagnostic test, and where validation data supporting the modification had been submitted in a supplemental EUA request, FDA stated that it did not intend to object to implementation of the modification while FDA conducted its review, except for modifications to add specimen types that have not been previously authorized with another test of the same technology. For such modifications made and implemented as discussed in the policies in the previous version of the guidance, FDA does not intend to object to such commercial manufacturers continuing to implement the modification while FDA conducts its review.
Under previous versions of the guidance, when a high-complexity CLIA-certified laboratory modified an EUA-authorized COVID-19 diagnostic test[^20] prior to November 15, 2021, for use with a new specimen type, where the new specimen type has been previously authorized for another test of the same technology[^21] and where the laboratory had validated the test for the new specimen type, FDA stated that it did not intend to object to the use of such a modified test without notification to FDA or a new or amended EUA. For all other types of modifications made by the high-complexity CLIA-certified laboratory prior to November 15, 2021, for an EUA-authorized COVID-19 diagnostic test, in previous versions of the guidance, FDA stated that it did not intend to object to the use of the test by high-complexity CLIA-certified laboratories, without notification to FDA or a new or amended EUA, where the modified test is validated using a bridging study to the EUA-authorized test.
For high-complexity CLIA-certified laboratories that modified an authorized COVID-19 molecular diagnostic test after November 15, 2021, but before issuance of the September 27, 2022, version of the guidance, including one for which such laboratory is not the developer of the original, EUA-authorized test, and the modifications do not change the indication for use set forth in the EUA (e.g., including new/different extraction kits or instruments that would not be expected to change the indication for use) and do not change the analyte specific reagents (e.g., the modifications do not change the PCR primers and/or probes), FDA stated that it did not intend to object to implementation of the modification to the diagnostic test without notification to FDA or a new or amended EUA where the laboratory has validated the modification and confirmed that the performance of the modified test is equivalent to the performance of the authorized test, and use of the test is limited to the high-complexity CLIA-certified laboratory in which the modification was made.[^23]
For such modifications made and implemented by high-complexity CLIA-certified laboratories as discussed in the policies in the previous versions of the guidance, FDA does not intend to object to such laboratories continuing to offer any of those modified tests.
In such cases, where the laboratory performing the modified test is not the developer of the original, EUA-authorized test, FDA encourages the laboratory to share its validation data with the developer of the original, EUA-authorized test so that the developer of the original, EUA-authorized test can use the validation data in support of a supplemental EUA request to add the modification or can incorporate it into a future submission through the traditional premarket review pathways.
## V. Validation
All clinical tests should be validated using clinical specimens and an appropriate comparator test prior to use.
In the context of a public health emergency, it is critically important that tests be validated prior to use because false results not only can negatively impact the individual patient but also can have a broad public health impact. However, FDA also generally accepts a lower level of evidence of validation for an EUA than for traditional premarket review pathways. FDA has provided recommendations regarding testing that should be performed to ensure analytical and clinical validity to the level of evidence expected for an EUA, including descriptions of appropriate comparators for different types of tests, in the EUA templates available through download from our website.[^24] Depending on the characteristics of a developer’s test, additional validation studies may be recommended.
Because the level of evidence required for authorization under traditional premarket review pathways is higher than that required for an EUA, the recommendations in the EUA templates may not be sufficient for developers seeking marketing authorization of their tests through traditional premarket review pathways. FDA can provide recommendations specific to a test developer’s situation through inquiries to [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov) or through pre-submission interactions.[^25]
Developers can use alternative approaches. FDA encourages developers to discuss any alternative technological approaches to validating their test with FDA through [CDRH-EUA-Templates@FDA.HHS.GOV](mailto:CDRH-EUA-Templates@FDA.HHS.GOV).
Additionally, FDA continues to expect certain serology tests to be independently evaluated by NIH/NCI,[^26] prior to authorization, when requested by the FDA. When performed, this additional testing can assist FDA in determining whether the EUA issuance criteria in section 564 of the FD&C Act have been met and whether FDA should authorize the test. This independent evaluation may also be used to assist FDA in determining whether the criteria for marketing authorization have been met for tests submitted through traditional premarket review pathways.
## VI. Availability of EUA Templates and Inquiries Regarding Validation
FDA has made available through download from our website[^27] a series of templates that developers may choose to use to facilitate the preparation and submission of an EUA request for various types of COVID-19 tests. The templates reflect FDA’s current thinking on validation recommendations for SARS-CoV-2 tests and the data and information that developers should submit to facilitate the EUA process. The templates provide information and recommendations, and FDA plans to update them as appropriate as more is learned about COVID-19 and more experience is gained with the EUA process for the various types of COVID-19 tests. Developers may use alternative approaches. Developers who are considering alternative approaches should consider seeking FDA’s feedback.
FDA can provide validation recommendations specific to a test developer’s situation both for those seeking EUA and for those seeking marketing authorization through traditional review pathways. Developers can send simple inquiries to [CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov) or submit a pre-EUA or pre-submission for more complex inquiries.[^28] For tests seeking marketing authorization through traditional premarket review pathways, FDA may recommend validation studies or supportive evidence in addition to the recommendations in the EUA templates.
Members of the public can submit questions about the templates to [CDRH-EUA-Templates@FDA.HHS.GOV](mailto:CDRH-EUA-Templates@FDA.HHS.GOV), or they can submit comments regarding the templates to the public docket established for this guidance.
---
[^1]: See 85 FR 7316; available at [https://www.federalregister.gov/documents/2020/02/07/2020-02496/determination-of-public-health-emergency](https://www.federalregister.gov/documents/2020/02/07/2020-02496/determination-of-public-health-emergency).
[^2]: Secretary of Health and Human Services, Determination that a Public Health Emergency Exists (originally issued on Jan. 31, 2020, and subsequently renewed), available at [https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx](https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx).
[^3]: 85 FR 7316; available at [https://www.federalregister.gov/documents/2020/02/07/2020-02496/determination-of-public-health-emergency](https://www.federalregister.gov/documents/2020/02/07/2020-02496/determination-of-public-health-emergency).
[^4]: Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak (Mar. 13, 2020), available at [https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/](https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/). On February 24, 2021, there was a Presidential Declaration continuing the national emergency concerning the COVID-19 pandemic beyond March 1, 2021. See Continuation of the National Emergency Concerning the Coronavirus Disease 2019 (COVID-19) Pandemic (February 24, 2021), available at [https://www.federalregister.gov/documents/2021/02/26/2021-04173/continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic](https://www.federalregister.gov/documents/2021/02/26/2021-04173/continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic).
[^5]: Throughout this guidance, the term “diagnostic test” is generally used to refer to molecular or antigen tests, both of which can be used to diagnose infection with the SARS-CoV-2 virus. Diagnostic tests may be designed for use in various settings, such as in a CLIA-certified laboratory, at the point of care at a site covered by a laboratory’s CLIA certificate, or at home. Screening tests, which are used for testing individuals without symptoms or other reasons to suspect COVID-19, are a subset of diagnostic tests. Molecular tests detect the presence of viral RNA and antigen tests detect the presence of viral proteins that are part of the SARS-CoV-2 virus. There may also be diagnostic tests that incorporate different technologies, such as breath tests, that have a reasonable expectation of technical and clinical success. While the principles in this guidance are generally still applicable to such tests, there are fewer available, so different approaches may be appropriate. Therefore, FDA recommends that developers of such tests contact FDA at CDRH-EUA-Templates@fda.hhs.gov to discuss the best approach for their test.
[^20]: This applies to modifications to any EUA-authorized diagnostic test, including a laboratory’s own test with an EUA or a purchased kit from a commercial manufacturer with an EUA, but does not apply to modifications of authorized home collection kits.
[^21]: For the purposes of this guidance, all nucleic acid amplification tests are considered to have the same technology.
[^22]: Other modifications, including new specimen types, test settings (e.g., point-of-care, home testing), and new patient populations (e.g., asymptomatic individuals), among others, do not fall under this policy.
[^23]: FDA generally considers equivalent performance to be where the LoD of the modified test (using the same validation material used in the LoD study described in the authorized test’s Instructions For Use (IFU)) is within 3x of the LoD established in the authorized test’s IFU or that the LoD of the modified test is within 3x of the LoD of the authorized test in a direct comparison LoD study.
[^24]: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas)
[^25]: See FDA Guidance document “Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program,” available at: [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program).
[^26]: The FDA is working with the NIH, the Centers for Disease Control and Prevention (CDC), and BARDA to assess the performance of certain commercial manufacturers’ serology tests. As part of this project, the FDA, working with partnering agencies, has designed a performance assessment protocol that offers a mechanism for an independent evaluation of certain lateral flow and certain enzyme-linked immunosorbent assay (ELISA) or similar technology-based SARS-CoV-2 antibody tests in a laboratory environment. Under this protocol, each test evaluated at the NIH/NCI will be evaluated with a well-characterized sample panel consisting of positive and negative plasma and/or serum samples. The approach represents a balanced attempt to provide a reasonable understanding of the potential performance of a significant number of the tests within a short time period. Performance results are considered during FDA’s review of an EUA request for the test.
[^27]: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas)
[^28]: See FDA Guidance document “Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program,” available at: [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program).
# 483 2023-03-24_FDA Website - Transition Plan for Medical Devices.md
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last updated: 2026-03-04 by BA
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web_url: https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2
summary_short: The FDA announces final March 24, 2023 guidances that lay out how medical devices covered by COVID-19 enforcement policies or issued COVID-19 EUAs should transition back to normal regulatory operations. It highlights FDA recommendations to create a transition implementation plan, prepare and submit an appropriate marketing submission, and take other follow-on actions, with links to the guidances and an April 18, 2023 webinar for stakeholders.
CONTENT
March 24, 2023 - The FDA has finalized two guidances: [Transition Plan for Medical Devices That Fall Within Enforcement Policies Issued During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-fall-within-enforcement-policies-issued-during-coronavirus-disease) and [Transition Plan for Medical Devices Issued Emergency Use Authorizations (EUAs) Related to Coronavirus Disease 2019 (COVID-19)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-issued-emergency-use-authorizations-euas-related-coronavirus-disease). The guidances outline the FDA's general recommendations to transition from certain policies adopted and operations implemented during the COVID-19 pandemic to normal operations, including the FDA's recommendations for:
Developing a transition implementation plan,
Submitting a marketing submission, and
Taking other actions with respect to these devices.
The FDA encourages stakeholders to review the two final guidances, view the webinar, and reach out to the FDA if they have questions or concerns. In particular, for manufacturers planning to seek marketing authorization for their devices, the FDA recommends beginning work on a marketing submission, including a transition implementation plan, as described in the guidances.
Additional Resources:
[Transition Plan for Medical Devices That Fall Within Enforcement Policies Issued During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-fall-within-enforcement-policies-issued-during-coronavirus-disease)
[Transition Plan for Medical Devices Issued Emergency Use Authorizations (EUAs) Related to Coronavirus Disease 2019 (COVID-19)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-issued-emergency-use-authorizations-euas-related-coronavirus-disease)
[Webinar on Guidances on COVID-19 Transition Plans for Medical Devices - April 18, 2023](https://www.fda.gov/medical-devices/medical-devices-news-and-events/webinar-guidances-covid-19-transition-plans-medical-devices-04182023)
# 12,172 2023-03-27_FDA Guidance - Transition Plan for Medical Devices Issued EUAs.md
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last updated: 2026-03-04 by BA
file_name: 2023-03-27_FDA Guidance - Transition Plan for Medical Devices Issued EUAs.md
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summary_short: The FDA “Transition Plan for Medical Devices Issued Emergency Use Authorizations (EUAs) Related to COVID-19” (March 27, 2023) describes how manufacturers should transition devices from EUA status to normal regulatory pathways after EUA declarations are terminated. It outlines expectations for marketing submissions, continued or discontinued distribution, labeling updates, and disposition of already distributed devices, with special provisions for in vitro diagnostics, CLIA categorization, and life-supporting or reusable equipment.
CONTENT
***INTERNAL TITLE:*** Transition Plan for Medical Devices Issued Emergency Use Authorizations (EUAs) Related to Coronavirus Disease 2019 (COVID-19)
Guidance for Industry, Other Stakeholders, and Food and Drug Administration Staff
Document issued on March 27, 2023.
The draft of this document was issued on December 23, 2021.
For questions about this document, contact the Regulation, Policy, and Guidance Staff at [RPG@fda.hhs.gov](mailto:RPG@fda.hhs.gov). For general questions about emergency use authorizations, contact the Office of the Commissioner/Office of the Chief Scientist/Office of Counterterrorism and Emerging Threats at [AskMCMi@fda.hhs.gov](mailto:AskMCMi@fda.hhs.gov).
## Preface
### Public Comment
You may submit electronic comments and suggestions at any time for Agency consideration to [https://www.regulations.gov](https://www.regulations.gov). Submit written comments to the Dockets Management Staff, Food and Drug Administration, 5630 Fishers Lane, Room 1061, (HFA-305), Rockville, MD 20852. Identify all comments with the docket number FDA-2021-D-1149. Comments may not be acted upon by the Agency until the document is next revised or updated.
### Additional Copies
Additional copies are available from the Internet. You may also send an email request to [CDRH-Guidance@fda.hhs.gov](mailto:CDRH-Guidance@fda.hhs.gov) to receive a copy of the guidance. Please include the document number GUI00020042 and complete title of the guidance in the request.
## Table of Contents
I. Introduction ......................................................................................................................... 1
II. Background ......................................................................................................................... 2
III. Scope ................................................................................................................................... 5
IV. Guiding Principles .............................................................................................................. 5
V. Transition Plan for Devices Authorized Under an EUA .................................................... 6
A. “Notifications of Intent” for Certain Reusable Life-Supporting or Life-Sustaining Devices ............................................................................................................................ 8
B. Devices distributed after the EUA termination date ....................................................... 9
1. Recommendations for “Transition Implementation Plan” ......................................... 10
2. Enforcement policy for devices with a marketing submission under review by FDA 12
3. Additional considerations for EUA-authorized in vitro diagnostics – Clinical Laboratory Improvement Amendments of 1988 (CLIA) categorization and waivers ........ 14
C. Devices not distributed after the EUA termination date ............................................... 16
D. Discontinuing distribution of a device .......................................................................... 17
E. Quality System considerations ...................................................................................... 18
F. Laboratory developed tests (LDTs) ............................................................................... 18
VI. Examples ........................................................................................................................... 19
Example 1 ........................................................................................................................... 19
Example 2 ........................................................................................................................... 20
Example 3 ........................................................................................................................... 21
Example 4 ........................................................................................................................... 22
## I. Introduction
FDA plays a critical role in protecting the United States (U.S.) from threats such as emerging infectious diseases, including Coronavirus Disease 2019 (COVID-19). FDA is committed to providing timely guidance to support response efforts to the COVID-19 pandemic. FDA recognizes that it will take time for device manufacturers, device distributors, healthcare facilities, healthcare providers, patients, consumers, and FDA to adjust from policies adopted and operations implemented during the COVID-19 pandemic to “normal operations.” To provide a clear policy for all stakeholders and FDA staff, the Agency is issuing this guidance to describe FDA’s general recommendations for this transition process with respect to devices issued emergency use authorizations (EUAs) related to COVID-19, including recommendations regarding submitting a marketing submission, as applicable, and taking other actions with respect to these devices.
FDA is concurrently issuing a companion transition guidance to describe FDA’s recommendations for devices that fall within certain enforcement policies issued during the COVID-19 public health emergency (PHE). FDA believes these transition guidances will help prepare manufacturers and other stakeholders for the transition to normal operations and foster compliance with applicable requirements under the FD&C Act and its implementing regulations.
In general, FDA’s guidance documents do not establish legally enforceable responsibilities. Instead, guidances describe the Agency’s current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should* in Agency guidances means that something is suggested or recommended, but not required.
## II. Background
In 2019, an outbreak of respiratory disease caused by a novel coronavirus began. The virus has been named “SARS-CoV-2,” and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). On January 31, 2020, the Secretary of Health and Human Services (HHS) issued a declaration of a PHE related to COVID-19 in accordance with section 319 of the Public Health Service Act (PHS Act) and mobilized the Operating Divisions of HHS. In addition, on March 13, 2020, the President declared a national emergency in response to COVID-19. On February 9, 2023, the HHS Secretary renewed the section 319 PHE declaration related to COVID-19, effective February 11, 2023. The section 319 PHE declaration related to COVID-19 is anticipated to expire at the end of the day on May 11, 2023.
FDA has authorized the emergency use of devices under section 564 of the Federal Food, Drug, and Cosmetic Act (FD&C Act). Section 564 of the FD&C Act authorizes FDA, after the HHS Secretary has made a declaration of emergency or threat justifying authorization of emergency use (an “EUA declaration”), to authorize the emergency use of an unapproved product or an unapproved use of an approved product for certain emergency circumstances. FDA may issue an EUA to allow a product to be used to diagnose, treat, or prevent a serious or life-threatening disease or condition referenced in the EUA declaration, when the statutory criteria are met, including FDA’s determination that, based on the totality of scientific evidence, the product may be effective for such use, the known and potential benefits outweigh the known and potential risks for such use, and that there are no adequate, approved, and available alternatives.
An EUA issued under section 564 of the FD&C Act remains in effect for the duration of the relevant EUA declaration, unless FDA chooses to revoke the EUA because the criteria for issuance are no longer met or revocation is appropriate to protect public health or safety. An EUA declaration under section 564 of the FD&C Act is distinct from, and is not dependent on, a declaration by the HHS Secretary of a PHE under section 319 of the PHS Act. The device EUAs related to COVID-19 remain in effect until the relevant EUA declaration under section 564 of the FD&C Act is terminated or FDA otherwise revokes a specific EUA, [^14] even if the section 319 PHE declaration related to COVID-19 expires before then. [^15]
Given the magnitude of the response to the COVID-19 pandemic, including the number of devices issued EUAs, FDA recognizes that stakeholders may need time to adjust after the termination of the device EUA declarations to help ensure an orderly and transparent transition to normal operations. Further, FDA is taking into account that the manufacture, distribution, and use of devices in the context of the COVID-19 pandemic raises unique considerations. These unique considerations include, for example, the manufacturing of devices by non-traditional manufacturers to address supply issues and the distribution and use of capital or reusable equipment (e.g., ventilators, extracorporeal membrane oxygenation systems) under EUAs.
FDA developed this guidance to describe a transition plan, among other things, to help avoid disruption in device supply and help facilitate compliance with applicable FD&C Act requirements after the termination of the relevant EUA declaration related to COVID-19 under section 564(b) of the FD&C Act.
Section 564 of the FD&C Act provides a statutory framework describing the circumstances in which an EUA declaration shall terminate and the process for such termination. [^16] Under section 564(b) of the FD&C Act, the HHS Secretary is required to provide advance notice that an EUA declaration will be terminated and to publish such notice in the Federal Register. [^17] When an EUA declaration is terminated, all EUAs issued under that declaration also terminate. After an EUA declaration terminates, it ceases to be in effect and the emergency use of all products under the EUA declaration are no longer authorized.
Pursuant to section 564(b)(2)(B) of the FD&C Act, when an EUA for an unapproved product ceases to be effective as a result of the termination of an EUA declaration, FDA must consult with the manufacturer of such product with respect to the appropriate disposition of the product. FDA believes that by issuing this guidance in draft with a proposed transition policy and requesting public comment (including from manufacturers of EUA-authorized devices), the Agency has satisfied the requirement to consult with manufacturers, while also efficiently managing Agency resources. To address any unique considerations or other issues related to disposition of product that are not otherwise discussed in this guidance, FDA recommends engagement with the Agency as soon as possible. [^18]
HHS intends to publish the advance notice of termination of each EUA declaration [^19] pertaining to devices in the Federal Register 180 days before the day on which the EUA declaration is terminated. The advance notice of termination of each device EUA declaration may occur simultaneously or at different times, depending on whether the circumstances underlying such declarations continue to exist. [^20] For purposes of this guidance, FDA refers to the date on which an EUA is terminated as the “EUA termination date.” During the time between the advance notice of termination of an EUA declaration and the EUA termination date, manufacturers of devices with EUAs issued pursuant to such an EUA declaration and others [^21] must continue to comply with the terms of the devices’ respective EUAs, including applicable conditions of authorization [^22] identified in the EUA letters of authorization for the devices.
FDA recommends that manufacturers of devices authorized under EUAs plan their post-EUA regulatory and disposition strategies now. When an EUA declaration is terminated, the Agency intends to promptly publish notice of termination of the associated EUAs in the Federal Register and an explanation of the reasons for the termination. [^23]
## III. Scope
This guidance applies to devices that have been issued an EUA under section 564 of the FD&C Act on the basis of a device EUA declaration related to COVID-19. [^24]
Current good manufacturing practice deviations authorized under section 564A(c) of the FD&C Act are outside the scope of this guidance.
This guidance does not apply to devices for which FDA has revoked the EUA under section 564(g)(2)(B)-(C) of the FD&C Act because the criteria under section 564(c) of the FD&C Act were no longer met or because other circumstances made such revocation appropriate to protect the public health or safety.
## IV. Guiding Principles
In developing this guidance, and its companion transition guidance regarding devices that fall within certain enforcement policies issued during the COVID-19 PHE, several guiding principles were followed. Some derive from existing policies and are widely known, and others are key to understanding the approach set forth in this guidance. Thus, anyone using this guidance should bear in mind the following guiding principles:
- This guidance is intended to help facilitate continued patient, consumer, and healthcare provider access to devices needed in the prevention, treatment, and diagnosis of COVID-19.
- FDA believes the policies and recommendations in this guidance will help to ensure an orderly and transparent transition for devices that fall within the scope of this guidance. FDA’s policies and recommendations in this guidance are consistent with the Agency’s statutory mission to both protect and promote the public health. [^25]
- FDA’s policies and recommendations follow, among other things, a risk-based approach with consideration of differences in the intended use and regulatory history of devices, including whether the device is life-supporting or life-sustaining, [^26] capital or reusable [^27] equipment, a single-use device, [^28] and whether another version of the device is FDA-cleared or -approved.
- As always, FDA will make case-by-case decisions regarding the enforcement of legal requirements in response to particular circumstances and questions that arise regarding a specific device or device type. This may include FDA revising or revoking an EUA, [^29] requesting a firm initiate a recall (see 21 CFR 7.45), [^30] or taking other actions, including an enforcement action. Moreover, FDA may revise the enforcement policies and recommendations in the guidance, as appropriate.
## V. Transition Plan for Devices Authorized Under an EUA
As previously stated, FDA recognizes that it will take time for device manufacturers, device distributors, healthcare facilities, healthcare providers, patients, consumers, and the Agency to adjust from policies adopted and operations implemented during the COVID-19 pandemic to normal operations. FDA seeks to encourage and facilitate an appropriate transition period to help, among other things, avoid exacerbating product shortages and supply chain disruptions. This transition plan takes into account the advance notice(s) of termination of the EUA declarations pertaining to devices, and the discussion below contains recommendations regarding the preparation and submission of marketing submissions (including the timing of such submissions), manufacturers' actions if they do not wish to continue distributing their product after the EUA termination date, and the distribution of devices within the scope of this guidance.
For purposes of this guidance, devices are considered to be "already distributed" if they are finished devices that are labeled and are in distribution in the U.S. supply chain or are in the possession of the end user. For purposes of this guidance, FDA would generally consider devices to be "in distribution" to mean those finished, labeled devices that are no longer in the manufacturer's possession that are in transit to or held in a third party’s device inventory not on behalf of the manufacturer, in a federal, state, or other governmental stockpile, or at a location where devices are then offered for direct sale to the end user.
During the time between the advance notice of termination of an EUA declaration and the EUA termination date, manufacturers of devices with EUAs issued pursuant to such an EUA declaration and others must continue to comply with the terms of the devices’ respective EUAs, including applicable conditions of authorization identified in the EUA letters of authorization for the devices.
FDA understands that there may be scenarios that are not specifically addressed in this guidance, but generally believes that the policies and recommendations described, regardless of the specific scenario for a manufacturer, will help avoid disruptions in critical devices and allow FDA to best manage its resources for review of marketing submissions. To address any unique considerations or other issues not otherwise discussed in this guidance, manufacturers may wish to initiate discussions with the Agency through the Q-Submission Program, including requesting feedback in Pre-Submissions. Manufacturers should submit any Pre-Submissions with the understanding that their device will no longer be authorized for emergency use beginning on the EUA termination date. If the manufacturer’s intent is to continue to distribute its device after the EUA declaration for the device has been terminated, the manufacturer should promptly start preparing, and FDA intends to help facilitate acceptance of, a marketing submission before the EUA termination date. For details on the Q-Submission Program, refer to the guidance “[Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program](https://www.google.com/url?q=https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program&sa=D&source=apps-viewer-frontend&ust=1734725789006654&usg=AOvVaw23XJU5bUWWiOVI7qzWrNcE&hl=en).”
### A. “Notifications of Intent” for Certain Reusable Life-Supporting or Life-Sustaining Devices
Given the public health significance of certain reusable life-supporting or life-sustaining devices that have been issued an EUA, FDA requests that manufacturers of such devices submit to FDA information regarding whether or not they intend to submit a marketing submission to FDA and continue distributing their product after the EUA termination date. This information will assist the Agency in resource planning for marketing submission review and providing support to manufacturers. This request applies to EUA-authorized devices with a product code listed in Table 1:
| Product Code | Device Type | Classification Regulation |
|--------------|---------------------------------------------------------|---------------------------|
| BSZ | Gas-machine, anesthesia | 21 CFR 868.5160 |
| CAW | Generator, oxygen, portable | 21 CFR 868.5440 |
| BTT | Humidifier, respiratory gas, (direct patient interface) | 21 CFR 868.5450 |
| QAV | High flow/high velocity humidified oxygen delivery device | 21 CFR 868.5454 |
| CBK | Ventilator, continuous, facility use | 21 CFR 868.5895 |
| MNT | Ventilator, continuous, minimal ventilatory support, facility use | 21 CFR 868.5895 |
| NOU | Continuous, ventilator, home use | 21 CFR 868.5895 |
| MNS | Ventilator, continuous, non-life-supporting | 21 CFR 868.5895 |
| ONZ | Mechanical ventilator | 21 CFR 868.5895 |
| BTL | Ventilator, emergency, powered (resuscitator) | 21 CFR 868.5925 |
| QOO | Ventilator tubing and accessories | No corresponding CFR section |
||
Manufacturers of the devices identified in Table 1 should submit the following information to the CDRH Document Control Center as soon as possible after issuance of this guidance:
- General information about the manufacturer, including contact information, name and place of business, and email address;
- EUA request number;
- Submission number(s) for related premarket submissions;
- A list of all model numbers or other device identifying information;
- Whether the manufacturer plans to submit a marketing submission; and
- If not planning to submit a marketing submission, the manufacturer should discuss, as applicable, its plans to discontinue distribution of the device, to restore the device to an FDA-cleared or -approved version, to provide a physical copy and/or electronic copy of updated labeling, and any other efforts to address or mitigate potential risks of devices already distributed as of the EUA termination date.
The manufacturer should submit this information designated with the EUA request number as an “EUA report.” FDA recommends that manufacturers notate the following on the cover letter of the submission: “Attention: Notification of Intent.” To the extent the Notification of Intent contains trade secret information or confidential commercial or financial information, FDA will handle that information in accordance with applicable laws, including 21 CFR 20.61.
### B. Devices distributed after the EUA termination date
For manufacturers of devices authorized under an EUA seeking the required marketing authorization for their devices, please refer to the recommendations and policies in the subsections below. FDA recommends that these manufacturers submit their marketing submissions to FDA with sufficient time for the submission to be accepted by FDA before the EUA termination date. The marketing submission should be administratively complete in that it includes all of the information necessary for FDA to conduct a substantive review. FDA understands there may be extenuating circumstances that may make doing so difficult (e.g., ongoing clinical trial or longer term non-clinical studies). Manufacturers in such circumstances should engage with the Agency early in the transition period.
FDA is taking into account that the use of devices during the COVID-19 pandemic may allow manufacturers to utilize a variety of data sources in their marketing submission. As such, FDA anticipates many manufacturers may wish to reference data from related marketing authorizations and submissions, and use real-world data obtained as a result of device use during the COVID-19 pandemic. FDA recommends that marketing submissions include in the cover letter a statement that the device is/was previously authorized under an EUA and the EUA request number, as well as submission number(s) for related premarket submissions. This information will help FDA track devices that are transitioning from an EUA to the required marketing authorization, facilitate review of the submission, and help ensure that transitioning devices can be appropriately considered in light of the policy described in Section V.B.(2) of this guidance.
#### (1) Recommendations for “Transition Implementation Plan”
FDA anticipates that some marketing submissions will include changes or updates to the device and/or its labeling compared to the product that has been distributed under the EUA. For example, a manufacturer may have distributed a singleplex in vitro diagnostic assay under an EUA, and the manufacturer intends to submit a marketing submission for a multiplex in vitro diagnostic assay; or a manufacturer may have distributed a remote monitoring device under an EUA, and the manufacturer intends to submit a marketing submission for such remote monitoring device with an additional, new indication. In addition, in some cases, a manufacturer may not receive a positive decision from FDA on its marketing submission.
To help address all of these situations efficiently, FDA recommends that manufacturers include in the cover letter of their marketing submission a “Transition Implementation Plan” that addresses the manufacturers’ plans for dealing with devices already distributed in the case of a positive decision as well as in the case of a negative decision on the marketing submission. To the extent the Transition Implementation Plan contains trade secret information or confidential commercial or financial information, FDA will handle that information in accordance with applicable laws, including 21 CFR 20.61.
FDA recommends that the Transition Implementation Plan include the following information, as applicable:
- Estimated number of devices under an EUA that are currently in U.S. distribution;
- An explanation of the manufacturer’s benefit-risk based plan for disposition of already distributed product in the event of a negative decision on the marketing submission. If the manufacturer is proposing to leave already distributed product in place, the plan should address the rationale for doing so and considerations such as the following, where relevant:
- Process for notifying patients, consumers, healthcare facilities, healthcare providers, and device distributors of the device’s regulatory status;
- Process and timeline for restoring already distributed devices to an FDA-cleared or -approved version;
- Process and timeline for providing a physical and/or electronic copy of updated labeling that accurately describes the product features and regulatory status (e.g., that the product lacks FDA clearance, approval, or authorization) for reusable devices. To help ensure accessibility to updated labeling for reusable life-supporting/life-sustaining devices, FDA recommends that stakeholders be provided an opportunity to request a physical copy of updated labeling, and after such request, be provided the requested labeling without additional cost; and
- A description of the maintenance plan for already distributed devices.
- An explanation of the manufacturer’s plans for addressing already distributed product in the event of a positive decision on the marketing submission, including considerations such as the following, where relevant:
- Process for notifying patients, consumers, healthcare facilities, healthcare providers, and device distributors of the device’s regulatory status; and
- Process and timeline for providing to users of already distributed devices updated labeling or components for the cleared or approved device, including updated labeling or components to reflect any cleared/approved changes to the already distributed device.
FDA encourages manufacturers to collaborate with device distributors, healthcare facilities, healthcare providers, patients, and consumers, as appropriate, regarding their Transition Implementation Plan to assist all stakeholders with transition planning.
Depending on FDA’s evaluation of the marketing submission, FDA may engage with the manufacturer during the Agency’s review of the submission to discuss the appropriate disposition of already distributed devices described in the Transition Implementation Plan. For marketing submissions that include changes to the device compared to the product that has been distributed under the EUA (e.g., modifications to address a cybersecurity concern), the manufacturer should discuss possible correction or removal with FDA regarding devices already distributed to the end user, as needed. As always, FDA will make case-by-case decisions regarding the enforcement of legal requirements in response to particular circumstances and questions that arise regarding a specific device or device type (e.g., requesting a firm initiate a recall (see 21 CFR 7.45) or taking other actions, including an enforcement action).
#### (2) Enforcement policy for devices with a marketing submission under review by FDA
As previously stated, FDA recognizes that it may take time for device manufacturers, including non-traditional device manufacturers, to adapt and adjust from their operations during the COVID-19 pandemic to normal operations. As such, at this time, FDA does not intend to object to the continued distribution of devices within the scope of this guidance after the EUA termination date where:
- The manufacturer has submitted a marketing submission to FDA and it is accepted by FDA before the EUA termination date; and
- FDA has not taken a final action on the marketing submission.
For these same devices, while the device is under FDA review, FDA does not intend to object to the devices not bearing a Unique Device Identification (UDI) (see 21 CFR Part 801 Subpart B and Part 830) or complying with other applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as previously authorized under the EUA. As always, FDA will make case-by-case decisions regarding the enforcement of legal requirements in response to particular circumstances and questions that arise regarding a specific device or device type.
The enforcement policy in this section (Section V.B.(2)) relates to FDA marketing authorization (e.g., 510(k) clearance), UDI, and certain labeling requirements. It does not apply to other legal requirements (such as registration and listing, Quality System (QS), and reports of corrections and removals requirements under 21 CFR Parts 807, 820, and 806, respectively) that may apply after the EUA termination date. Moreover, it does not apply after FDA has taken a final action on the marketing submission for a device. At that time, FDA expects manufacturers to comply with all applicable regulatory requirements for the device/manufacturer. Following the device’s marketing authorization, this includes labeling updates (see 21 CFR Part 801), compliance with UDI requirements (see 21 CFR Part 801 Subpart B and Part 830), and any applicable updates to registration and listing information, including the submission number (see 21 CFR Part 807 Subparts B-D). After marketing authorization, manufacturers also should follow the steps outlined in their Transition Implementation Plan.
In addition, and as always, FDA will make case-by-case decisions regarding the enforcement of legal requirements in response to particular circumstances and questions that arise regarding a specific device or device type. This may include FDA revising or revoking an EUA, requesting a firm initiate a recall (see 21 CFR 7.45), or taking other actions, including an enforcement action. Moreover, FDA may revise the enforcement policies and recommendations in the guidance, as appropriate.
As mentioned previously, FDA recommends that marketing submissions include in the cover letter a statement that the device is/was previously authorized under an EUA and the EUA request number, as well as submission number(s) for related premarket submissions. This information will help FDA track devices that are transitioning from an EUA to the required marketing authorization, facilitate review of the submission, and help ensure that transitioning devices can be appropriately considered in light of the policy described in this section (Section V.B.(2) of this guidance).
In addition, during this transition period and after the EUA termination date, FDA may receive questions from stakeholders (e.g., other Agencies, governmental stockpilers, healthcare providers) about a device’s regulatory status for devices distributed as described in this section (Section V.B.(2)) while the marketing submission is under review by FDA. Typically, if a device has an EUA or conventional marketing authorization (e.g., 510(k) clearance), this information would be publicly available. The existence of a marketing submission under review is not typically disclosed unless certain circumstances apply, such as when the device is on the market. As such, for devices distributed as described in this section, FDA may share that a manufacturer is distributing such device as described in the policy in this guidance, which could indirectly reveal that the manufacturer has a marketing submission under review by FDA.
#### (3) Additional considerations for EUA-authorized in vitro diagnostics – Clinical Laboratory Improvement Amendments of 1988 (CLIA) categorization and waivers
In vitro diagnostics (IVDs) authorized under an EUA are generally authorized for use in specific settings, such as those certified as laboratories under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), that meet the requirements to perform high or moderate complexity tests, or for use at the point-of-care (POC), i.e., in patient care settings operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation. FDA’s determination that an EUA-authorized IVD is deemed to be in a particular category of examinations and procedures under CLIA is effective only while the relevant declaration under section 564(b) of the FD&C Act is in effect. Outside of EUAs, CLIA categorization typically is determined by FDA after FDA has cleared or approved a marketing submission. Prior to a CLIA categorization as moderate complexity or waived, an IVD is considered to be high complexity and, under CLIA, use of that test is limited to laboratories that are certified under CLIA, and that meet the requirements to perform tests of high complexity.
For IVDs authorized under an EUA for use in laboratories certified under CLIA that meet the requirements to perform moderate complexity tests, FDA intends to categorize the test’s complexity immediately following FDA’s final action on the marketing submission, per FDA’s typical categorization process.
For IVDs authorized under an EUA for use in patient care settings operating under a CLIA Certificate of Waiver, FDA intends to accept marketing submissions under the Dual 510(k) and CLIA Waiver by Application pathway, or Dual De Novo and CLIA Waiver marketing submissions modeled after the 510(k) and CLIA Waiver by Application pathway, as appropriate. Manufacturers intending to submit a Dual Submission are encouraged to consider the recommendations in the guidance “Recommendations for Dual 510(k) and CLIA Waiver by Application Studies,” for information on the process and content of Dual Submissions. Consistent with the recommendations in that guidance, data regarding actual use of the IVDs in CLIA-waived settings for comparison and reproducibility studies will be helpful in making a CLIA waiver determination. FDA anticipates that, in many cases, manufacturers will be able to reference data from related marketing authorizations and submissions, including the EUA request, and real-world data obtained as a result of use of the IVD under the EUA may be submitted in support of a CLIA Waiver by Application. As described in the guidance “Recommendations for Dual 510(k) and CLIA Waiver by Application Studies,” FDA recommends submitting a Pre-Submission to discuss planned study designs for comparison and reproducibility studies that support the marketing submission and the CLIA waiver, and the Dual Submission should be submitted following a Pre-Submission.
For IVDs authorized under an EUA for home use, if a marketing submission for such test is subsequently cleared, approved, or authorized for home use, the test will be waived by regulation under 42 CFR 493.15(c), meaning that the test will be categorized as waived without the need for a CLIA Waiver by Application.
FDA recommends that any marketing submission that may necessitate a CLIA categorization decision (e.g., tests intended for use in moderate complexity laboratories or in CLIA Certificate of Waiver settings) be submitted as soon as possible to facilitate FDA’s review of the marketing submission and CLIA categorization request (or CLIA Waiver by Application) prior to the termination of the EUA declaration to reduce the potential for disruption in distribution and use.
For IVDs authorized under an EUA for use in high complexity, moderate complexity, and waived settings where, as described in Section V.B.(2) of this guidance, the manufacturer has submitted a marketing submission to FDA and it is accepted by FDA before the EUA termination date, and FDA has not taken a final action on the marketing submission or made a determination on CLIA categorization, at this time, FDA does not intend to object to the continued distribution and use of such tests consistent with the policy described in Section V.B.(2) of this guidance and in a manner consistent with the EUA that was in effect prior to the EUA termination date.
### C. Devices not distributed after the EUA termination date
When a manufacturer does not intend to continue to distribute its device beyond the EUA termination date, at this time, FDA does not intend to object to the disposition and use[^67] of already distributed devices (i.e., FDA does not intend to request market removal[^68]) as follows:
1. Single-use, non-life-supporting/non-life-sustaining devices (e.g., face masks), including IVDs, that were distributed before the EUA termination date are used by the end user prior to the product expiration date,[^69] as applicable.
2. Reusable, non-life-supporting/non-life-sustaining devices (e.g., non-invasive remote patient monitoring devices) that were distributed before the EUA termination date are used by their end user and either:
a. Are restored[^70] by the manufacturer to an FDA-cleared or -approved version of the device,[^71] or
b. Have[^72] a physical and/or electronic copy of updated labeling that accurately describes the product features and regulatory status (e.g., that the product lacks FDA clearance, approval, or authorization).
3. Reusable life-supporting/life-sustaining devices (e.g., ventilators, extracorporeal membrane oxygenation systems, continuous renal replacement therapy systems) that were distributed before the EUA termination date are restored[^73] by the manufacturer to an FDA-cleared or -approved version of the device[^74] so that they may be used by their end user. If not restored, a physical and/or electronic copy of updated labeling that accurately describes the product features and regulatory status (e.g., that the product lacks FDA clearance, approval, or authorization) should be provided,[^75] and such devices are not to be used.[^76][^77] To help ensure accessibility to updated labeling, FDA recommends that stakeholders be provided an opportunity to request a physical copy of updated labeling, and after such request, be provided the requested labeling without additional cost.
Manufacturers that do not intend to distribute their devices after the EUA termination date should also refer to relevant information included in this guidance in other sections (though note that recommendations in Section V.B. are intended only for manufacturers that intend to distribute their device after the EUA termination date). In addition, manufacturers should be aware of any applicable legal requirements for their device, such as adverse event reporting under 21 CFR Part 803, and are expected to comply with such requirements for the duration in which they are applicable, which may extend beyond the cessation of distribution.
For IVDs authorized under an EUA for use in high complexity, moderate complexity, and waived settings that were already distributed before the EUA termination date, at this time, FDA does not intend to object to the continued use of such tests prior to the product expiration date in a manner consistent with the EUA that was in effect prior to the EUA termination date.[^78]
Manufacturers may also voluntarily withdraw their devices from the market. For manufacturers that do not intend to continue distributing their devices and that intend to voluntarily withdraw their devices from the market, FDA recommends completing withdrawal of the devices from the market prior to the EUA termination date; otherwise, if withdrawal of the devices from the market is not completed prior to the EUA termination date, FDA recommends restoring and/or updating labeling for reusable non-life-supporting/non-life-sustaining devices and for reusable life-supporting/life-sustaining devices as outlined in the policy above prior to the EUA termination date. Manufacturers should be aware of any applicable legal requirements for their device, such as adverse event reporting under 21 CFR Part 803, and continue to comply with such requirements for the duration in which they are applicable, which may extend beyond the cessation of distribution or withdrawal. Generally, it is anticipated that, over time, legal requirements will no longer apply when the manufacturer’s device withdrawal activities are completed.
FDA encourages manufacturers that do not intend to continue to distribute their devices after the EUA termination date to communicate with device distributors, healthcare facilities, healthcare providers, patients, and consumers, as appropriate, regarding their product disposition to assist all stakeholders with transition planning. In addition, thinking through elements of the “Transition Implementation Plan” outlined in Section V.B.(1) of this guidance may help manufacturers and stakeholders with this process.
### D. Discontinuing distribution of a device
FDA expects manufacturers to discontinue distribution of a device within the scope of this guidance:
1. On the EUA termination date, if the manufacturer has not submitted a required marketing submission[^79] for its device and had it accepted by FDA before the EUA termination date; or
2. On the date the manufacturer receives a negative decision on its marketing submission as FDA’s final action, or on the date the manufacturer withdraws its submission or fails to provide a complete response to an FDA request for additional information[^80] within the allotted time identified in FDA’s letter.
In addition, manufacturers should be aware of any applicable legal requirements for their device, such as adverse event reporting under 21 CFR Part 803, and continue to comply with such requirements for the duration in which they are applicable, which may extend beyond the cessation of distribution. Generally, to help determine the applicable legal requirements after cessation of distribution, FDA expects manufacturers of devices and others[^81] to review terms of the devices’ respective EUAs, including the conditions of authorization[^82] that were included in the EUA letters of authorization for the devices.
FDA encourages manufacturers to communicate with device distributors, healthcare facilities, healthcare providers, patients, and consumers, as appropriate, regarding their product disposition to assist all stakeholders with transition planning.
### E. Quality System considerations
FDA recognizes that there may be situations that raise unique compliance considerations, particularly regarding QS requirements. For example, non-traditional device manufacturers that previously operated under different quality standards or requirements may face challenges that take more time to address in transitioning to a system that fully complies with 21 CFR Part 820. FDA intends to take such considerations into account when making case-by-case compliance and enforcement decisions. Some manufacturers who intend to continue distributing their devices after the EUA termination date may choose to request an exemption or variance from a device QS requirement as outlined in 21 CFR 820.1(e) and section 520(f)(2) of the FD&C Act. Any such exemption or variance should be requested within 90 days of publication of the advance notice of termination of the EUA declaration pertaining to the device at issue to help ensure FDA considers your request in time.
### F. Laboratory developed tests (LDTs)
For laboratory developed tests (LDTs)[^83] in general, FDA has generally exercised enforcement discretion, meaning that FDA generally does not exercise its authority to enforce the regulatory requirements for these devices, although it maintains that authority. FDA has not applied this general enforcement discretion approach to, among other LDTs, those used for declared emergencies under section 564 of the FD&C Act. As such, following termination of the EUA declaration for COVID-19 IVDs, FDA intends to have the same enforcement approach for COVID-19 LDTs as it does for other LDTs.
## VI. Examples
The following hypotheticals are intended to illustrate the transition policy outlined above. To exemplify the timeline of the Transition Implementation Plan outlined in this section (Section VI. of this guidance), for purposes of the examples, FDA set the hypothetical advance notice of termination date for the EUA declaration pertaining to the device at issue as July 1 in Year 1, and the EUA termination date as January 1 in Year 2. This date is not intended to propose an actual advance notice of termination or EUA termination date; it is hypothetical and for illustrative purposes only. Note that these generalized examples do not account for every possible detail, risk, or consideration a manufacturer should evaluate or that may be relevant to FDA decisions regarding a particular device.
### Example 1
A single-use surgical mask that is intended for use in healthcare settings by healthcare personnel as personal protective equipment to provide a physical barrier to fluids and particulate materials was authorized for emergency use under an umbrella EUA for surgical masks. The manufacturer does not intend to continue distributing the surgical mask after the EUA is no longer in effect.
On July 1, the advance notice of termination of the relevant EUA declaration is published. After July 1, the manufacturer continues to distribute the surgical masks and continues to comply with all conditions of authorization.
On the EUA termination date (January 1), the relevant EUA declaration is terminated and the umbrella EUA is no longer in effect. On January 1, the manufacturer ceases distribution of the surgical mask. Before January 1, the manufacturer had recently sold surgical masks directly to retailers and device distributors. Some of the surgical masks are in transit to these customers, and others are being held in device distributors’ warehouses in the U.S.
The policies included in this guidance relate to the following actions by the device manufacturer and others:
- The surgical masks in transit or in device distributors’ warehouses remain distributed (they were already distributed by the EUA termination date), and they are used by the end user prior to their expiration date.
- If on January 1, some of the surgical masks are in the manufacturer’s possession, the surgical masks in the manufacturer’s possession are not subsequently distributed (they were not already distributed by the EUA termination date).
- The manufacturer does not update the labeling of the already distributed surgical masks (they are single-use, non-life-supporting/non-life-sustaining devices).
- User exhaustion of already distributed surgical masks is described in Section V.C. of this guidance.
- Even after the cessation of distribution, the manufacturer continues to submit any adverse event reports of which it becomes aware to FDA consistent with 21 CFR Part 803.
### Example 2
A continuous ventilator was authorized under the umbrella EUA for ventilators and ventilator accessories to support patients who develop respiratory distress due to COVID-19.
On July 1, the advance notice of termination of the relevant EUA declaration is published. Before August 1, to help FDA plan for transition-related premarket review activities, the manufacturer submits an “EUA report” to the CDRH Document Control Center with “Attention: Notification of Intent” on the cover letter of the submission to inform FDA that it does not intend to pursue marketing authorization. This EUA report includes the information outlined in Section V.A. of this guidance, which includes the manufacturer’s plans to have already distributed ventilators remain distributed.
On the EUA termination date (January 1), the relevant EUA declaration is terminated and the umbrella EUA is no longer in effect. On January 1, the manufacturer ceases distribution of the ventilator. FDA does not intend to object if the manufacturer implements a plan (that was included in the Notification of Intent) for the already distributed ventilators to remain distributed (e.g., ventilators in device distributors’ warehouses), including ventilators in the possession of end users (e.g., ventilators in healthcare facilities). As part of the plan, the manufacturer interacts with affected stakeholders, such as healthcare facilities, to determine the stakeholders’ interest in keeping distributed ventilators. The ventilator manufacturer updates the electronic labeling as outlined in Section V.C. of this guidance, and emails a copy of the electronic labeling to affected stakeholders that have expressed an interest in keeping the ventilators.
The policies included in this guidance relate to the following actions by the device manufacturer and others:
- The already distributed ventilators are not used.
- Should healthcare facilities wish to retain the ventilator that lacks FDA clearance, approval, or authorization for use in the future, the future use of the device would be subject to the regulatory requirements of any future authorization, including marketing authorization or EUA.
- For governmental stockpilers that wish to retain a device that lacks requisite FDA clearance, approval, or authorization for use in the future, FDA recommends engaging with the Agency to discuss the public health need for future deployment and/or use of the device in specific circumstances (e.g., regional natural disaster, localized disease outbreaks).
- Even after the cessation of distribution, the manufacturer continues to submit any adverse event reports of which it becomes aware to FDA consistent with 21 CFR Part 803.
### Example 3
A non-traditional device manufacturer worked with a traditional device manufacturer (original equipment manufacturer (OEM)) to produce, as a contract manufacturer, ventilators that were designed by the traditional device manufacturer. Such devices were authorized under the umbrella EUA for ventilators and ventilator accessories and distributed by the OEM during the COVID-19 pandemic.
On July 1, the advance notice of termination of the relevant EUA declaration is published. Before August 1, to help FDA plan for transition-related premarket review activities, the OEM submits an “EUA report” to the CDRH Document Control Center with “Attention: Notification of Intent” on the cover letter of the submission to inform FDA that it intends to pursue marketing authorization. This EUA report includes the information outlined in Section V.A. of this guidance.
On October 1, the OEM submits a marketing submission to FDA. In its marketing submission, the OEM includes a “Transition Implementation Plan” for already distributed ventilators in the case of a positive decision as well as in the case of a negative decision on the marketing submission. On October 10, the marketing submission is determined to be administratively incomplete because it is missing a test report for a biocompatibility endpoint; the marketing submission is not accepted for review (an “RTA1 decision”). The OEM resolves the acceptance review deficiency by including the missing test report for the biocompatibility endpoint and resubmits the marketing submission on November 1. On November 8, the marketing submission is accepted for substantive review.
On the EUA termination date (January 1), the relevant EUA declaration is terminated and the umbrella EUA is no longer in effect. The OEM has submitted a marketing submission and it was accepted by FDA. Under these circumstances, FDA does not intend to object to the continued distribution of the ventilators before FDA takes a final action on the marketing submission (see Section V.B.(2) of this guidance). Additionally, the OEM has kept the device labeling as described in the EUA-authorized device labeling. Under these circumstances, FDA does not intend to object to the device labeling not complying with applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as previously authorized under the EUA while the marketing submission is under FDA review (see Section V.B.(2) of this guidance).
In this scenario, in the course of FDA’s substantive review, FDA identifies a potential control software issue that could result in patient harm. FDA issues a request for additional information and informs the OEM that the marketing submission is being placed on hold pending receipt of a response to the deficiency. The OEM updates its software, performs the appropriate testing, and provides additional information and a response to the deficiency.
On July 10, the OEM receives a positive decision as part of FDA’s final action on the marketing submission. FDA and the OEM engage on the manufacturer’s Transition Implementation Plan to address already distributed devices, which includes the manufacturer updating software for already distributed ventilators and providing updated electronic labeling to the relevant stakeholders in accordance with the FDA-cleared version of the ventilator. The OEM continues to submit any adverse event reports of which it becomes aware to FDA consistent with 21 CFR Part 803.
### Example 4
A molecular diagnostic test kit manufactured by a commercial manufacturer was issued an individual EUA for the qualitative detection of nucleic acid from SARS-CoV-2 in upper and lower respiratory specimens in authorized laboratories. [^88]
On July 1, the advance notice of termination of the relevant EUA declaration is published. On October 1, the manufacturer submits a marketing submission to FDA, which is accepted by the Agency. In its marketing submission, the manufacturer includes a “Transition Implementation Plan” for already distributed molecular diagnostic test kits in the case of a positive decision as well as in the case of a negative decision on the marketing submission.
On the EUA termination date (January 1), the relevant EUA declaration is terminated and the EUA for the device is no longer in effect. The manufacturer has submitted a marketing submission and it was accepted by FDA. Under these circumstances, FDA does not intend to object to the continued distribution of the device before FDA takes a final action on the marketing submission (see Section V.B.(2) of this guidance). Additionally, the manufacturer has kept the device labeling as described in the EUA-authorized device labeling. Under these circumstances, FDA does not intend to object to the device labeling not complying with applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as previously authorized under the EUA while the marketing submission is under FDA review (see Section V.B.(2) of this guidance).
#### a) Positive Decision
In this scenario, the manufacturer receives a positive decision on February 20, as part of FDA’s final action on the marketing submission. FDA and the manufacturer engage on the manufacturer’s Transition Implementation Plan to address already distributed devices. The manufacturer does not update the device labeling for already distributed devices (these devices are single-use, non-life-supporting/non-life-sustaining devices); however, the manufacturer updates the device labeling for devices that are in production and those in its possession in accordance with the FDA-cleared version of the molecular diagnostic test kit. No outstanding issues were identified during FDA review that would result in a correction or removal of the molecular diagnostic test kits that were already distributed. The manufacturer continues to submit any adverse event reports of which it becomes aware to FDA consistent with 21 CFR Part 803.
#### b) Negative Decision
In this scenario, the manufacturer receives a negative decision on March 1, as part of FDA’s final action on the marketing submission. FDA and the manufacturer engage on the manufacturer’s Transition Implementation Plan to address already distributed devices. During FDA’s substantive review, FDA found that specific lots of the molecular diagnostic test kit had a high number of false positive reports, which may lead to a delay in both the correct diagnosis and treatment for the actual cause of a person’s illness. The manufacturer issues a voluntary recall for the affected lots of the molecular diagnostic test kit by informing relevant stakeholders to dispose of the affected lots.
The policies included in this guidance relate to the following actions by the device manufacturer and others:
- For unaffected lots of the molecular diagnostic test kit that are not subject to the recall and are already distributed, the devices remain distributed with device distributors and retail sellers who have already purchased the devices so that they may be used prior to the product expiration date.
- The manufacturer has a small number of unaffected lots of the molecular diagnostic test kit that are not subject to the recall in its possession; the manufacturer does not distribute these devices.
- The manufacturer does not update the device labeling of already distributed devices (these devices are single-use, non-life-supporting/non-life-sustaining devices); however, the manufacturer does communicate publicly about the recall about the affected lots of the molecular diagnostic test kit.
- Even after the cessation of distribution, the manufacturer continues to submit any adverse event reports of which it becomes aware to FDA consistent with 21 CFR Part 803.
---
[^14]: See sections 564(f)-(g) of the FD&C Act.
[^15]: See the HHS “Fact Sheet: COVID-19 Public Health Emergency Transition Roadmap,” (February 9, 2023), available at [link](https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html).
[^16]: Section 564(b)(2) of the FD&C Act.
[^17]: Sections 564(b)(3) and (4) of the FD&C Act.
[^18]: FDA recommends that manufacturers engage with the Agency through the Q-Submission Program, including requesting feedback in Pre-Submissions, to discuss the appropriate disposition of their product. For details on the Q-Submission Program, refer to the guidance “Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program,” available at [link](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program).
[^19]: See footnote 10.
[^20]: See section 564(b)(2)(A) of the FD&C Act.
[^21]: Certain EUAs include conditions of authorization for parties other than the manufacturer, such as healthcare facilities or distributors.
[^22]: See section 564(e) of the FD&C Act.
[^23]: See section 564(h)(1) of the FD&C Act.
[^24]: See footnote 10.
[^25]: See section 1003(b) of the FD&C Act.
[^26]: Life-supporting or life-sustaining devices are defined in 21 CFR 860.3. A list of life-supporting or life-sustaining devices can be found by searching FDA’s product classification database: [link](https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfm).
[^27]: A reusable device is intended for repeated use either on the same or different patients, with appropriate cleaning and other reprocessing between uses. For additional information see the guidance “Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling” available at [link](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/reprocessing-medical-devices-health-care-settings-validation-methods-and-labeling).
[^28]: A single-use device is a device that is intended for one use or on a single patient during a single procedure. For additional information see the guidance “Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling.”
[^29]: See sections 564(f)-(g) of the FD&C Act.
[^30]: 21 CFR 7.45(a) states that FDA “may request a firm to initiate a recall when the following determinations have been made: (1) That a product that has been distributed presents a risk of illness or injury or gross consumer deception. (2) That the firm has not initiated a recall of the product. (3) That an agency action is necessary to protect the public health and welfare.”
[^67]: FDA recognizes that not all use would necessarily be violative (see, e.g., section 564(f)(2) of the FD&C Act). To the extent such use is violative, FDA generally does not intend to object as described herein.
[^68]: FDA uses the term “removal” consistent with the definition in 21 CFR 806.2(j).
[^69]: For IVDs that were authorized under EUA, this is the product expiration date listed as of the EUA termination date. Extension of the expiration date cannot be authorized after the EUA is terminated.
[^70]: In situations where manufacturers do not believe restoration is possible or in the best interest of public health, FDA recommends additional engagement with the Agency on the appropriate disposition of a product if it is not otherwise discussed in this guidance.
[^71]: For example, an FDA-cleared or -approved version may include an earlier software version, component replacement, or different labeling that removes information related to the use of the device under the EUA.
[^72]: The manufacturer should provide labeling to the original purchaser, and collaborate with the original purchaser to ensure that labeling is distributed to relevant stakeholders, including device distributors, healthcare facilities, healthcare providers, patients, consumers, etc.
[^73]: See footnote 70.
[^74]: See footnote 71.
[^75]: See footnote 72.
[^76]: FDA recognizes that not all use would necessarily be violative (see, e.g., section 564(f)(2) of the FD&C Act).
[^77]: Should healthcare facilities wish to retain a device that lacks FDA clearance, approval, or authorization for use in the future, the future use of the device would be subject to the regulatory requirements of any future authorization, including marketing authorization or EUA, as applicable. For governmental stockpilers that wish to retain a device that lacks requisite FDA clearance, approval, or authorization for use in the future, FDA recommends engaging with the Agency to discuss the public health need for future deployment and/or use of the device in specific circumstances (e.g., regional natural disaster, localized disease outbreaks).
[^78]: Laboratories using such tests should consider whether CLIA requirements administered by CMS may apply.
[^79]: See, e.g., sections 510(k), 513(f)(2), 515, and 520(m) of the FD&C Act.
[^80]: For more information on FDA requests for additional information (i.e., deficiency letters) and how to respond, see the guidance “Developing and Responding to Deficiencies in Accordance with the Least Burdensome Provisions,” available at [FDA guidance documents](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/developing-and-responding-deficiencies-accordance-least-burdensome-provisions).
[^81]: Certain EUAs include conditions of authorization for parties other than the manufacturer, such as healthcare facilities or distributors.
[^82]: See section 564(c) of the FD&C Act.
[^83]: An LDT is a type of IVD that is designed, manufactured, and used within a single site laboratory certified under CLIA that meets the requirements to perform tests of high complexity.
[^88]: Available at [FDA Guidance](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2#individual-molecular).
# 17,421 2023-03-27_FDA Guidance - Transition Plan for Medical Devices That Fall Within Enforcement Policies.md
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summary_short: The FDA “Transition Plan for Medical Devices That Fall Within Enforcement Policies Issued During the COVID-19 Public Health Emergency” (March 27, 2023) lays out a phased, 180-day wind-down for devices that were marketed under COVID-era enforcement discretion guidance. It specifies Phase 1–3 compliance expectations (e.g., MDR reporting, corrections/removals, registration/listing), when marketing submissions should be submitted and accepted to keep distributing after the policies end, and when FDA may continue enforcement discretion while a submission is under review. It also includes Notification of Intent requests for certain reusable life-supporting/sustaining devices and recommends a Transition Implementation Plan to manage already-distributed products under both positive and negative FDA decisions.
CONTENT
***INTERNAL TITLE:*** Transition Plan for Medical Devices That Fall Within Enforcement Policies Issued During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency
Guidance for Industry, Other Stakeholders, and Food and Drug Administration Staff
Document issued on March 27, 2023.
The draft of this document was issued on December 23, 2021.
For questions about this document, contact the Regulation, Policy, and Guidance Staff at [RPG@fda.hhs.gov](mailto:RPG@fda.hhs.gov).
## Preface
### Public Comment
You may submit electronic comments and suggestions at any time for Agency consideration to [https://www.regulations.gov](https://www.regulations.gov). Submit written comments to the Dockets Management Staff, Food and Drug Administration, 5630 Fishers Lane, Room 1061, (HFA-305), Rockville, MD 20852. Identify all comments with the docket number FDA-2021-D-1118. Comments may not be acted upon by the Agency until the document is next revised or updated.
### Additional Copies
Additional copies are available from the Internet. You may also send an email request to [CDRH-Guidance@fda.hhs.gov](mailto:CDRH-Guidance@fda.hhs.gov) to receive a copy of the guidance. Please include the document number GUI00021011 and complete title of the guidance in the request.
## Table of Contents
I. Introduction ....................................................................................................................... 1
II. Background ....................................................................................................................... 3
III. Scope ................................................................................................................................ 5
IV. Guiding Principles .......................................................................................................... 6
V. Phased Transition Plan for Devices That Fall Within COVID-19 Enforcement Policies Described in Guidances in List 1 ............................................................................................. 7
A. Devices not distributed after Phase 2 ........................................................................... 11
B. Phase 1 .......................................................................................................................... 13
C. Phase 2 .......................................................................................................................... 13
(1) “Notifications of Intent” for Certain Reusable Life-Supporting or Life-Sustaining Devices ............................................................................................................................. 14
D. Phase 3 .......................................................................................................................... 15
(1) Enforcement policy for devices with a marketing submission under review by FDA 16
(2) Recommendations for “Transition Implementation Plan” ........................................ 18
E. Discontinuing distribution of a device ......................................................................... 20
F. Quality System considerations ..................................................................................... 21
VI. Examples ......................................................................................................................... 21
Example 1 .......................................................................................................................... 21
Example 2 .......................................................................................................................... 23
Example 3 .......................................................................................................................... 24
Example 4 .......................................................................................................................... 25
## I. Introduction
FDA plays a critical role in protecting the United States (U.S.) from threats such as emerging infectious diseases, including Coronavirus Disease 2019 (COVID-19). FDA is committed to providing timely guidance to support response efforts to the COVID-19 pandemic. FDA recognizes that it will take time for device[^1] manufacturers,[^2] device distributors, healthcare facilities, healthcare providers, patients, consumers, and FDA to adjust from policies adopted and operations implemented during the COVID-19 public health emergency (PHE) to “normal operations.”[^3] To provide a clear policy for all stakeholders and FDA staff, the Agency is issuing this guidance to describe FDA’s general recommendations for a phased transition process with respect to devices that fall within certain enforcement policies issued during the COVID-19 PHE, including recommendations regarding submitting a marketing submission, as applicable, and taking other actions with respect to these devices.
FDA is concurrently issuing a companion transition guidance to describe FDA’s recommendations for devices issued emergency use authorizations (EUAs) related to COVID-19.[^4] The companion transition guidance does not include phases as described in this transition plan for devices that fall within enforcement policies and instead relies on the advance notice(s) of termination process required under section 564 of the Federal Food, Drug, and Cosmetic Act (FD&C Act). FDA believes that these transition guidances will help prepare manufacturers and other stakeholders for the transition to normal operations and foster compliance with applicable requirements under the FD&C Act and its implementing regulations.
In general, FDA’s guidance documents do not establish legally enforceable responsibilities. Instead, guidances describe the Agency’s current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should* in Agency guidances means that something is suggested or recommended, but not required.
## II. Background
In 2019, an outbreak of respiratory disease caused by a novel coronavirus began. The virus has been named “SARS-CoV-2,” and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). On January 31, 2020, the Secretary of Health and Human Services (HHS) issued a declaration of a PHE related to COVID-19 in accordance with section 319 of the Public Health Service (PHS) Act (hereinafter referred to as “section 319 PHE declaration”) and mobilized the Operating Divisions of HHS.[^5] In addition, on March 13, 2020, the President declared a national emergency in response to COVID-19.[^6] On February 9, 2023, the HHS Secretary renewed the section 319 PHE declaration related to COVID-19, effective February 11, 2023. The section 319 PHE declaration related to COVID-19 is anticipated to expire at the end of the day on May 11, 2023.[^7]
In response to the COVID-19 pandemic, the device supply chain has been stressed because the demand for certain devices has exceeded available supply. FDA recognized early in the COVID-19 pandemic the importance of maintaining the availability of certain devices. FDA’s policies have helped facilitate the availability of devices intended to diagnose, treat, and prevent COVID-19 and associated conditions – including mitigating exposure to the SARS-CoV-2 virus – and to help address manufacturing limitations or supply chain issues due to disruptions caused by the COVID-19 pandemic.
FDA issued various guidance documents that describe enforcement policies for certain devices that are intended to support the emergency response to the COVID-19 pandemic.[^8] These policies have helped to facilitate the availability of devices such as in vitro diagnostics, personal protective equipment intended for medical purposes, and ventilators. Additionally, FDA issued guidance to help expand the availability and remote monitoring capabilities of certain devices, including infusion pumps and non-invasive remote patient monitoring devices, to reduce the risk of exposure for patients, healthcare providers, and other healthcare professionals to individuals diagnosed with COVID-19.
Generally, the guidances that set forth COVID-19-related enforcement policies for certain devices initially stated that they were intended to remain in effect only for the duration of the section 319 PHE declaration. As FDA announced in the Federal Register on March 13, 2023, many of these guidance documents – the guidances in List 1 (see below) – have been revised to state that they are intended to continue in effect for 180 days after the section 319 PHE declaration expires unless a different intended duration is set forth in the finalized version of this guidance.9,10 A different intended duration is _not_ being set forth in this guidance – as described in Section V., the implementation date is the date the section 319 PHE declaration expires and the guidances are intended to continue in effect for 180 days after that date. FDA recommends reviewing the cover page for the relevant List 1 guidance to help determine the transition period for your device.
Given the magnitude of the response to the COVID-19 pandemic, FDA recognizes that a phased approach may help to ensure an orderly and transparent transition from the policies and recommendations in the List 1 guidances to normal operations. Further, FDA is taking into account that the manufacture, distribution, and use of devices in the context of the COVID-19 pandemic raises unique considerations. These unique considerations include, for example, the manufacturing of devices by non-traditional manufacturers to address supply issues and the distribution and use of capital or reusable equipment (e.g., ventilators, extracorporeal membrane oxygenation systems) that fall within enforcement policies.
FDA developed this guidance to describe a phased approach, as set forth in Section V., among other things, to help avoid disruption in device supply and help facilitate compliance with applicable legal requirements after the enforcement policies are no longer in effect. This phased approach will allow FDA to better understand the landscape of devices that fall within the relevant enforcement policies, provide support to manufacturers, and assist the Agency in resource planning for marketing submission review.
## III. Scope
This guidance applies to devices that fall within the enforcement policies described in the guidances identified in List 1 below.11
**List 1**
- [Enforcement Policy for Remote Digital Pathology Devices During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-remote-digital-pathology-devices-during-coronavirus-disease-2019-covid-19-public)
- [Enforcement Policy for Imaging Systems During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-imaging-systems-during-coronavirus-disease-2019-covid-19-public-health-emergency)
- [Enforcement Policy for Non-Invasive Fetal and Maternal Monitoring Devices Used to Support Patient Monitoring During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-non-invasive-fetal-and-maternal-monitoring-devices-used-support-patient)
- [Enforcement Policy for Telethermographic Systems During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-telethermographic-systems-during-coronavirus-disease-2019-covid-19-public-health)
- [Enforcement Policy for Digital Health Devices for Treating Psychiatric Disorders During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-digital-health-devices-treating-psychiatric-disorders-during-coronavirus-disease)
- [Enforcement Policy for Extracorporeal Membrane Oxygenation and Cardiopulmonary Bypass Devices During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-extracorporeal-membrane-oxygenation-and-cardiopulmonary-bypass-devices-during)
- [Enforcement Policy for Remote Ophthalmic Assessment and Monitoring Devices During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-remote-ophthalmic-assessment-and-monitoring-devices-during-coronavirus-disease-2019-covid-19-public)
- [Enforcement Policy for Infusion Pumps and Accessories During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-infusion-pumps-and-accessories-during-coronavirus-disease-2019-covid-19-public)
- [Enforcement Policy for Face Shields, Surgical Masks, and Respirators During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-face-shields-surgical-masks-and-respirators-during-coronavirus-disease-covid-19-public)
- [Enforcement Policy for Gowns, Other Apparel, and Gloves During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-gowns-other-apparel-and-gloves-during-coronavirus-disease-covid-19-public-health)
- [Enforcement Policy for Sterilizers, Disinfectant Devices, and Air Purifiers During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-sterilizers-disinfectant-devices-and-air-purifiers-during-coronavirus-disease)
- [Enforcement Policy for Ventilators and Accessories and Other Respiratory Devices During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-ventilators-and-accessories-and-other-respiratory-devices-during-coronavirus)
- [Enforcement Policy for Modifications to FDA Cleared Molecular Influenza and RSV Tests During the COVID-19 Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-modifications-fda-cleared-molecular-influenza-and-rsv-tests-during-covid)
- [Coagulation Systems for Measurement of Viscoelastic Properties: Enforcement Policy During the COVID-19 Public Health Emergency (Revised)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/coagulation-systems-measurement-viscoelastic-properties-enforcement-policy-during-coronavirus)
- [Enforcement Policy for Viral Transport Media During the COVID-19 Public Health Emergency (Revised)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-viral-transport-media-during-coronavirus-disease-2019-covid-19-public-health)
## IV. Guiding Principles
In developing this guidance, and its companion transition guidance regarding device issues EUAs related to COVID-19, several guiding principles were followed. Some derive from existing policies and are widely known, and others are key to understanding the approach set forth in this guidance. Thus, anyone using this guidance should bear in mind the following guiding principles:
- This guidance is intended to help facilitate continued patient, consumer, and healthcare provider access to devices needed in the prevention, treatment, and diagnosis of COVID-19.
- FDA believes the policies and recommendations in this guidance will help to ensure an orderly and transparent transition for devices that fall within the scope of this guidance. FDA’s policies and recommendations in this guidance are consistent with the Agency’s statutory mission to both protect and promote the public health.
- FDA’s policies and recommendations follow, among other things, a risk-based approach with consideration of differences in the intended use and regulatory history of devices, including whether the device is life-supporting or life-sustaining, capital or reusable equipment, a single-use device, and whether another version of the device is FDA-cleared or -approved.
- As always, FDA will make case-by-case decisions regarding the enforcement of legal requirements in response to particular circumstances and questions that arise regarding a specific device or device type. This may include requesting a firm initiate a recall (see 21 CFR 7.45), or taking other actions, including an enforcement action. Moreover, FDA may revise the enforcement policies and recommendations in the guidance, as appropriate.
## V. Phased Transition Plan for Devices That Fall Within COVID-19 Enforcement Policies Described in Guidances in List 1
As previously stated, FDA recognizes that it will take time for device manufacturers, device distributors, healthcare facilities, healthcare providers, patients, consumers, and the Agency to adjust from policies adopted and operations implemented during the COVID-19 PHE to normal operations. FDA seeks to encourage and facilitate an appropriate transition period to help, among other things, avoid exacerbating product shortages and supply chain disruptions. This transition plan takes into account that the guidances in List 1 will no longer be in effect after the 180-day transition period discussed in this guidance ends. The discussion below contains recommendations regarding the preparation and submission of marketing submissions (including the timing of such submissions), manufacturers’ actions if they do not wish to continue distributing their product after the end of Phase 2, and the distribution of devices that fall within the scope of this guidance.
For purposes of this guidance, devices are considered to be “already distributed” if they are finished devices that are labeled and are in distribution in the U.S. supply chain or are in the possession of the end user. For purposes of this guidance, FDA would generally consider devices to be “in distribution” to mean those finished, labeled devices that are no longer in the manufacturer’s possession that are in transit to or held in a third party’s device inventory not on behalf of the manufacturer, in a federal, state, or other government stockpile, or at a location where devices are then offered for direct sale to the end user.
Given the duration of the COVID-19 pandemic and the need to safeguard the public health in a post-pandemic environment, FDA is implementing a 180-day transition period that will begin on the “implementation date” (see discussion below regarding this date). The guidances in List 1 will no longer be in effect after the 180-day transition period ends. FDA believes a phased transition over the 180 days following the implementation date as set forth in this guidance will help foster compliance with applicable legal requirements. This approach consists of three phases as described later in this section and outlined in Table 2.
The implementation date is the date the COVID-19 section 319 PHE declaration expires or 45 days after the finalization of this guidance, whichever comes later. Because the COVID-19 section 319 PHE declaration is anticipated to expire at least 45 days after the finalization of this guidance, or May 11, 2023, the implementation date is that date. The guidance documents identified in List 1 will no longer be in effect after the 180-day transition period ends, or after November 7, 2023.
A timeline for this process is provided in Figure 1.
_Timeline diagram showing the three-phase transition period: Phase 1 begins on implementation date (May 11, 2023), Phase 2 starts 90 days later (August 9, 2023), and Phase 3 starts 180 days later (November 7, 2023), when enforcement policies in List 1 expire._
**Figure 1. Transition Timeline. Implementation date occurring on the date the COVID-19 section 319 PHE declaration expires.**
In the bullets below, FDA describes our transition period expectations and recommendations for all manufacturers that distributed devices as described in an enforcement policy in a guidance in List 1, both for those who do and do not pursue marketing authorization for their devices. FDA believes these expectations and recommendations will help facilitate a smooth and consistent transition to normal operations.
A summary of the three phases are as follows:
- **Phase 1**: Begins on the implementation date. If not already doing so, manufacturers should follow 21 CFR Part 803 (i.e., adverse event reporting requirements) in order to prepare for Phase 3.
- **Phase 2**: Begins 90 days after the implementation date. Before the start of Phase 2 and in order to prepare for Phase 3, if not already doing so, manufacturers should: (1) follow 21 CFR Part 806 (i.e., reports of corrections and removals requirements), and (2) if planning to continue to distribute their devices after Phase 2, should also follow 21 CFR Part 807 Subparts B-D (i.e., registration and listing requirements).
- **Phase 3**: Begins 180 days after the implementation date. After the 180-day transition period ends, the guidances in List 1 will no longer be in effect. At this time, FDA does not intend to object to continued distribution of devices within the scope of this guidance where a required marketing submission has been submitted and accepted[^35^] by FDA before the start of Phase 3 and FDA has not taken a final action[^36^] on the marketing submission. In addition, for these same devices, while the device is under FDA review, FDA does not intend to object to the devices not complying with certain Unique Device Identification (UDI) requirements (see 21 CFR Part 801 Subpart B) and other applicable labeling requirements (see 21 CFR Part 801) (see Section V.D.(1) of this guidance). This enforcement policy does not apply to other legal requirements (such as registration and listing, Quality System (QS), and reports of corrections and removals requirements under 21 CFR Parts 807, 820, and 806, respectively).
The three phases of the transition plan, including additional considerations and recommendations related to each phase, are described in more detail below.
FDA recommends manufacturers submit a “Transition Implementation Plan” with their marketing submission that addresses the manufacturers’ plans for dealing with devices already distributed in the case of a positive decision as well as in the case of a negative decision on the marketing submission (see Section V.D.(2) of this guidance). The marketing submission should be administratively complete in that it includes all of the information necessary for FDA to conduct a substantive review.[^37^] FDA understands there may be extenuating circumstances that make doing so difficult (e.g., ongoing clinical trial or longer term non-clinical studies). Manufacturers in such circumstances should engage with the Agency early in the transition period.[^38^]
FDA understands there may be other circumstances that are not specifically addressed in this guidance, but generally believes that the policies and recommendations described in Table 2, regardless of the specific scenario for a manufacturer, will help avoid disruptions in critical devices and allow FDA to best manage its resources for review of marketing submissions. To address any unique considerations or other issues not otherwise discussed in this guidance, manufacturers may wish to initiate discussions with the Agency through the Q-Submission Program, including requesting feedback in Pre-Submissions. If the manufacturer’s intent is to continue to distribute its device after Phase 2, the manufacturer should promptly start preparing, and FDA intends to help facilitate acceptance of, a marketing submission before Phase 3 begins. For details on the Q-Submission Program, refer to the guidance “[Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program.](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program)”[^39^]
### A. Devices not distributed after Phase 2
When a manufacturer that has been distributing its device as described in an enforcement policy in a guidance in List 1 does not intend to continue to distribute its device after Phase 2, at this time, FDA does not intend to object to the disposition and use[^40^] of already distributed devices (i.e., FDA does not intend to request market removal[^41^]) as follows:
1. Single-use, non-life-supporting/non-life-sustaining devices (e.g., face masks) that were distributed before the end of Phase 2 are used by the end user prior to the product expiration date, as applicable.
2. Reusable, non-life-supporting/non-life-sustaining devices (e.g., infusion pumps) that were distributed before the end of Phase 2 are used by their end user and either:
a. Are restored[^42^] by the manufacturer to an FDA-cleared or -approved version of the device,[^43^] or
b. Have[^44^] a physical and/or electronic copy of updated labeling that accurately describes the product features and regulatory status (e.g., that the product lacks FDA clearance, approval, or authorization).
3. Reusable life-supporting/life-sustaining devices (e.g., ventilators, extracorporeal membrane oxygenation systems) that were distributed before the end of Phase 2 are restored[^45^] by the manufacturer to an FDA-cleared or -approved version of the device[^46^] so that they may be used by their end user. If not restored, a physical and/or electronic copy of updated labeling that accurately describes the product features and regulatory status (e.g., that the product lacks FDA clearance, approval, or authorization) should be provided,[^47^] and such devices are not to be used.[^48^,^49^] To help ensure accessibility to updated labeling, FDA recommends that stakeholders be provided an opportunity to request a physical copy of updated labeling, and after such request, be provided the requested labeling without additional cost.
Manufacturers that do not intend to distribute their devices after Phase 2 should also refer to relevant information included in other sections of this guidance (though note that recommendations in Section V.D.(1) are intended only for manufacturers that intend to distribute their device after the end of Phase 2). In addition, manufacturers should be aware of any applicable legal requirements for their device, such as adverse event reporting under 21 CFR Part 803, and are expected to comply with such requirements for the duration in which they are applicable, which may extend beyond the cessation of distribution.
Manufacturers may also voluntarily withdraw their devices from the market. For manufacturers that do not intend to continue distributing their devices and that intend to voluntarily withdraw their devices from the market, FDA recommends completing withdrawal of the devices from the market prior to the withdrawal of the guidances in List 1; otherwise, if withdrawal of the devices from the market is not completed prior to the withdrawal of the guidances in List 1, FDA recommends restoring and/or updating labeling for reusable non-life-supporting/non-life-sustaining devices and for reusable life-supporting/life-sustaining devices as outlined in the policy above prior to the withdrawal of the guidances in List 1. Manufacturers should be aware of any applicable legal requirements for their device, such as adverse event reporting under 21 CFR Part 803, and continue to comply with such requirements for the duration in which they are applicable, which may extend beyond the cessation of distribution or withdrawal. Generally, it is anticipated that, over time, legal requirements will no longer apply when the manufacturer’s device withdrawal activities are completed.
FDA encourages manufacturers that do not intend to continue to distribute their devices after Phase 2 to communicate with device distributors, healthcare facilities, healthcare providers, patients, and consumers, as appropriate, regarding their product disposition to assist all stakeholders with transition planning. In addition, thinking through elements of the “Transition Implementation Plan” outlined in Section V.D.(2) of this guidance may help manufacturers and stakeholders with this process.
### B. Phase 1
Phase 1 starts on the implementation date, as described above. In order to prepare for Phase 3, if not already doing so, manufacturers should follow adverse event reporting requirements[^50] under 21 CFR Part 803. Manufacturers should submit any adverse event reports that were stored (e.g., because of pandemic-related high employee absenteeism) and should refer to applicable FDA guidance regarding adverse event reporting during a pandemic.
During (and preferably before the start of) this phase, manufacturers that intend to continue distribution of their devices after Phase 2 should begin preparation of any required marketing submission to help avoid disruptions in critical devices and allow FDA to best manage its resources for review of marketing submissions. While preparing a marketing submission, manufacturers can use the [FDA Guidance Search Tool](https://www.fda.gov/regulatory-information/search-fda-guidance-documents) to identify relevant guidance documents that may be helpful in preparing the submission.
FDA is taking into account that the use of devices during the COVID-19 pandemic may allow manufacturers to utilize a variety of data sources in their marketing submission. As such, FDA anticipates many manufacturers may wish to reference data from related marketing authorizations and submissions, and use real-world data obtained as a result of device use during the COVID-19 pandemic.[^52] FDA recommends that marketing submissions include in the cover letter a statement that the device was distributed as described in an enforcement policy, as well as submission number(s) for related premarket submissions. This information will help FDA track devices that are transitioning to the required marketing authorization,[^53] facilitate review of the submission, and help ensure that the transitioning devices can be appropriately considered in light of the policy described in Section V.D.(1) of this guidance.
### C. Phase 2
Phase 2 begins 90 days after the implementation date. Before the start of Phase 2 and in order to prepare for Phase 3, if not already doing so, manufacturers should follow correction and removal requirements under 21 CFR Part 806. Before the start of Phase 2, manufacturers that intend to continue to distribute their devices after Phase 2 should also register their establishments and list[^54] their device(s) or update existing registration and listing (R&L) if they have not already done so. For manufacturers that register and list by the start of Phase 2, FDA recommends that manufacturers utilize the term “enforcement” (as a shorthand for “enforcement policy”) in the premarket submission field if a submission number is not yet available. If the device subsequently receives marketing authorization, FDA expects manufacturers to comply with all applicable registration and listing requirements, which may require updating the listing information.
As discussed above, manufacturers that intend to continue to distribute their devices after Phase 2 should continue preparation of any required marketing submission[^55] as FDA expects such manufacturers to submit a marketing submission to FDA and have it accepted before the start of Phase 3 to help avoid disruptions in critical devices and allow FDA to best manage its resources for review of marketing submissions.
In addition, FDA recommends that manufacturers of certain life-supporting or life-sustaining devices within the scope of this guidance – regardless of whether they intend to continue distribution of their devices after Phase 2 – submit a “Notification of Intent” to FDA as described in Section V.C.(1) of this guidance.
#### (1) “Notifications of Intent” for Certain Reusable Life-Supporting or Life-Sustaining Devices
Given the public health significance of certain reusable life-supporting or life-sustaining devices, FDA requests that manufacturers of such devices submit to FDA information about whether or not they intend to submit a marketing submission to FDA and continue distributing their product after Phase 2. This information will assist the Agency in resource planning for marketing submission review and providing support to manufacturers. This request applies to devices that fall within the scope of this guidance and that have a product code listed in Table 1:
| Product Code | Device Type | Classification Regulation |
|--------------|------------------------------------------------------------|---------------------------|
| BSZ | Gas-machine, anesthesia | 21 CFR 868.5160 |
| CAW | Generator, oxygen, portable | 21 CFR 868.5440 |
| BTT | Humidifier, respiratory gas, (direct patient interface) | 21 CFR 868.5450 |
| QAV | High flow/high velocity humidified oxygen delivery device | 21 CFR 868.5454 |
| CBK | Ventilator, continuous, facility use | 21 CFR 868.5895 |
| MNT | Ventilator, continuous, minimal ventilatory support, facility use | 21 CFR 868.5895 |
| NOU | Continuous, ventilator, home use | 21 CFR 868.5895 |
| MNS | Ventilator, continuous, non-life-supporting | 21 CFR 868.5895 |
| ONZ | Mechanical ventilator | 21 CFR 868.5895 |
| BTL | Ventilator, emergency, powered (resuscitator) | 21 CFR 868.5925 |
||
Manufacturers of the devices identified in Table 1 should submit the following information to the CDRH Document Control Center[^56] before the start of Phase 2:[^57]
- General information about the manufacturer, including contact information, name and place of business, and email address;
- Title of the relevant enforcement policy guidance;
- Submission number(s) for related premarket submissions;
- A list of all model numbers or other device identifying information;
- Whether the manufacturer plans to submit a marketing submission; and
- If not planning to submit a marketing submission, the manufacturer should discuss, as applicable, its plans to discontinue distribution of the device, to restore the device to an FDA-cleared or -approved version, to provide a physical copy and/or electronic copy of updated labeling, and any other efforts to address or mitigate potential risks of devices that remain distributed after Phase 2.
If another version of the device is FDA-cleared or -approved and a modified version is/was distributed as described in a policy in a guidance in List 1, the manufacturer should submit this information in a premarket notification (i.e., 510(k)) or PMA “amendment” for the cleared or approved device.[^58] FDA recommends that manufacturers notate the following on the cover letter of the submission: “Attention: Notification of Intent.” To the extent the Notification of Intent contains trade secret information or confidential commercial or financial information, FDA will handle that information in accordance with applicable laws, including 21 CFR 20.61.
### D. Phase 3
Phase 3 begins 180 days after the implementation date. After the 180-day transition period ends, the guidances in List 1 will no longer be in effect. Before the start of Phase 3, any required marketing submission[^59] is expected to be submitted to and accepted by FDA if the manufacturer intends to continue distribution of the device after Phase 2. Where possible, FDA strongly encourages manufacturers to work to complete such submissions well in advance of the start of Phase 3 to avoid potential delays created by a large influx of new submissions and to best serve the public health.
#### (1) Enforcement policy for devices with a marketing submission under review by FDA
As previously stated, FDA recognizes that it may take time for device manufacturers, including non-traditional device manufacturers, to adapt and adjust from their operations during the COVID-19 PHE to normal operations. As such, at this time, FDA does not intend to object to the continued distribution of devices within the scope of this guidance after the guidances in List 1 are no longer in effect where:
- The manufacturer has submitted a marketing submission to FDA and it is accepted by FDA before the start of Phase 3; and
- FDA has not taken a final action on the marketing submission.
For these same devices, while the device is under FDA review, FDA does not intend to object to the devices not complying with certain UDI requirements (see 21 CFR Part 801 Subpart B) or other applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as described in the relevant List 1 guidance. As always, FDA will make case-by-case decisions regarding the enforcement of legal requirements in response to particular circumstances and questions that arise regarding a specific device or device type.
The enforcement policy in this section (Section V.D.(1)) relates to FDA marketing authorization (e.g., 510(k) clearance), and certain UDI and other applicable labeling requirements. It does not apply to other legal requirements (such as registration and listing, QS, and reports of corrections and removals requirements under 21 CFR Parts 807, 820, and 806, respectively) that may apply. Moreover, it does not apply after FDA has taken a final action on the marketing submission for a device. At that time, FDA expects manufacturers to comply with all applicable regulatory requirements for the device/manufacturer. Following the device’s marketing authorization, this includes labeling updates (see 21 CFR Part 801), compliance with UDI requirements (see 21 CFR Part 801 Subpart B and Part 830), and any applicable updates to registration and listing information, including the submission number (see 21 CFR Part 807 Subparts B-D). After marketing authorization, manufacturers also should follow the steps outlined in their Transition Implementation Plan.
In addition, and as always, FDA will make case-by-case decisions regarding the enforcement of legal requirements in response to particular circumstances and questions that arise regarding a specific device or device type. This may include FDA requesting a firm initiate a recall (see 21 CFR 7.45) or taking other actions, including an enforcement action. Moreover, FDA may revise the enforcement policies and recommendations in the guidance, as appropriate.
As mentioned previously, FDA recommends that marketing submissions include in the cover letter a statement that the device is/was distributed as described in an enforcement policy, and submission number(s) for related premarket submissions. This information will help FDA track devices that are transitioning to the required marketing authorization, facilitate review of the submission, and help ensure that transitioning devices can be appropriately considered in light of the policy described in this section (Section V.D.(1) of this guidance). The marketing submission should be administratively complete in that it includes all of the information necessary for FDA to conduct a substantive review. FDA understands there may be extenuating circumstances that may make doing so difficult (e.g., ongoing clinical trial or longer term non-clinical studies). Manufacturers in such circumstances should engage with the Agency early in the transition period.
In addition, during this transition period and after the start of Phase 3, FDA may receive questions from stakeholders (e.g., other Agencies, governmental stockpilers, healthcare providers) about a device’s regulatory status for devices distributed as described in this section (Section V.D.(1)) while the marketing submission is under review by FDA. Typically, if a device has an EUA or conventional marketing authorization (e.g., 510(k) clearance), this information would be publicly available. The existence of a marketing submission under review is not typically disclosed unless certain circumstances apply, such as when the device is on the market. As such, for devices distributed as described in this section, FDA may share that a manufacturer is distributing such device as described in the policy in this guidance, which could indirectly reveal that the manufacturer has a marketing submission under review by FDA.
#### (2) Recommendations for “Transition Implementation Plan”
FDA anticipates that some marketing submissions will include changes or updates to the device and/or its labeling compared to the product that was distributed as described in the relevant guidance in List 1. For example, a manufacturer may have distributed fetal dopplers as described in an enforcement policy, and the manufacturer intends to submit a marketing submission for such fetal dopplers with an additional, new indication. In addition, in some cases, a manufacturer may not receive a positive decision from FDA on its marketing submission.
To help address all of these situations efficiently, FDA recommends manufacturers include in the cover letter of their marketing submissions a “Transition Implementation Plan” that addresses the manufacturers’ plans for dealing with devices already distributed in the case of a positive decision as well as in the case of a negative decision on the marketing submission. To the extent the Transition Implementation Plan contains trade secret information or confidential commercial or financial information, FDA will handle that information in accordance with applicable laws, including 21 CFR 20.61.
FDA recommends the Transition Implementation Plan include the following information, as applicable:
- Estimated number of devices that fall within the policies outlined in any of the guidances referenced in List 1 above that are currently in U.S. distribution;
- An explanation of the manufacturer’s benefit-risk based plan for disposition of already distributed product in the event of a negative decision on the marketing submission. If the manufacturer is proposing to leave already distributed product in place, the plan should address the rationale for doing so and considerations such as the following, where relevant:
- Process for notifying patients, consumers, healthcare facilities, healthcare providers, and device distributors of the device’s regulatory status;
- Process and timeline for restoring already distributed devices to an FDA-cleared or -approved version;
- Process and timeline for providing a physical and/or electronic copy of updated labeling that accurately describes the product features and regulatory status (e.g., that the product lacks FDA clearance, approval, or authorization) for reusable devices. To help ensure accessibility to updated labeling for reusable life-supporting/life-sustaining devices, FDA recommends that stakeholders be provided an opportunity to request a physical copy of updated labeling, and after such request, be provided the requested labeling without additional cost; and
- A description of the maintenance plan for already distributed devices.
- An explanation of the manufacturer’s plans for addressing already distributed product in the event of a positive decision on the marketing submission, including considerations such as the following, where relevant:
- Process for notifying patients, consumers, healthcare facilities, healthcare providers, and device distributors of the device’s regulatory status; and
- Process and timeline for providing to users of already distributed devices updated labeling or components for the cleared or approved device, including updated labeling or components to reflect any cleared/approved changes to the already distributed device.
FDA encourages manufacturers to collaborate with device distributors, healthcare facilities, healthcare providers, patients, and consumers, as appropriate, regarding their Transition Implementation Plan to assist all stakeholders with transition planning.
Depending on FDA’s evaluation of the marketing submission, FDA may engage with the manufacturer during the Agency’s review of the submission to discuss the appropriate disposition of already distributed devices described in the Transition Implementation Plan. For marketing submissions that include changes to the device compared to the already distributed device (e.g., modifications to address a cybersecurity concern), the manufacturer should discuss possible correction or removal with FDA regarding devices already distributed to the end user, as needed. As always, FDA will make case-by-case decisions regarding the enforcement of legal requirements in response to particular circumstances and questions that arise regarding a specific device or device type (e.g., requesting a firm initiate a recall, see 21 CFR 7.45), or taking other actions, including an enforcement action.
### E. Discontinuing distribution of a device
FDA expects manufacturers to discontinue distribution of a device within the scope of this guidance:
1) Before the start of Phase 3, if the manufacturer has not submitted a required marketing submission for its device and had it accepted by FDA before the start of Phase 3; or
2) On the date the manufacturer receives a negative decision on its marketing submission as FDA’s final action, or on the date the manufacturer withdraws its submission or fails to provide a complete response to an FDA request for additional information within the allotted time identified in FDA’s letter.
In addition, manufacturers should be aware of any applicable legal requirements for their device, such as adverse event reporting under 21 CFR Part 803, and continue to comply with such requirements for the duration in which they are applicable, which may extend beyond the cessation of distribution.
FDA encourages manufacturers to communicate with device distributors, healthcare facilities, healthcare providers, patients, and consumers, as appropriate, regarding their product disposition to assist all stakeholders with transition planning.
### F. Quality System considerations
FDA recognizes that there may be situations that raise unique compliance considerations, particularly regarding QS requirements. For example, non-traditional device manufacturers that previously operated under different quality standards or requirements may face challenges that take more time to address in transitioning to a system that fully complies with 21 CFR Part 820. FDA intends to take such considerations into account when making case-by-case compliance and enforcement decisions. Some manufacturers who intend to continue distributing their devices beyond Phase 2 may choose to request an exemption or variance from a device QS requirement as outlined in 21 CFR 820.1(e) and section 520(f)(2) of the FD&C Act. Any such exemption or variance should be requested within 90 days of the announcement of the implementation date for this guidance to help ensure FDA considers your request in time.
## VI. Examples
The following hypothetical examples are intended to illustrate the phased transition plan outlined above. To exemplify the timeline of the phased transition plan outlined in Section V. of this guidance, for purposes of the examples, FDA set the implementation date for all devices that fall within this enforcement policy as the implementation date, May 11, 2023, consistent with the timeline shown in Figure 1. The dates outlined in each example follow this example phased transition plan timeline. Note that these generalized examples do not account for every possible detail, risk, or consideration a manufacturer should evaluate or that may be relevant to FDA decisions regarding a particular device.
### Example 1
A 510(k)-cleared fetal doppler was modified to add Bluetooth functionality as described in the policies in the guidance, “[Enforcement Policy for Non-Invasive Fetal and Maternal Monitoring Devices Used to Support Patient Monitoring During the COVID-19 Public Health Emergency.](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-non-invasive-fetal-and-maternal-monitoring-devices-used-support-patient)”
#### a) Manufacturer who intends to continue distributing beyond Phase 2 and receives a positive decision on its marketing submission
**Phase 1 (May 11, 2023)**
In the above-referenced guidance, FDA describes its intent not to object to modification of certain fetal dopplers in certain circumstances without marketing authorization by FDA. The enforcement policy in the guidance does not address other requirements, including adverse event reporting, reports of corrections and removals, and QS requirements. The manufacturer continues to comply with requirements under 21 CFR Parts 803, 806, and 820.
**Phase 2 (August 9, 2023)**
As an indication of its intent to market its device beyond Phase 2, the fetal doppler manufacturer updates its existing listing under 21 CFR Part 807 Subparts B-D, as applicable. On October 1, 2023, the manufacturer submits a marketing submission to FDA, which is accepted by the Agency. Along with its marketing submission, the manufacturer includes a “Transition Implementation Plan” for already distributed fetal dopplers in the case of a positive decision as well as in the case of a negative decision on the marketing submission.
**Phase 3 (November 7, 2023)**
The above-referenced guidance is no longer in effect after the 180-day transition period ends, and FDA has not yet taken a final action on the manufacturer’s marketing submission. Under these circumstances, FDA does not intend to object to the continued distribution of the fetal doppler before FDA takes a final action on the marketing submission (see Section V.D.(1) of this guidance). The manufacturer continues to comply with all other legal requirements applicable to the device (such as registration and listing, QS, and reports of corrections and removals requirements under 21 CFR Parts 807, 820, and 806). Additionally, the manufacturer has kept the device labeling as described in the labeling recommendations provided in the above-referenced guidance. Under these circumstances, FDA does not intend to object to the device labeling not complying with applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as described in the relevant List 1 guidance while the marketing submission is under FDA review (see Section V.D.(1) of this guidance).
The manufacturer receives a positive decision on its marketing submission on December 29, 2023 (90 days after submission), although outstanding software anomalies were identified and modifications to the device were made during FDA’s premarket review. Based on the Transition Implementation Plan included with the marketing submission, FDA is aware of the number of already distributed devices that may have these anomalies and engages with the manufacturer on how to address these issues with the already distributed devices and provide updated electronic labeling to the relevant stakeholders. The manufacturer initiates a correction to address the software anomalies in the fetal dopplers that were distributed prior to the positive marketing decision.
Additionally, as part of its Transition Implementation Plan, the manufacturer updates its website to add the updated device labeling. All devices distributed after receiving the positive decision will have the updated labeling.
#### b) Manufacturer who intends to continue distribution beyond Phase 2 and receives a negative decision on its marketing submission
**Phase 1 (May 11, 2023)**
In the above-referenced guidance, FDA describes its intent not to object to modification of certain fetal dopplers in certain circumstances without marketing authorization by FDA. The enforcement policy in the guidance does not address other requirements, including adverse event reporting, reports of corrections and removals, and QS requirements. The manufacturer continues to comply with requirements under 21 CFR Parts 803, 806, and 820.
**Phase 2 (August 9, 2023)**
As an indication of its intent to market its device beyond Phase 2, the fetal doppler manufacturer updates its existing listing under 21 CFR Part 807 Subparts B-D, as applicable. On October 1, 2023, the manufacturer submits a marketing submission to FDA, which is accepted by the Agency. Along with its marketing submission, the manufacturer includes a “Transition Implementation Plan” for already-distributed fetal dopplers in the case of a positive decision as well as in the case of a negative decision on the marketing submission.
**Phase 3 (November 7, 2023)**
The above-referenced guidance is no longer in effect after the 180-day transition period ends, and FDA has not yet taken a final action on the manufacturer’s marketing submission. Under these circumstances, FDA does not intend to object to the continued distribution of the fetal doppler before FDA takes a final action on the marketing submission (see Section V.D.(1) of this guidance). The manufacturer continues to comply with all other legal requirements applicable to the device (such as registration and listing, QS, and reports of corrections and removals requirements under 21 CFR Parts 807, 820, and 806). Additionally, the manufacturer has kept the device labeling as described in the labeling recommendations provided in the above-referenced guidance. Under these circumstances, FDA does not intend to object to the device labeling not complying with applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as described in the relevant List 1 guidance while the marketing submission is under FDA review (see Section V.D.(1) of this guidance).
The manufacturer receives a negative decision on its marketing submission on January 15, 2024 (90 days after submission), due to outstanding software anomalies that were identified and could not be addressed by the manufacturer during FDA’s premarket review. As described in the Transition Implementation Plan included with the marketing submission, the manufacturer initiates a correction to restore the fetal doppler to the FDA-cleared version. In addition, the manufacturer ceases distributing the modified device.
### Example 2
A FDA-cleared diagnostic x-ray system was modified to become portable and falls within the enforcement policy described in the guidance [“Enforcement Policy for Imaging Systems During the COVID-19 Public Health Emergency.”](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-imaging-systems-during-coronavirus-disease-2019-covid-19-public-health-emergency)
**Phase 1 (May 11, 2023)**
In the above-referenced guidance, FDA describes its intent not to object to modifications to certain imaging systems in certain circumstances without marketing authorization by FDA. The enforcement policy in the guidance does not address other requirements, including requirements in 21 CFR Parts 803, 807 Subparts B-D, 806, 820, and 830. The manufacturer continues to comply with these requirements.
**Phase 2 (August 9, 2023)**
As an indication of its intent to market its device beyond Phase 2, the portable x-ray system manufacturer updates its existing listing, under 21 CFR Part 807 Subparts B-D, as applicable. On September 29, 2023, the manufacturer submits a marketing submission to FDA, which is accepted by the Agency. In its marketing submission, the manufacturer includes a “Transition Implementation Plan” for already-distributed portable x-ray systems in the case of a positive decision as well as in the case of a negative decision on the marketing submission.
**Phase 3 (November 7, 2023)**
The above-referenced guidance is no longer in effect after the 180-day transition period ends, and FDA has not yet taken a final action on the manufacturer’s marketing submission. Under these circumstances, FDA does not intend to object to the continued distribution of the portable x-ray system before FDA takes a final action on the marketing submission (see Section V.D.(1) of this guidance). The manufacturer continues to comply with all other legal requirements applicable to the device (such as registration and listing, QS, and reports of corrections and removals requirements under 21 CFR Parts 807, 820, and 806). Additionally, the manufacturer has kept the device labeling as described in the labeling recommendations provided in the above-referenced guidance. Under these circumstances, FDA does not intend to object to the device labeling not complying with applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as described in the relevant List 1 guidance while the marketing submission is under FDA review (see Section V.D.(1) of this guidance).
The manufacturer does not respond to a request from FDA for additional information within the specified timeframe identified in the Agency’s deficiency letter. FDA issues a notice of withdrawal as the Agency’s final action on the marketing submission on March 15, 2024. FDA and the manufacturer engage regarding the manufacturer’s Transition Implementation Plan to address already distributed devices. The diagnostic x-ray is a reusable, non-life-supporting/non-life-sustaining device; as such, the manufacturer, following the Transition Implementation Plan, updates its website to accurately describe the product features and regulatory status of the already distributed, modified devices. FDA may request the firm initiate a recall of such devices in certain circumstances if a recall has not already been initiated (see 21 CFR 7.45). In addition, the manufacturer ceases distributing the modified device.
### Example 3
A FDA-cleared ventilator was modified to make material changes to components in the gas pathway to accommodate supplier shortages and falls within the enforcement policy described in the guidance, [“Enforcement Policy for Ventilators and Accessories and Other Respiratory Devices During the COVID-19 Public Health Emergency.”](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-ventilators-and-accessories-and-other-respiratory-devices-during-coronavirus)
**Phase 1 (May 11, 2023)**
In the above-referenced guidance, FDA describes its intent not to object to modifications to ventilators in certain circumstances without marketing authorization by FDA. The enforcement policy in the guidance does not address other requirements, including requirements in 21 CFR Parts 803, 807 Subparts B-D, 806, and 820, and 830. The manufacturer continues to comply with these requirements.
**Phase 2 (August 9, 2023):**
As an indication of its intent to market its device beyond Phase 2, the ventilator manufacturer updates its existing listing, under 21 CFR Part 807 Subparts B-D, as applicable. On October 1, 2023, the ventilator manufacturer also submits an amendment to the manufacturer’s previously cleared marketing submission to the CDRH Document Control Center with “Attention: Notification of Intent” on the cover letter of the submission to describe the manufacturer’s intent to submit a marketing submission. This submission amendment includes the information outlined in Section V.C.(1) of this guidance. In its marketing submission that was accepted by the Agency on December 20, the manufacturer includes a “Transition Implementation Plan” for already distributed ventilators in the case of a positive decision as well as in the case of a negative decision on the marketing submission.
**Phase 3 (November 7, 2023):**
The above-referenced guidance is no longer in effect after the 180-day transition period ends, and FDA has not yet taken a final action on the manufacturer’s marketing submission. Under these circumstances, FDA does not intend to object to the continued distribution of the ventilator before FDA takes a final action on the marketing submission (see Section V.D.(1) of this guidance). The manufacturer continues to comply with all other legal requirements applicable to the device (such as registration and listing, QS, and reports of corrections and removals requirements under 21 CFR Parts 807, 820, and 806). Additionally, the manufacturer has kept the device labeling as described in the labeling recommendations provided in the above-referenced guidance. Under these circumstances, FDA does not intend to object to the device labeling not complying with applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as described in the relevant List 1 guidance while the marketing submission is under FDA review (see Section V.D.(1) of this guidance).
The ventilator manufacturer receives a positive decision on its marketing submission on January 2, 2024. The manufacturer continues to distribute the modified ventilator with updated labeling. In addition, the manufacturer communicates with users of the modified ventilator, distributed as described in the above-referenced guidance, apprising them of the regulatory status of the device and providing updated electronic labeling.
### Example 4
A new telethermographic system that has not been FDA-cleared and is intended for adjunctive diagnostic screening by providing an initial body temperature assessment for triage use, falls within the enforcement policy described in the guidance, “Enforcement Policy for Telethermographic Systems During the COVID-19 Public Health Emergency.”[^83]
#### a) Manufacturer who intends to continue distribution beyond Phase 2
**Phase 1 (May 11, 2023):**
In the guidance, FDA describes its intent not to object to the distribution and use of certain telethermographic systems without submission of a 510(k), reports of corrections and removals, registration and listing, and compliance with the QS regulation and UDI, and other applicable labeling requirements in certain circumstances. The enforcement policy in the guidance does not address other requirements, including requirements in 21 CFR Part 803. The manufacturer continues to comply with 21 CFR Part 803.
**Phase 2 (August 9, 2023):**
As an indication of its intent to market its device beyond Phase 2, the telethermographic system manufacturer registers and lists, consistent with 21 CFR Part 807 Subparts B-D, as applicable. On October 5, 2023, the manufacturer submits a marketing submission to FDA, which is accepted by the Agency. In its marketing submission, the manufacturer includes a “Transition Implementation Plan” for already distributed telethermographic systems in the case of a positive decision as well as in the case of a negative decision on the marketing submission.
**Phase 3 (November 7, 2023):**
The above-referenced guidance is no longer in effect after the 180-day transition period ends, and FDA has not yet taken a final action on the manufacturer’s marketing submission. The manufacturer complies with all other legal requirements applicable to the device (such as registration and listing, QS, and reports of corrections and removals requirements under 21 CFR Parts 807, 820, and 806). Additionally, the manufacturer has kept the device labeling as described in the labeling recommendations provided in the above-referenced guidance. Under these circumstances, FDA does not intend to object to the device labeling not complying with applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as described in the relevant List 1 guidance while the marketing submission is under FDA review (see Section V.D.(1) of this guidance).
The manufacturer receives a “not substantially equivalent” decision on January 3, 2024, after FDA’s review of the manufacturer’s marketing submission. The manufacturer ceases distributing the telethermographic system. FDA and the manufacturer engage regarding the manufacturer’s Transition Implementation Plan to address already distributed devices. FDA may request the firm initiate a recall of such devices in certain circumstances if a recall has not already been initiated (see 21 CFR 7.45).
#### b) Manufacturer who does not intend to continue distribution beyond Phase 2
A new telethermographic system that has not been FDA-cleared and is intended for adjunctive diagnostic screening by providing an initial body temperature assessment for triage use was distributed under the enforcement policy described in the guidance, “[Enforcement Policy for Telethermographic Systems During the COVID-19 Public Health Emergency.](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-telethermographic-systems-during-coronavirus-disease-2019-covid-19-public-health)”[^84]
**Phase 1 (May 11, 2023):**
In the above-referenced guidance, FDA describes its intent not to object to the distribution and use of a certain telethermographic system without submission of a 510(k), reports of corrections and removals, registration and listing, and compliance with the QS regulation, UDI, and other applicable labeling requirements in certain circumstances. The enforcement policy in the guidance does not address other requirements, including 21 CFR Part 803. The manufacturer continues to comply with 21 CFR Part 803.
**Phase 2 (August 9, 2023):**
The manufacturer decides that it does not want to continue to market and distribute the device beyond Phase 2. The manufacturer ceases distributing the device on November 1, 2023. The telethermographic system is a reusable, non-life-supporting/non-life-sustaining device. Devices that were distributed before the end of Phase 2 remain distributed. In addition, the manufacturer continues to report adverse events that it becomes aware of, even after the manufacturer has ceased distributing the telethermographic system.
**Phase 3 (November 7, 2023):**
The above-referenced guidance is no longer in effect after the 180-day transition period ends. Prior to the start of Phase 3, the manufacturer provides updated electronic labeling for the telethermographic system, and such labeling accurately describes all product features and notes that the product is not FDA-cleared, -approved, or -authorized for marketing. The manufacturer leaves already distributed telethermographic systems in the field. The manufacturer continues to engage in adverse event reporting to FDA concerning the device.
**Table 2. Summary of Recommendations for a Phased Transition**
| **PHASE** | 1 | 2 | 3 |
|-----------|---|---|---|
| **STARTING TIME** | 0 days (implementation date – May 11, 2023) | 90 days after the implementation date – August 9, 2023 | 180 days after the implementation date – November 7, 2023 |
| **ACTIONS** | Manufacturers should, if not already doing so, follow adverse event reporting requirements under 21 CFR Part 803. Manufacturers should submit any stored adverse event reports and should refer to applicable [FDA guidance](#) regarding adverse event reporting during a pandemic. Manufacturers that intend to continue distribution of their devices after Phase 2 should begin to prepare their required marketing submissions. | Before the start of Phase 2, manufacturers that intend to continue to continue to distribute their devices after Phase 2 should register their establishments and list their device(s), or update their existing registration and listing, under 21 CFR Part 807 Subparts B-D, as applicable. Before the start of Phase 2, if not already doing so, manufacturers should submit reports of corrections and removals consistent with 21 CFR Part 806 (regardless of whether they intend to continue distribution of their devices after Phase 2). Manufacturers of devices under the product codes listed in Table 1 of this guidance should send a Notification of Intent to FDA (regardless of whether they intend to continue distribution of their devices after Phase 2). Manufacturers that intend to distribute their devices after Phase 2 should continue to prepare to submit a marketing submission to FDA and have it accepted by FDA before the start of Phase 3. | After the 180-day transition period ends, the List 1 guidances containing COVID-19 related enforcement policies will no longer be in effect. Before the start of Phase 3, if manufacturers submit a marketing submission(s), and that submission is accepted by FDA, at this time, FDA does not intend to object to the continued distribution of the device after Phase 2 as described in Section V.D.(1) of this guidance. With the marketing submission, the manufacturer should include a "Transition Implementation Plan" that addresses the manufacturer's plans for devices already in distribution in the case of a positive decision or a negative decision on the marketing submission. FDA recommends that the Transition Implementation Plan include the information in Section V.D.(2) of this guidance, as applicable. Moreover, for devices for which FDA has accepted a marketing submission prior to the start of Phase 3, FDA does not intend at this time to object to the devices not complying with certain UDI and other applicable labeling requirements where they are labeled as described in the relevant List 1 guidance. This enforcement policy does not apply to other applicable legal requirements (such as registration and listing, QS, and reports of corrections and removals requirements under 21 CFR Parts 807, 820, and 806, respectively). |
||
---
[^1]: Section 201(h)(1) of the Federal Food, Drug, and Cosmetic Act provides that the term “device” means: “an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is—
(A) recognized in the official National Formulary, or the United States Pharmacopeia, or any supplement to them,
(B) intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals, or
(C) intended to affect the structure or any function of the body of man or other animals, and which does not achieve its primary intended purposes through chemical action within or on the body of man or other animals and which is not dependent upon being metabolized for the achievement of its primary intended purposes. The term ‘device’ does not include software functions excluded pursuant to section 520(o)” of the Federal Food, Drug, and Cosmetic Act.
[^2]: Throughout this guidance, when describing policies for devices that fall within enforcement policies issued during the COVID-19 public health emergency declared under section 319 of the Public Health Service Act, FDA uses the term “manufacturer” to refer to any person who designs, manufactures, fabricates, assembles, or processes a finished device. See 21 CFR 820.3(o). Other entities, including those that introduce such devices into commercial distribution, such as initial importers and certain distributors, should ensure they understand, and where applicable, they should follow, the recommendations that pertain to such devices.
[^3]: Throughout this guidance, FDA refers to “normal operations” as a shorthand for the circumstances when the declaration of the PHE related to COVID-19 under section 319 of the Public Health Service Act has expired and/or the relevant device emergency use declarations related to COVID-19 under section 564 of the Federal Food, Drug, and Cosmetic Act are terminated.
[^4]: The guidance “Transition Plan for Medical Devices Issued Emergency Use Authorizations (EUAs) Related to Coronavirus Disease 2019 (COVID-19),” available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-issued-emergency-use-authorizations-euas-related-coronavirus-disease](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-issued-emergency-use-authorizations-euas-related-coronavirus-disease), will be referred to as the “companion transition guidance” in the remainder of this guidance.
[^5]: Secretary of Health and Human Services, Determination that a Public Health Emergency Exists (originally issued on January 31, 2020, and subsequently renewed), available at [https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx](https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx).
[^6]: Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak (March 13, 2020), available at [https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/](https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/). On February 24, 2021, there was a Presidential Declaration continuing the national emergency concerning the COVID-19 pandemic beyond March 1, 2021. See Continuation of the National Emergency Concerning the Coronavirus Disease 2019 (COVID-19) Pandemic (86 FR 11599), available at [https://www.federalregister.gov/documents/2021/02/26/2021-04173/continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic](https://www.federalregister.gov/documents/2021/02/26/2021-04173/continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic).
[^7]: See the HHS “Fact Sheet: COVID-19 Public Health Emergency Transition Roadmap,” (February 9, 2023), available at [https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html](https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html).
[^8]: For links to the COVID-19-related FDA guidances, see the webpage “COVID-19-Related Guidance Documents for Industry, FDA Staff, and Other Stakeholders,” available at [https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders](https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-related-guidance-documents-industry-fda-staff-and-other-stakeholders).
[^35^]: For more information regarding FDA’s acceptance policies for marketing submissions, see the guidances “Refuse to Accept Policy for 510(k)s,” available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/refuse-accept-policy-510ks](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/refuse-accept-policy-510ks), “Acceptance and Filing Reviews for Premarket Approval Applications (PMAs),” available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/acceptance-and-filing-reviews-premarket-approval-applications-pmas](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/acceptance-and-filing-reviews-premarket-approval-applications-pmas), and “Acceptance Review for De Novo Classification Requests,” available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/acceptance-review-de-novo-classification-requests](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/acceptance-review-de-novo-classification-requests).
[^36^]: For purposes of this guidance, FDA uses the term “final action” to mean a Medical Device User Fee Amendments (MDUFA) decision, which can include positive decisions, negative decisions, and notices of withdrawals, consistent with the: 510(k) Actions/Clock guidance, available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/fda-and-industry-actions-premarket-notification-510k-submissions-effect-fda-review-clock-and-goals](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/fda-and-industry-actions-premarket-notification-510k-submissions-effect-fda-review-clock-and-goals); De Novo Actions/Clock guidance, available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/fda-and-industry-actions-de-novo-classification-requests-effect-fda-review-clock-and-goals](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/fda-and-industry-actions-de-novo-classification-requests-effect-fda-review-clock-and-goals); PMA Actions/Clock guidance, available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/fda-and-industry-actions-premarket-approval-applications-pmas-effect-fda-review-clock-and-goals](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/fda-and-industry-actions-premarket-approval-applications-pmas-effect-fda-review-clock-and-goals).
[^37^]: See footnote 35.
[^38^]: FDA recommends that manufacturers engage with the Agency through the Q-Submission Program, including requesting Pre-Submissions, to discuss extenuating circumstances. For details on the Q-Submission Program, refer to the guidance “Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program,” available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program).
[^39^]: Available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program).
[^40^]: FDA recognizes that not all uses would necessarily be violative. To the extent such use is violative, FDA generally does not intend to object as described herein.
[^41^]: FDA uses the term “removal” consistent with the definition in 21 CFR 806.2(i).
[^42^]: In situations where manufacturers do not believe restoration is possible or in the best interest of public health, FDA recommends additional engagement with the Agency on the appropriate disposition of a product if it is not otherwise discussed in this guidance.
[^43^]: For example, an FDA-cleared or -approved version may include an earlier software version, component replacement, or different labeling that removes information related to the use of the device as described in an enforcement policy.
[^44^]: The manufacturer should provide labeling to the original purchaser, and collaborate with the original purchaser to ensure that labeling is distributed to relevant stakeholders, including device distributors, healthcare facilities, healthcare providers, patients, consumers, etc.
[^45^]: See footnote 42.
[^46^]: See footnote 43.
[^47^]: See footnote 44.
[^48^]: FDA recognizes that not all use would necessarily be violative.
[^49^]: Should healthcare facilities wish to retain a device that lacks FDA clearance, approval, or authorization for use in the future, the future use of the device would be subject to the regulatory requirements of any future authorization, including marketing authorization or EUA, as applicable. For governmental stockpilers that wish to retain a device that lacks requisite FDA clearance, approval, or authorization for use in the future, FDA recommends engaging with the Agency to discuss the public health need for future deployment and/or use of the device in specific circumstances (e.g., regional natural disaster, localized disease outbreaks).
[^50]: For more information on adverse event reporting requirements under 21 CFR Part 803, see the guidance “Medical Device Reporting for Manufacturers,” available at [FDA guidance document](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/medical-device-reporting-manufacturers).
[^51]: Available at [FDA guidance document search](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/).
[^52]: Data derived from real-world sources may be submitted in support of a marketing submission. See the guidance titled “Use of Real-World Evidence to Support Regulatory Decision-Making for Medical Devices,” available at [FDA guidance document](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/use-real-world-evidence-support-regulatory-decision-making-medical-devices).
[^53]: See, e.g., sections 510(k), 513(i)(2), 515, and 520(m) of the FD&C Act.
[^54]: 21 CFR Part 807, Subparts B-D.
[^55]: See, e.g., sections 510(k), 513(i)(2), 515, and 520(m) of the FD&C Act.
[^56]: The mailing address for the CDRH Document Control Center can be found in 21 CFR 807.90(a)(1) and 814.104(d)(1). FDA encourages manufacturers to submit Notifications of Intent as eCopies. Information about the eCopy program can be found in the guidance “eCopy Program for Medical Device Submissions,” available at [FDA guidance document](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/ecopy-program-medical-device-submissions).
[^57]: Submitting this information as soon as possible after issuance of this guidance is encouraged because it will assist the Agency in resource planning, help to avoid any supply disruptions, and otherwise help to ensure a smooth transition for these devices after the guidances in List 1 are no longer in effect.
[^58]: FDA recommends that the information be submitted as an “amendment” to the 510(k) or PMA file to facilitate efficient tracking of the “Notification of Intent” submissions.
[^59]: See, e.g., sections 510(k), 513(f)(2), 515, and 520(m) of the FD&C Act. For devices that are class I or II and exempt from premarket notification (e.g., shoe covers, face shields), no 510(k) submission is required unless the limitations of exemption are exceeded (see, e.g., 21 CFR 878.9).
[^60]: This includes a marketing submission for the device within the scope of the guidances in List 1, or a marketing submission for a device that is a derivative of, or the next generation of, the device within the scope of the guidances in List 1.
[^61]: Manufacturers that do not have an accepted marketing submission before the start of Phase 3 should refer to the policy described in Section V.A. of this guidance.
[^62]: See footnote 36.
[^63]: For example, if a manufacturer made modifications to the labeling of a cleared fetal doppler as described in the “Enforcement Policy for Non-Invasive Fetal and Maternal Monitoring Devices Used to Support Patient Monitoring During the COVID-19 Public Health Emergency” guidance, FDA generally does not intend to object to the manufacturer not complying with applicable labeling requirements (see 21 CFR Part 801) where the device continues to be labeled as described in that guidance while the marketing submission for the modified device is under review.
[^64]: Based on comments received on this draft guidance, as well as the companion transition guidance, FDA understands that updating the labeling of these devices while they are under FDA review, and then again if they are subsequently cleared, approved, or authorized, would be challenging for manufacturers. This policy takes those comments into account and is least burdensome for manufacturers and FDA. As noted elsewhere, manufacturers should engage with the Agency if they have questions specific to their device (e.g., regarding updating the device labeling to acknowledge that the device is currently under FDA review when the FDA review is expected to take an extended period of time).
[^65]: For manufacturers that register and list by the start of Phase 2, FDA recommends that manufacturers utilize the term “enforcement” in the premarket submission field if a submission number is not yet available. If the device subsequently receives marketing authorization, FDA expects manufacturers to comply with all applicable registration and listing requirements, which may require updating the listing information.
[^66]: For more information regarding FDA regulatory requirements for a specific device and FDA policies related to those requirements, manufacturers can use the FDA Guidance Search Tool to identify relevant guidance documents: [FDA Guidance Search](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/). After the start of Phase 3, FDA will look to any other applicable compliance policies and otherwise apply our general risk-based approach in making compliance and enforcement decisions. For more information, see the guidance “Factors to Consider Regarding Benefit-Risk in Medical Device Product Availability, Compliance, and Enforcement Decisions,” available at [Factors to Consider](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/factors-consider-regarding-benefit-risk-medical-device-product-availability-compliance-and).
[^67]: 21 CFR 7.45(a) states that FDA “may request a firm to initiate a recall when the following determinations have been made: (1) That a product that has been distributed presents a risk of illness or injury or gross consumer deception. (2) That the firm has not initiated a recall of the product. (3) That an agency action is necessary to protect the public health and welfare.”
[^68]: See, e.g., sections 510(k), 513(f)(2), 515, and 520(m) of the FD&C Act.
[^69]: For more information regarding FDA’s acceptance policies for marketing submissions, see the guidances “Refuse to Accept Policy for 510(k)s,” available at [Refuse to Accept Policy](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/refuse-accept-policy-510ks), “Acceptance and Filing Reviews for Premarket Approval Applications (PMAs),” available at [Acceptance and Filing Reviews](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/acceptance-and-filing-reviews-premarket-approval-applications-pmas), and “Acceptance Review for De Novo Classification Requests,” available at [Acceptance Review for De Novo Classification Requests](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/acceptance-review-de-novo-classification-requests).
[^70]: FDA recommends that manufacturers engage with the Agency through the Q-Submission Program, including requesting Pre-Submissions, to discuss extenuating circumstances. For details on the Q-Submission Program, refer to the guidance “Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program.”
[^71]: See, e.g., 21 CFR 807.95(a)(1).
[^72]: To the extent the marketing submission contains trade secret information or confidential commercial or financial information, FDA will handle that information in accordance with applicable laws, including 21 CFR 20.61.
[^83]: Available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-telethermographic-systems-during-coronavirus-disease-2019-covid-19-public-health](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-telethermographic-systems-during-coronavirus-disease-2019-covid-19-public-health).
[^84]: Available at [https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-telethermographic-systems-during-coronavirus-disease-2019-covid-19-public-health](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-telethermographic-systems-during-coronavirus-disease-2019-covid-19-public-health).
# 655 2023-04-18_FDA Website - Webinar on Guidances on COVID-19 Transition Plans.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2023-04-18_FDA Website - Webinar on Guidances on COVID-19 Transition Plans.md
file_date: 2023-04-18
title: FDA Website - Webinar on Guidances on COVID-19 Transition Plans
category: regulatory
subcategory: fda-policy
tags:
source_file_type: website
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: NA
pdf_github_url: NA
conversion_input_file_type: docx
conversion: manual cut and paste
license: Public Domain
tokens: 655
words: 437
notes: date converted 2024-04-05
web_url: https://www.fda.gov/medical-devices/medical-devices-news-and-events/webinar-guidances-covid-19-transition-plans-medical-devices-04182023
summary_short: The Webinar on Guidances on COVID-19 Transition Plans summarizes FDA’s April 18, 2023 stakeholder webinar explaining two final guidances for transitioning COVID-19-related medical devices from EUA/enforcement-policy flexibilities back to normal regulatory operations. It highlights recommendations on marketing submissions, timing, and a 180-day transition period with examples, along with Q&A addressing manufacturer and stakeholder implementation issues.
CONTENT
Summary
On April 18, 2023, the U.S. Food and Drug Administration (FDA) hosted a webinar for stakeholders interested in learning more about the two final guidances on the Coronavirus Disease 2019 (COVID-19) transition plans for medical devices.
During this webinar, the FDA:
Helped prepare manufacturers and other stakeholders for the orderly and transparent transition to normal operations.
Described recommendations regarding submitting a marketing submission and the timeline for doing so.
Provided examples to illustrate the transition policies and exemplify the 180-day transition period timeline.
Answered your questions about the guidances on the COVID-19 transition plans.
Background
In response to the COVID-19 pandemic, the device supply chain has been stressed because the demand for certain devices has exceeded available supply. As such, since the beginning of the COVID-19 pandemic, FDA took a number of proactive steps to help facilitate the availability of critical medical devices, including issuing emergency use authorizations (EUAs), which has enabled access to medical devices to help diagnose, treat, or prevent COVID-19. In addition, FDA issued guidances to help expand the availability of certain devices to help patients, health care providers, and other health care professionals access devices for COVID-19-related uses.
Given the magnitude of the COVID-19 pandemic, the FDA recognizes that stakeholders may need time to adjust to help ensure an orderly and transparent transition to normal operations. Further, the FDA is taking into account that the manufacture, distribution, and use of devices in the context of the COVID-19 pandemic raises unique considerations. These considerations include, for example, the manufacturing of devices by non-traditional manufacturers to address supply issues and the distribution and use of capital or reusable equipment that fall within enforcement policies issued during the COVID-19 public health emergency (PHE) declared under section 319 of the Public Health Service Act or under relevant device EUA declarations related to COVID-19 issued under section 564 of the Federal Food, Drug, and Cosmetic Act.
To provide clarity to manufacturers, the FDA issued two guidance documents to provide recommendations to manufacturers that may or may not want to continue to distribute certain medical devices after the PHE declaration expires and certain enforcement policies issued during the COVID-19 PHE are no longer in effect, or the relevant EUA declaration related to COVID-19 terminates.
See the guidances for more information:
[Transition Plan for Medical Devices That Fall Within Enforcement Policies Issued During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-fall-within-enforcement-policies-issued-during-coronavirus-disease)
[Transition Plan for Medical Devices Issued Emergency Use Authorizations (EUAs) Related to Coronavirus Disease 2019 (COVID-19)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-issued-emergency-use-authorizations-euas-related-coronavirus-disease)
Meeting Materials
The presentation, printable slides, and transcript are available at CDRH Learn under “Specialty Technical Topics”, sub-section “ COVID-19 Transition Policy”.
# 4,124 2023-09-23_FDA Response Letter - To Compliant regarding FDA Reference Panel from Dec 2020.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2023-09-23_FDA Response Letter - To Compliant regarding FDA Reference Panel from Dec 2020.md
file_date: 2023-09-23
title: FDA Response Letter - To Compliant regarding FDA Reference Panel from Dec 2020
category: regulatory
subcategory: fda-policy
tags:
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notes: Unsure about license
summary_short: The FDA letter dated September 29, 2023 responds to an Information Quality Act request from a law firm seeking removal of the FDA SARS-CoV-2 Reference Panel Comparative Data, claiming it was inaccurate and harmed EUA test developers. FDA explains the reference panel and protocol were scientifically sound for comparing relative limits of detection across assays, that participation and public posting were conditions of EUA authorization, and that variability in posted results supports the panel’s validity rather than a systemic flaw. It notes FDA later stopped distributing the reference panel when materials reached effective expiration and removed the comparative data from its website as outdated, denying requests for a public statement blaming accuracy concerns or for additional validation data publication.
CONTENT
September 29, 2023
Via Email
James P. Ellison
Jeffrey N. Gibbs
Gail H. Javitt
Michael D. Shumsky
Hyman Phelps & McNamara, P.C.
700 13th Street NW, Suite 1200
Washington, DC 20005
Dear Mr. Ellison, Mr. Gibbs, Ms. Javitt, and Mr. Shumsky:
This letter responds to your letter dated December 22, 2020, requesting that the U.S. Food and Drug Administration (FDA) remove FDA SARS-CoV-2 Reference Panel Comparative Data for COVID-19 molecular diagnostic assays contained on FDA’s website. Your request is based on your allegation that the data are inaccurate and misleading and, as a result, do not meet the statutory, Office of Management and Budget (OMB), Department of Health and Human Services (HHS), and FDA guidelines under the Information Quality Act (IQA), Pub. L. No. 106-554 (2000).
For the reasons set forth below, part of your request is now moot and we are denying the other parts of your request.
## I. Introduction
You assert that you are writing on behalf of unidentified clients who hold Emergency Use Authorization (EUA) for their tests and have participated in the Reference Panel program, which is a condition of authorization. You claim that your clients generated data for their tests using the FDA reference panel materials and instructions, and that the reference panel data generated by your clients do not correlate with the Limit of Detection (LoD) they previously established for their tests. You allege that your clients have been subject to “direct harm” because their tests are “being inaccurately presented as having a low sensitivity.” You also allege that health care practitioners and the public are being misled about critical information regarding these diagnostic assays. As a result of these alleged inadequacies, you contend that FDA’s disclosure of the FDA SARS-CoV-2 Reference Panel data violates the 2000 IQA.
Your letter requests that FDA (1) remove the SARS-CoV-2 Reference Panel Comparative Data from its website “until such time as all the information it contains is accurate,” (2) issue a public statement explaining that the data was removed “because of concerns regarding the accuracy of the data,” and (3) publish the data demonstrating “the validity of the reference panel and protocol.”
As discussed below, we have determined that the FDA SARS-CoV-2 Reference Panel and protocol instructions, which are used to generate the SARS-CoV-2 Reference Panel Comparative Data, are scientifically sound for their intended purpose of providing a relative LoD that can be used to establish a comparison of analytical test performances. Accordingly, we are denying your request.
We note that FDA stopped use of the FDA SARS-CoV-2 Reference Panel when it determined the reference panel materials it was providing test developers had, in effect, reached their expiration date. FDA has also removed the SARS-CoV-2 Reference Panel Comparative Data from its website as part of its regular review and updating of COVID-related information because that data has become outdated.
## II. Information Quality Act
In 2002, the Office of Management and Budget issued Guidelines for Ensuring and Maximizing the Quality, Objectivity, Utility and Integrity of Information Disseminated by Federal Agencies (Guidelines). As you note in your letter, the principles and core values underlying these Guidelines were updated and reinforced recently through the OMB Memorandum, Improving Implementation of the Information Quality Act (Apr. 24, 2019).1 FDA issued its agency-specific guidelines on September 30, 2002 (FDA Guidelines).2 You stated that “FDA does not appear to have updated its guidelines recently” in response to the OMB 2019 Memorandum. Although the updated guidelines have not yet been reflected on the HHS website, FDA has implemented the guidelines and complies with the latest guidelines. FDA’s practices are consistent with the Memorandum.
## III. Reference Panel and Protocol
The Reference Panel and its protocol provide both the material and procedure to be used to evaluate the analytical sensitivity or relative LoD of an assay used to detect SARS-CoV-2.
### A. Limit of Detection for SARS-CoV-2 Tests
Establishing the analytical sensitivity of a test, often referred to as the LoD (i.e., the lowest quantity or concentration of a component that can be reliably detected with a given assay in at
1 OMB, Memorandum, Improving Implementation of the Information Quality Act (Apr. 24, 2019)1, https://www.whitehouse.gov/wp-content/uploads/2019/04/M-19-15.pdf. 2 HHS Office of the Assistant Secretary for Planning and Evaluation, HHS Guidelines for Ensuring and Maximizing the Quality, Objectivity, and Integrity of Information Disseminated to the Public (HHS Guidelines) (Oct. 1, 2002), https://aspe.hhs.gov/report/hhs-guidelines-ensuring-and-maximizing-quality- objectivity-utility-and-integrity-information-disseminated-public.
U.S. Food & Drug Administration 10903 New Hampshire Avenue Silver Spring, MD 20993 FDA.GOV least 19/20 replicates), is a standard analytical procedure. For SARS-CoV-2 molecular tests, FDA has provided an EUA template with recommendations for determining the LoD.3 The template is updated as appropriate as we learn more about the COVID-19 disease and gain experience with the EUA process for the various types of COVID-19 tests.
The EUA template also provides recommendations to establish an assay clinical sensitivity. Clinical sensitivity is the probability that the test will identify as positive a clinical specimen that has been identified with a reference method. Clinical specimens are the preferred material for determining performance. Since natural clinical specimens were not available to test developers in the early phases of the COVID-19 pandemic, FDA authorized tests based on available data from contrived samples generated from a range of SARS-CoV-2 material sources for analytical and clinical performance evaluation. “Contrived” means that developers could “spike” some specified materials (e.g., viral RNA or inactivated virus) into a clinical matrix (e.g., BAL fluid, sputum, or nasopharyngeal swab). However, this approach is less likely than use of natural patient specimens to accurately characterize test performance.
The LoD, which is required in the labeling for each EUA-authorized test, was therefore based on the material and methodology used by the test developer, and these vary across the hundreds of EUA-authorized tests. As of the end of December 2020, when you had sent your letter, FDA had issued EUAs to over 230 nucleic acid-based tests (NATs) for SARS-CoV-2. Many of these tests (59) were developed and EUA-authorized based only on contrived specimens in the early phases of the pandemic, before clinical specimens were available to the test developers. As clinical specimens became available, FDA recommended that developers obtain and use patient specimens to validate their tests. In addition, FDA recommended evaluating the performance of the test with a comparator test by using clinical specimens. For the analytical performance, a quantified known positive clinical specimen, as determined by an EUA-authorized test, could also be used to create dilutions in clinical matrix for LoD determination. As of July 14, 2023, 277 NATs for SARS-CoV-2 were authorized for emergency use.
Since the LoD of the 230-plus molecular tests was determined using samples spiked with different types of materials, the performance of these tests, as reflected in the labeling originally authorized under the EUAs, cannot be directly compared. In addition, when clinical samples became available, different developers did not utilize the same samples and therefore results obtained with clinical specimens cannot be directly compared across assays either. Use of the same reference material across test developers is thus critical to allow a determination and direct comparison of the relative LoD of NATs for SARS-CoV-2.
For the analytical sensitivities of different tests to be compared, the clinical matrix must be spiked with the same material that has the different targets at the ratios found in the original virus. The material must be the same for different labs and be stable during transport and under the conditions stored prior to testing. Panels developed at the FDA laboratory produced the amount needed to fulfill testing for hundreds of assays, and to achieve consistency of the viral titer, sample composition, and targets present. For these reasons, FDA supplied the FDA SARS-CoV-2 Reference Panel with recommended handling procedures so that each lab would be assured that the material remained functional. Results of the testing to determine LoD were then checked with the blinded panel. This is a robust and efficient procedure to compare analytical sensitivities of a large number of different assays.
Recognizing that the availability of well-characterized reference reagents that all molecular tests can be compared against is critical to performance standardization of EUA-authorized assays during a pandemic, FDA had included in the EUA Letters of Authorization for every molecular-based test a requirement that the test developer would evaluate its test with an FDA- recommended reference material when such material was made available, and would update the test’s labeling to include the results of that additional data. This requirement is set forth in the following Condition of Authorization:
“You will evaluate the analytical limit of detection and assess traceability* of your product with any FDA-recommended reference material(s). After submission to and concurrence with the data by FDA, you will update your labeling to reflect the additional testing. Such labeling updates will be made in consultation with, and require concurrence of, DMD/OHT7- OIR/OPEQ/CDRH.” * Traceability refers to tracing analytical sensitivity/reactivity back to an FDA- recommended reference material.”
Thus, from the beginning, test developers submitting an EUA request for a SARS-CoV-2 NAT knew not only that they would be required to participate in testing with an FDA-recommended reference material but also that the data from that testing would be made publicly available for their EUA-authorized test. Data from evaluation of tests using the same reference panel provide more accurate information on the relative performance of different tests, allowing comparative studies that will give the FDA, professionals, laboratories, and patients a better understanding of the relative sensitivity of the various tests. The FDA SARS-CoV-2 Reference Panel also includes an additional coronavirus allowing the evaluation of cross- reactivity to MERS-CoV.
### B. Development and Validation of the Reference Panel
FDA began distributing the FDA SARS-CoV-2 Reference Panel in May 2020. To develop the FDA SARS-CoV-2 Reference Panel, FDA obtained live virus in February 2020. The SARS- CoV-2 strain used in this panel was cultivated, heat-inactivated, sequenced, and genetically characterized by the Center for Biologics Evaluation and Research (CBER) to produce reference reagents.
FDA appropriately validated the Reference Panel and protocol. In developing, producing, and characterizing the Reference Panel for SARS-CoV-2, CDRH/CBER followed the same scientific approach, methods, and principles used in the development and production of reference reagents for Zika virus tests, which are described in detail in the published articles “Production and characterization of Zika virus RNA reference reagents as a response to a public health emergency,” Transfusion, volume 58, September 2018, and “A Zika Reference Panel for Molecular-Based Diagnostic Devices as a US Food and Drug Administration Response Tool to a Public Health Emergency,” The Journal of Molecular Diagnostics, Vol. 21, No. 6, November 2019. The value of reference materials containing heat-inactivated SARS- CoV-2 virus has also been recognized in international studies; see, e.g., “RNA reference materials with defined viral RNA loads of SARS-CoV-2—A useful tool towards a better PCR assay harmonization,” PLoS ONE 17(1): e0262656 (January 20, 2022) available at https://doi.org/10.1371/journal.pone.0262656.
For Zika virus, CDRH used a variation of the CBER-developed reference reagents to create a reference panel for Zika virus tests suitable to in vitro diagnostics developers. CDRH created the reference panel known as Zika FDA-RP using dilutions of the culture media virus stocks in defibrinated human plasma. The stocks were diluted to various concentrations of NAT- detectable units (NDU), or NDU/mL. A single NDU is the minimum level of target that will result in a positive PCR result, which is not interchangeable with viral copy number/mL. The methodology for production of reagents and preparation of the reference panel, as well as the designs for the LoD range finding study, LoD confirmation study, and LoD blinded validation, are described in detail in the above-referenced article, “A Zika Reference Panel for Molecular- Based Diagnostic Devices as a US Food and Drug Administration Response Tool to a Public Health Emergency.” Those details will not be repeated here but can be found in the attached article. Articles are accepted for publication in The Journal of Molecular Diagnostics only after external scientific review. The FDA reference panel for Zika virus tests, developed and studied as described in this published article, was used to evaluate the performance of Zika virus diagnostic assays before they received an EUA.
Although the details about the preparation of the reference reagents, and the production and validation of the FDA SARS-CoV-2 Reference Panel, have not yet been published4, FDA followed the same scientific approach and methodology that was described in detail in the peer-reviewed, published articles describing the Zika FDA-RP, which was used successfully to evaluate Zika virus assays prior to granting an EUA. In addition, to further evaluate both the material and the protocol, FDA conducted a pilot study with several commercial manufacturers and laboratories prior to sending the FDA SARS-CoV-2 Reference Panel to all developers of EUA-authorized tests. The results of this pilot study supported the quality and utility of this specific FDA SARS-CoV-2 Reference Panel as well as the clarity of its protocol, providing additional external confirmation of the scientific validity of the FDA SARS-CoV-2 Reference Panel prior to distributing it to developers of EUA-authorized tests.
Furthermore, results obtained using the FDA SARS-CoV-2 Reference Panel show a wide distribution of values that further support that the reference panel was of appropriate quality for its use at the time the IQA complaint was submitted (12/22/2020). If the design of the Reference Panel were flawed, it should have resulted in all devices showing high LoD values with no expected dispersion.
4 FDA is developing a manuscript with information on the SARS-CoV-2 Reference Panel, but it has not been internally reviewed and cleared.
You have not provided any data or evidence to support your claim that the Reference Panel or protocol were flawed, or that use of the Reference Panel or protocol led to the FDA SARS- CoV-2 Reference Panel Comparative Data being unreliable. In contrast, existing data and information supports that the development, validation and use of the Reference Panel was appropriate for its stated purpose.
## IV. The FDA SARS-CoV-2 Reference Panel Comparative Data Is Not “Influential”
In your letter, you assert that the FDA SARS-CoV-2 Reference Panel Comparative Data constitute “influential” information as that term is used in the context of the IQA. The OMB Guidelines state that “influential” “means that the agency can reasonably determine that dissemination of the information will have or does have a clear and substantial impact on important public policies or important private sector decisions.” As explicitly contemplated by the OMB’s Guidelines, FDA’s Guidelines further explain this term in light of FDA’s areas of responsibility, stating:
For purposes of this guidance, influential information is defined as disseminated information that results from or is used in support of agency actions that are expected to have an annual effect on the economy of $100 million or more or will adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local or tribal governments or communities. It should be noted that the definition applies to “information” itself, not to decisions that the information may support. Even if a decision or action by FDA is itself very important, a particular piece of information supporting it may or may not be “influential.”
In asserting that the information is “influential,” you base this on your view that FDA intends it to be influential because FDA has said that this type of comparison information has been “shown to be useful to healthcare providers and laboratories using these tests.” When a person or firm is deciding which authorized COVID molecular test to use, the comparative performance information can be useful. To the extent such information is considered, however, it is one of a wide range of considerations. The SARS-CoV-2 Reference Panel Comparative Data can help people understand the relative performance of authorized molecular tests, but relative performance is, and should be, just one consideration along with many other considerations, such as the indication a test is authorized for, test availability, test throughput, and cost. FDA is not aware of any information that shows, or even suggests, that healthcare providers and labs rely solely or even heavily on the posted relative performance information and, even if they did, they would merely be choosing one FDA-reviewed and authorized molecular test over another. In short, although this information can be useful, it is not “influential” as that term is used in the OMB and FDA Guidelines.
## V. Conclusion
Your request that FDA remove the SARS-CoV-2 Reference Panel Comparative Data from its website “until such time as all the information it contains is accurate,” is moot because FDA subsequently removed that information as part of its regular review and updating of COVID-
U.S. Food & Drug Administration 10903 New Hampshire Avenue Silver Spring, MD 20993 FDA.GOV
related information because it had become outdated. For the reasons stated above, FDA denies your request that it issue a public statement explaining that the data was removed “because of concerns regarding the accuracy of the data” and that FDA publish data demonstrating the validity of the Reference Panel and protocol.
Thank you for your interest in the quality of information disseminated by FDA. If you do not agree with FDA’s decision about your complaint (including any corrective action), you may send a request for reconsideration within 30 days of receipt of our decision. You may use any of the Procedures for Submitting Complaints described in the FDA specific guidelines contained in the HHS Information Quality Guidelines available at: https://aspe.hhs.gov/reports/hhs-guidelines-ensuring-maximizing-quality-objectivity-utility- integrity-information-disseminated. A request for reconsideration should state the reasons why you believe the response is inadequate, should be designated as an “Information Quality Appeal,” and sent to the following address:
Food and Drug Administration Office of Ombudsman 10903 New Hampshire Avenue WO Building 32, Room 4260 Silver Spring, MD 29993 Email: Ombuds@OC.FDA.gov
A request for reconsideration should include a copy of your original request and the Agency’s decision. The Agency will respond to all requests for appeals within the time frame specified in the procedure you use. Where a procedure does not specify a time frame for a response to your appeal, we will respond in a timely manner, in accordance with OMB and HHS Guidelines.
Sincerely,
Ellen J. Flannery
Deputy Center Director for Policy
Director, Office of Policy
Center for Devices and Radiological Health
cc: Jeffrey Shuren, M.D., J.D.
Timothy Stenzel, M.D., Ph.D.
Mark Raza, J.D.
Laurie Lenkel
# 507 2023-11-08_FDA Website - In Vitro Diagnostics EUAs.md
METADATA
last updated: 2026-03-04 by BA
file_name: 2023-11-08_FDA Website - In Vitro Diagnostics EUAs.md
file_date: 2023-11-08
title: FDA Website - In Vitro Diagnostics EUAs
category: regulatory
subcategory: fda-policy
tags:
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notes: date converted 2024-04-05
web_url: https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas
summary_short: The In Vitro Diagnostics EUAs page explains FDA’s COVID-19 IVD EUA framework after the May 11, 2023 expiration of the HHS public health emergency and the end of certain COVID-19 enforcement-policy guidances. It clarifies that the PHE’s end did not eliminate FDA’s authority to keep existing EUAs in effect or issue EUAs under FD&C Act section 564, and it directs manufacturers to FDA’s EUA transition-plan guidance and related FAQs for expectations when EUA declarations eventually end.
CONTENT
November 8, 2023 - The COVID-19 public health emergency (PHE) declared under section 319 of the Public Health Service (PHS) Act [expired](https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html) on May 11, 2023. The COVID-19 enforcement policy guidances within scope of the [Transition Plan for Medical Devices That Fall Within Enforcement Policies Issued During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency]((https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-fall-within-enforcement-policies-issued-during-coronavirus-disease)) are no longer in effect.
The end of the COVID-19 PHE and certain COVID-19 enforcement policy guidances no longer being in effect do not impact the FDA's ability to authorize devices, including tests, for emergency use. Existing emergency use authorizations (EUAs) for devices relating to COVID-19 remain in effect under section 564 of the Federal Food, Drug, and Cosmetic Act. The FDA encourages manufacturers of devices issued EUAs related to COVID-19 to review the guidance: [Transition Plan for Medical Devices Issued Emergency Use Authorizations(EUAs) Related to Coronavirus Disease 2019 (COVID-19)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-issued-emergency-use-authorizations-euas-related-coronavirus-disease) and [Transition Plan for Medical Devices Issued Emergency Use Authorizations (EUAs) Related to Coronavirus Disease 2019 (COVID-19)](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/transition-plan-medical-devices-issued-emergency-use-authorizations-euas-related-coronavirus-disease), which outlines the FDA's recommendations and expectations to such manufacturers to transition to normal operations when the declarations that allowed for FDA to issue EUAs under section 564 of the Federal Food, Drug, and Cosmetic Act end. Additional information is provided on the page [FAQs: What happens to EUAs when a public health emergency ends?](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/faqs-what-happens-euas-when-public-health-emergency-ends)
# 6,657 FDA SARS-CoV-2 Reference Panel Comparative Data - Complied by Matt McFarlane.md
METADATA
last updated: 2026-03-04 by BA
file_name: FDA SARS-CoV-2 Reference Panel Comparative Data - Complied by Matt McFarlane.md
file_date: 2021-01-11
title: FDA SARS-CoV-2 Reference Panel Comparative Data
category: regulatory
subcategory: fda-policy
tags:
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summary_short: The FDA SARS-CoV-2 Reference Panel Comparative Data spreadsheet compiles EUA-reported LoDs and FDA reference panel LoDs for many authorized molecular tests, enabling side-by-side comparison of relative analytical sensitivity across developers and platforms. It includes test names, developers, notes on data-release wave and versioning caveats, and a calculated FDA/EUA LoD ratio to highlight discrepancies between EUA-submitted LoD claims and reference-panel results.
CONTENT
***INTERNAL TITLE*** FDA SARS-CoV-2 Reference Panel Comparative Data
*Compiled by Matt McFarlane*
## Data
| Test | EUA LOD (/3ml swab) | FDA Panel LOD (/3ml swab) | FDA/EUA LOD | DataNote | Developer | Full Test | |
|--------------------------------------|-----------------------|-----------------------------|---------------|------------------|---------------------------------------------------------------------------------|-------------------------------------------------------------------------------------|----------------------------------------------------------------------------|
| PerkinElmer | 28 | 540 | 19.28571429 | 1st data release | PerkinElmer, Inc. | PerkinElmer New Coronavirus Nucleic Acid Detection Kit | |
| ScienCell | 9600 | 1620 | 0.16875 | 1st data release | ScienCell Research Laboratories | ScienCell SARS-CoV-2 Coronavirus Real-time RT-PCR (RT-qPCR) Detection Kit | |
| BioCore | 1500 | 1800 | 1.2 | 1st data release | BioCore Co., Ltd. | BioCore 2019-nCoV Real Time PCR Kit | |
| DiaCarta (4 1plex wells) | 600 | 1800 | 3.0 | 1st data release | DiaCarta, Inc | QuantiVirus SARS-CoV-2 Test kit | Results were obtained with the version of the test authorized on 4/08/2020 |
| DiaCarta (duplex) | 300 | 1800 | 6.0 | 1st data release | DiaCarta, Inc | QuantiVirus SARS-CoV-2 Multiplex Test Kit | |
| Hologic (Panther RTqPCR) | 600 | 1800 | 3.0 | 1st data release | Hologic, Inc. | Panther Fusion SARS-CoV-2 Assay | |
| Hologic (TMA) | 638 | 1800 | 2.821316614 | 1st data release | Hologic, Inc. | Aptima SARS-CoV-2 assay | |
| Seasun (PCR) | 3000 | 1800 | 0.6 | 1st data release | SEASUN BIOMATERIALS | U-TOP COVID-19 Detection Kit | |
| PrivaPath (letsgetchecked) | 600 | 2160 | 3.6 | 1st data release | PrivaPath Diagnostics, Inc.2 | LetsGetChecked Coronavirus (COVID-19) Test | |
| BD Max (2 duplex) | 120 | 5400 | 45.0 | 1st data release | Becton, Dickinson & Company (BD) | BioGX SARS-CoV-2 Reagents for BD MAX System | |
| CirrusDx | 1170 | 5400 | 4.615384615 | 1st data release | CirrusDx Laboratories | CirrusDx SARS-CoV-2 Assay | |
| EuroImmun | 450 | 5400 | 12.0 | 1st data release | Euroimmun US, Inc. | EURORealTime SARS-Cov-2 | |
| Helix (PCR) | 3000 | 5400 | 1.8 | 1st data release | Helix OpCo LLC (dba Helix) | Helix COVID-19 Test | |
| LabGenomics | 60000 | 5400 | 0.09 | 1st data release | LabGenomics Co., Ltd. | LabGun COVID-19 RT-PCR Kit | |
| Quest Diagnostics | 408 | 5400 | 13.23529412 | 1st data release | Quest Diagnostics Infectious Disease, Inc. | Quest SARS-CoV-2 rRT-PCR | |
| Rheonix | 1875 | 5400 | 2.88 | 1st data release | Rheonix, Inc. | Rheonix COVID-19 MDx Assay | |
| Roche | 138 | 5400 | 39.13043478 | 1st data release | Roche Molecular Systems, Inc. (RMS) | cobas SARS-CoV-2 | |
| Applied DNA | 3750 | 7500 | 2.0 | 1st data release | Applied DNA Sciences, Inc. | Linea COVID-19 Assay Kit | |
| Abbott (m2000) | 120 | 8100 | 67.5 | 1st data release | Abbott Molecular | Abbott RealTime SARS-CoV-2 assay | |
| Fulgent | 15000 | 10800 | 0.72 | 1st data release | Fulgent Therapeutics, LLC | Fulgent COVID-19 by RT-PCR Test | |
| Enzo | 840 | 10800 | 12.85714286 | 1st data release | Enzo Life Sciences, Inc. | AMPIPROBE SARS-CoV-2 Test System | |
| Access Bio | 1286 | 16200 | 12.59720062 | 1st data release | Access Bio, Inc. | CareStart COVID-19 MDx RT-PCR | |
| Applied BioCode | 0.017 TCID50/ml | 16200 | | 1st data release | Applied BioCode, Inc. | BioCode SARS-CoV-2 Assay | |
| Assurance Sci. | 15000 | 16200 | 1.08 | 1st data release | Assurance Scientific Laboratories | Assurance SARS-CoV-2 Panel | |
| BD Max (triplex) | 120 | 16200 | 135.0 | 1st data release | Becton, Dickinson & Company | BD SARS-CoV-2 Reagents for BD MAX System | Results were obtained with the version of the test authorized on 9/23/2020 |
| BioFire Defense | 990 | 16200 | 16.36363636 | 1st data release | BioFire Defense, LLC | BioFire COVID-19 Test | |
| Boston Heart | 750 | 16200 | 21.6 | 1st data release | Boston Heart Diagnostics | Boston Heart COVID-19 RT-PCR Test | |
| Cepheid | 750 | 16200 | 21.6 | 1st data release | Cepheid | Xpert Xpress SARS-CoV-2 test | |
| ChromaCode | 3000 | 16200 | 5.4 | 1st data release | ChromaCode Inc. | HDPCR SARS-CoV-2 Assay | |
| Ethos | 60000 | 16200 | 0.27 | 1st data release | Ethos Laboratories | Ethos Laboratories SARS-CoV-2 MALDI-TOF Assay | |
| GeneMatrix | 7500 | 16200 | 2.16 | 1st data release | GeneMatrix, Inc | NeoPlex COVID-19 Detection Kit | |
| Hackensack Uni MC | 12000 | 16200 | 1.35 | 1st data release | Hackensack University Medical Center (HUMC) Molecular Pathology Laboratory | CDI Enhanced COVID-19 Test | |
| Kogene | 12000 | 16200 | 1.35 | 1st data release | KogeneBiotech Co., Ltd. | PowerChek 2019-nCoV Real-time PCR Kit | |
| Luminex (NxTAG) | 15000 | 16200 | 1.08 | 1st data release | Luminex Molecular Diagnostics, Inc. | NxTAG CoV Extended Panel Assay | |
| Patients Choice | 300000 | 16200 | 0.054 | 1st data release | Patients Choice Laboratories, LLC | PCL SARS-CoV-2 Real-Time RT-PCR Assay | |
| CDC (inf+CoV2) | ? | 17100 | | 1st data release | Centers for Disease Control and Prevention (CDC) | Influenza SARS-CoV-2 (Flu SC2) Multiplex Assay | |
| DiaSorin | 1500 | 18000 | 12.0 | 1st data release | DiaSorin Molecular LLC | Simplexa COVID-19 Direct assay | |
| Quidel | 2400 | 18000 | 7.5 | 1st data release | Quidel Corporation | Lyra SARS-CoV-2 Assay | |
| Seasun (LAMP, 1 duplex) | 21000 | 18000 | 0.8571428571 | 1st data release | Seasun Biomaterials, Inc | AQ-TOP COVID-19 Rapid Detection Kit | |
| Sherlock BioSci | 20250 | 18000 | 0.8888888889 | 1st data release | Sherlock BioSciences, Inc. | Sherlock CRISPR SARS-CoV-2 Kit | |
| UNC | 2640 | 18000 | 6.818181818 | 1st data release | University of North Carolina Medical Center | UNC Health SARS-CoV-2 real-time RT-PCR test | |
| Exact Sciences | 7800 | 18075 | 2.317307692 | 1st data release | Exact Sciences Laboratories | SARS-CoV-2 (N gene detection) Test | |
| CDC | 9500 | 54000 | 5.684210526 | 1st data release | Centers for Disease Control and Prevention (CDC) | CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel (CDC) | |
| Acupath | 75000 | 54000 | 0.72 | 1st data release | Acupath Laboratories, Inc | Acupath COVID-19 Real-Time (RT-PCR) Assay | |
| Avellino Lab USA | 165000 | 54000 | 0.3272727273 | 1st data release | Avellino Lab USA, Inc. | AvellinoCoV2 test | |
| Color | 2250 | 54000 | 24.0 | 1st data release | Color Genomics, Inc.2 | Color Genomics SARS-CoV-2 RT-LAMP Diagnostic Assay | Results were obtained with the version of the test authorized on 8/28/2020 |
| Eli Lilly | 3000 | 54000 | 18.0 | 1st data release | Eli Lilly and Company | Lilly SARS-CoV-2 Assay | |
| Gravity (CDC Primers) | 7200 | 54000 | 7.5 | 1st data release | Gravity Diagnostics, LLC | Gravity Diagnostics COVID-19 Assay | |
| HealthQuest | 60000 | 54000 | 0.9 | 1st data release | HealthQuest Esoterics | HealthQuest Esoterics TaqPath SARS-CoV-2 Assay | |
| Boston CH | 6900 | 54000 | 7.826086957 | 1st data release | Infectious Diseases Diagnostics Laboratory (IDDL), Boston Children's Hospital | Childrens-Altona-SARS-CoV-2 Assay | |
| Psomagen | 3000 | 54000 | 18.0 | 1st data release | Psomagen, Inc. | Psoma COVID-19 RT Test | |
| Yale | 6000 | 540000 | 90.0 | 1st data release | Diatherix Eurofins Laboratory | SARS-CoV-2 PCR Test | |
| Luminex (Aries) | 999 | 540000 | 540.5405405 | 1st data release | Luminex Corporation | ARIES SARS-CoV-2 Assay | |
| Qiagen | 1500 | 540000 | 360.0 | 1st data release | QIAGEN GmbH | QIAstat-Dx Respiratory SARS-CoV-2 Panel | |
| Abbott (ID Now) | 313 | 15000 | 47.92332268 | 1st data release | Abbott Diagnostics Scarborough, Inc. | ID NOW COVID-19 | |
| Quidel (LyraDirect) | 5120 | 27000 | 5.2734375 | 1st data release | Quidel Corporation | Lyra Direct SARS-CoV-2 Assay | |
| Bio-Rad | 450 | 1800 | 4.0 | 2nd data release | Bio-Rad Laboratories, Inc | Bio-Rad SARS-CoV-2 ddPCR Test | |
| Altru | 1875 | 5400 | 2.88 | 2nd data release | Altru Diagnostics, Inc. | Altru Dx SARS-CoV-2 RT-PCR assay | |
| OPTI | 2700 | 5400 | 2.0 | 2nd data release | OPTI Medical Systems, Inc. | OPTI SARS-COV-2 RT PCR Test | |
| Roche (infA/B+CoV2, Cobas) | 182 | 5400 | 29.67032967 | 2nd data release | Roche Molecular Systems, Inc. | cobas SARS-CoV-2 & Influenza A/B | |
| Illumina | 3000 | 16200 | 5.4 | 2nd data release | Illumina, Inc. | Illumina COVIDSeq Test | |
| NeuMoDx | 450 | 16200 | 36.0 | 2nd data release | NeuMoDx Molecular, Inc. | NeuMoDx SARS-CoV-2 Assay | |
| ZhuHai Sinochips | 7500 | 16200 | 2.16 | 2nd data release | ZhuHai Sinochips Bioscience Co., Ltd | COVID-19 Nucleic Acid RT-PCR Test Kit | |
| Columbia Uni. | 840 | 18000 | 21.42857143 | 2nd data release | Columbia University Laboratory of Personalized Genomic Medicine | TRIPLEX CII-SARS-CoV-2 rRT-PCR TEST | |
| 1drop | 600 | 54000 | 90.0 | 2nd data release | 1drop Inc. | 1copy COVID-19 qPCR Multi Kit | |
| BioMérieux | 1140 | 54000 | 47.36842105 | 2nd data release | BioMérieux SA | SARS-COV-2 R-GENE | |
| Cedars-Sinai | 30000 | 54000 | 1.8 | 2nd data release | Cedars-Sinai Medical Center, Department of Pathology and Laboratory Medicine | SARS-CoV-2-Assay | |
| Curative | 600 | 54000 | 90.0 | 2nd data release | KorvaLabs Inc. | Curative-Korva SARS-Cov-2 Assay | |
| Phosphorus Dx | 15000 | 54000 | 3.6 | 2nd data release | Phosphorus Diagnostics LLC | Phosphorus COVID-19 RT-qPCR Test | 4 |
| Ultimate Dx | 300 | 54000 | 180.0 | 2nd data release | Ultimate Dx Laboratory | UDX SARS-CoV-2 Molecular Assay | |
| Ipsum | 25500 | 540000 | 21.17647059 | 2nd data release | Ipsum Diagnostics, LLC | COV-19 IDx assay | Results were obtained with the version of the test authorized on 4/01/2020 |
| Thermo Fisher | 750 | 540000 | 720.0 | 2nd data release | Thermo Fisher Scientific, Inc. | TaqPath COVID-19 Combo Kit | |
| PreciGenome | 1714 | 540000 | 315.0525088 | 2nd data release | PreciGenome LLC3 | FastPlex Triplex SARS-CoV-2 detection kit (RT-Digital PCR) | |
| MicroGen DX | 300 | 540000 | 1800.0 | 2nd data release | Southwest Regional PCR Laboratory LLC. dba MicroGen DX | COVID-19 Key | |
| SDI | 1500 | 540000 | 360.0 | 2nd data release | Specialty Diagnostic (SDI) Laboratories | SDI SARS-CoV-2 Assay | |
| Boston Medical | 3000 | 1800000 | 600.0 | 2nd data release | Boston Medical Center | BMC-CReM COVID-19 Test | |
| Viracor Eurofins | 219 | 540 | 2.465753425 | 3rd data release | Viracor Eurofins Clinical Diagnostics | Viracor SARS-CoV-2 assay | |
| Zymo | 750 | 1350 | 1.8 | 3rd data release | Zymo Research Corporation1 | Quick SARS-CoV-2rRT-PCR Kit | |
| Fast Track | 0.0069 TCID50/ml | 1620 | | 3rd data release | Fast Track Diagnostics Luxembourg S.á.r.l. (a Siemens Healthineers Company) | FTD SARS-COV-2 | |
| UMass | 12000 | 5400 | 0.45 | 3rd data release | UMass Memorial Medical Center | UMass Molecular Virology Laboratory 2019-nCoV rRT-PCR Dx Panel | |
| Texas DSHS | 60 | 5400 | 90.0 | 3rd data release | Texas Department of State Health Services, Laboratory Services Section | Texas Department of State Health Services (DSHS) SARS-CoV-2 Assay | |
| Nationwide CH | 94 | 5400 | 57.44680851 | 3rd data release | Nationwide Children's Hospital | SARS-CoV-2 Assay (CH) | |
| Maccura | 3000 | 5400 | 1.8 | 3rd data release | Maccura Biotechnology (USA) LLC | SARS-CoV-2 Fluorescent PCR Kit | |
| Cormeum | 6000 | 5400 | 0.9 | 3rd data release | Cormeum Laboratory Services | Cormeum SARS-CoV-2 Assay | |
| CSI Labs | 18750 | 5400 | 0.288 | 3rd data release | CSI Laboratories | CSI SARS-CoV-2 RT PCR Test | |
| Biocollections | 3000 | 5400 | 1.8 | 3rd data release | Biocollections Worldwide, Inc. | Biocollections Worldwide SARS-Co-V-2 Assay | |
| BayCare | 138 | 5400 | 39.13043478 | 3rd data release | BayCare SARS-CoV-2 RT PCR Assay | BayCare SARS-CoV-2 RT PCR Assay | |
| Tempus | 750 | 7200 | 9.6 | 3rd data release | Tempus Lab, Inc. | iC SARS-CoV2 Test | |
| Gencurix | 18000 | 8100 | 0.45 | 3rd data release | Gencurix, Inc. | GenePro SARS-CoV-2 Test | |
| BGI genomics | 450 | 9000 | 20.0 | 3rd data release | BGI Genomics Co. Ltd | Real-Time Fluorescent RT-PCR Kit for Detecting SARS-CoV-2 | |
| Guardant Health | 375 | 16200 | 43.2 | 3rd data release | Guardant Health, Inc.2 | Guardant-19 | |
| ClearDx | 6000 | 16200 | 2.7 | 3rd data release | Clear Labs, Inc. | Clear Dx SARS-CoV-2 Test | |
| Sandia | 18750 | 16200 | 0.864 | 3rd data release | Sandia National Laboratories | SNL-NM 2019 nCoV Real-Time RT-PCR Diagnostic Assay | |
| Roche (infA/B+CoV2, Liat) | 36 | 16200 | 450.0 | 3rd data release | Roche Molecular Systems, Inc. | cobas SARS-CoV-2 & Influenza A/B Nucleic Acid Test for use on the cobas Liat System | |
| Optolane | 15000 | 16200 | 1.08 | 3rd data release | OPTOLANE Technologies, Inc. | Kaira 2019-nCoV Detection Kit | |
| LumiraDx | 1500 | 16200 | 10.8 | 3rd data release | LumiraDx UK Ltd. | LumiraDx SARS-CoV-2 RNA STAR | |
| BioSewoom | 18750 | 16200 | 0.864 | 3rd data release | BioSewoom, Inc. | Real-Q 2019-nCoV Detection Kit | |
| InBios | 3300 | 18000 | 5.454545455 | 3rd data release | InBios International, Inc. | Smart Detect SARS-CoV-2 rRT-PCR Kit | |
| BioFire (RP) | 480 | 18000 | 37.5 | 3rd data release | BioFire Diagnostics, LLC | BioFire Respiratory Panel 2.1 (RP2.1) | |
| Diagnostic Solutions | 10 | 54000 | 5400.0 | 3rd data release | Diagnostic Solutions Laboratory, LLC | DSL COVID-19 Assay | |
| SolGent | 600 | 54000 | 90.0 | 3rd data release | SolGent Co., Ltd | DiaPlexQ Novel Coronavirus (2019-nCoV) Detection Kit | |
| Miami Baptist | 6000 | 54000 | 9.0 | 3rd data release | Pathology/Laboratory Medicine Lab of Baptist Hospital Miami | COVID-19 RT-PCR Test (Miami) | |
| Vela (v1, 2 duplex wells per sample) | 1680 | 54000 | 32.14285714 | 3rd data release | Vela Operations Singapore Pte Ltd | ViroKey SARS-CoV-2 RT-PCR Test | |
| MD Anderson | 15000 | 54000 | 3.6 | 3rd data release | University of Texas MD Anderson Cancer Center, Molecular Diagnostics Laboratory | MD Anderson High-throughput SARS-CoV-2 RT-PCR Assay | |
| Stanford | 3000 | 54000 | 18.0 | 3rd data release | Stanford Health Care Clinical Virology Laboratory | Stanford SARS-CoV-2 assay | |
| T2 Biosystems | 6000 | 54000 | 9.0 | 3rd data release | T2 Biosystems, Inc. | T2SARS-CoV-2 Panel | |
| Gene By Gene | 18750 | 54000 | 2.88 | 3rd data release | Gene By Gene | Gene By Gene SARS-CoV-2 Detection Test | |
| AIT Labs | 3000 | 54000 | 18.0 | 3rd data release | AIT Laboratories | SARS-CoV-2 Assay (AIT) | |
| Gravity (ThermoPrimers) | 3000 | 54000 | 18.0 | 3rd data release | Gravity Diagnostics, LLC | Gravity Diagnostics SARS-CoV-2 RT-PCR Assay | |
| Solaris | 30000 | 54000 | 1.8 | 3rd data release | Solaris Diagnostics | Solaris Multiplex SARS-CoV-2 Assay | |
| Biomeme | 5400 | 54000 | 10.0 | 3rd data release | Biomeme, Inc. | Biomeme SARS-CoV-2 Real-Time RT-PCR Test | |
| Visby | 3336 | 162000 | 48.56115108 | 3rd data release | Visby Medical, Inc. | Visby Medical COVID-19 | |
| Primerdesign | 990 | 162000 | 163.6363636 | 3rd data release | Primerdesign Ltd.3 | Primerdesign Ltd COVID-19 genesig Real-Time PCR assay | |
| GenMark (Panel) | 750 | 540000 | 720.0 | 3rd data release | GenMark Diagnostics, Inc. | ePlex Respiratory Pathogen Panel 2 | |
| UTMG | 100 PFU | 540000 | | 3rd data release | UTMG Pathology Laboratory2 | UTHSC/UCH SARS-CoV-2-RT-PCR Assay | |
| Omnipathology | 3690 | 540000 | 146.3414634 | 3rd data release | Omnipathology Solutions Medical Corporation | Omni COVID-19 Assay by RT-PCR | |
| LCT | 609 | 540000 | 886.6995074 | 3rd data release | Laboratorio Clinico Toledo | Laboratorio Clinico Toledo SARS-CoV-2 Assay | |
| Express Gene | 2400 | 540000 | 225.0 | 3rd data release | Express Gene LLC, DBA: Express Gene Molecular Diagnostics Laboratory | Express Gene 2019-nCoV RT-PCR Diagnostic Panel | |
| Alpha Genomix | 12000 | 540000 | 45.0 | 3rd data release | Alpha Genomix Laboratories3 | Alpha Genomix TaqPath SARS-CoV-2 Combo Assay | |
| BioTNS | 11145 | 1620000 | 145.3566622 | 3rd data release | TNS Co., Ltd (Bio TNS) | COVID-19 RT-PCR Peptide Nucleic Acid (PNA) kit | |
| Cue Health | 40 | 3000 | 75.0 | 3rd data release | Cue Health Inc.a | Cue COVID-19 Test | |
| Atila BioSystems | 3500 | 9000 | 2.571428571 | 3rd data release | Atila BioSystems, Inc. | iAMP COVID-19 Detection Kit | |
||
## Chart
_Scatter Plot showing EUA tests with EUA LOD on y axis and FDA Panel LOD on x axis. Above the line = Developer obtained worse LOD in original EUA than with FDA panel_
METADATA
last updated: 2026-03-10_105729
file_name: _archive-combined-files_fl-fda-submissions_190k.md
category: regulatory
subcategory: fl-fda-submissions
gfile_url: **FLAGGED - TBD user-facing Google-hosted public file URL**
words:
tokens:
CONTENT
# _archive-combined-files_fl-fda-submissions_190k (16 files, 190,321 tokens)
# 2,051 _context-commentary_regulatory-fl-fda-submissions.md
METADATA
last updated: 2026-03-02 RT
file_name: _context-commentary_regulatory-fl-fda-submissions.md
category: regulatory
subcategory: fl-fda-submissions
words: 1401
tokens: 2051
CONTENT
## Context
This subcategory contains FloodLAMP's FDA Emergency Use Authorization (EUA) submissions and associated Instructions for Use (IFU) documents for its SARS-CoV-2 diagnostic tests. There are 15 files spanning from November 2020 to October 2021, representing the full arc of FloodLAMP's regulatory submission effort. For background on the EUA framework itself and how it differs from standard 510(k) IVD approvals, see the FDA policy subcategory `regulatory/fda-policy`. For the correspondence with the FDA that accompanied these submissions, see `regulatory/fl-fda-correspondence`.
The subcategory documents four distinct test products and several ancillary submissions. The "QuickColor" test is the main FloodLAMP test, and one that was used for all of FloodLAMP's surveillance pilot programs. When the "FloodLAMP test" is used throughout the files in this archive, the QuickColor test is the one being referred to.
- **FloodLAMP Glass Milk LAMP Test** (Pre-EUA, November 2020): The earliest submission, a colorimetric RT-LAMP assay using silica ("glass milk") purification of nucleic acids from saliva and anterior nares swab specimens (from the Harvard Rabe-Cepko protocol). This was a pre-EUA — a preliminary package submitted to initiate FDA engagement and enter the review queue. It targeted asymptomatic screening with sample pooling at a baseline level of 10. The limit of detection (LoD) was 2 copies/uL (approximately 2,000 copies/mL).
- **FloodLAMP EasyPCR COVID-19 Test** (EUA Submission + IFU, v1.0 March 2021, v1.1 May 2021): An extraction-free, duplex RT-qPCR assay using the CDC N1 and human RNaseP primer-probe sets, with TCEP-based chemical inactivation and heat treatment. It required standard RT-PCR instruments (QuantStudio, Bio-Rad CFX96) but no nucleic acid extraction equipment. The LoD was 3,100 copies/mL. Clinical evaluation at Stanford showed 97.5% positive agreement and 100% negative agreement against a high-sensitivity comparator on 80 specimens.
- **FloodLAMP QuickColor COVID-19 Test** (EUA Submission + IFU, v1.0 March 2021, v1.1 May 2021, v1.2 draft October 2021): An extraction-free, colorimetric RT-LAMP assay with a visual pink-to-yellow readout requiring no specialized instrumentation. It used 18 LAMP primers targeting three SARS-CoV-2 genes (ORF1ab, N, E) and the same TCEP-based inactivation as the EasyPCR test. The LoD was 12,500 copies/mL. Clinical evaluation at Stanford showed 90% positive agreement and 100% negative agreement on 80 specimens. The v1.2 IFU introduced triplicate repeat procedures for inconclusive results.
- **FloodLAMP FLAMP (QuickFluor) COVID-19 Test** (EUA Submission + IFU draft, March 2021, NOT SUBMITTED): A fluorimetric RT-LAMP assay using real-time fluorescence readout on RT-PCR instruments. It used the same primers and inactivation as QuickColor but with fluorescent detection instead of colorimetric. The LoD was 50,000 copies/mL and clinical evaluation showed 80% positive agreement. This test was prepared but never submitted to the FDA.
- **Pooled Swab Collection and Screening Studies** (Pre-EUA submissions, May 2021): Three documents supporting FloodLAMP's pooling and asymptomatic screening strategy — a pre-EUA for a direct-to-consumer pooled swab collection kit (allowing 1–4 self-collected anterior nasal swabs in a single tube), collection kit instructions, and a proposed validation study design for pooling and serial asymptomatic screening aligned to FDA guidance.
Each submission follows the FDA's EUA template structure: purpose, measurand, applicant information, regulatory status, proposed intended use, device description and test principle, controls, interpretation of results, manufacturing and component sourcing, and performance evaluation (LoD, inclusivity, cross-reactivity, interfering substances, clinical evaluation). The IFU documents mirror much of this content in an operational format for laboratory use.
All of FloodLAMP's tests shared a common TCEP-based chemical inactivation step and were designed as "open source protocol" tests — meaning designated CLIA high-complexity laboratories could source all components directly from commercial vendors rather than purchasing proprietary kits. This open-source approach is central to FloodLAMP's strategy, as documented in the `regulatory/open-euas` subcategory. The EasyPCR and QuickColor tests were designed to work as an integrated pair: QuickColor for high-throughput colorimetric screening (45-minute turnaround, no instruments) and EasyPCR for rapid PCR-based confirmation (~1 hour 45 minutes). New England Biolabs supported both tests with their LAMP master mix and Luna RT-qPCR kit, and LGC Biosearch Technologies supplied production-scale LAMP primer sets.
The submissions evolved across versions. The v1.0 submissions (March 2021) proposed intended use for "individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval." The v1.1 submissions (May 2021) reframed the intended use around "routine screening programs" in settings like schools and workplaces. None of these submissions received FDA authorization.
## Commentary
The primary commentary for submissions is combined with the correspondence category — see `regulatory/fl-fda-correspondence/_context-commentary_regulatory-fl-fda-correspondence.md` regarding FloodLAMP's FDA engagement. Here are comments on the more technical aspects of the EUA submission process.
The EUA submission process involves two main types of documents: the submission itself and the Instructions for Use (IFU). The submission is the regulatory document — it follows the FDA's structured template with sections covering purpose, measurand, intended use, device description, performance evaluation, manufacturing, and so on. The IFU is the operational document intended for the laboratories that will run the test. They overlap substantially in content, but serve different audiences and purposes. Both must be prepared and aligned, and both are substantial documents. For FloodLAMP, each test's submission ran 5,000–10,000 words, and each IFU ran 7,000–14,000 words.
A critical concept in understanding these documents is that the FDA authorizes test systems, not tests in isolation. The entire system — reagents from specific vendors, validated instruments, the exact workflow, controls, and interpretation criteria — is what receives authorization. Changing a single component can require revalidation. For open-source protocol tests like FloodLAMP's, this posed an inherent tension: the whole point was to enable broad deployment using commodity components from multiple suppliers, but the regulatory framework required specificity at every level. FloodLAMP addressed this by validating multiple instruments (QuantStudio 6 Flex, QuantStudio 7 Pro, Bio-Rad CFX96) and multiple primer and probe vendors (Eurofins Genomics, IDT, LGC Biosearch) within a single submission.
The bench science for EUA validation can actually move quite fast. In a conversation with another test developer — an academic who started a company during the pandemic and did obtain an EUA — they described doing the core validation work in a weekend. The bottleneck is not the assay work itself but the surrounding logistics and documentation. For FloodLAMP, the single biggest delay was getting registered with BEI Resources to obtain the cross-reactivity reagents. The FDA requires testing against a panel of related pathogens and respiratory flora, and BEI is the primary source for those reference organisms. The registration and shipping process takes weeks, and for a small organization running lean, that waiting period was a significant constraint.
Even with the FDA's templates available, the document preparation is a heavy lift for anyone who has not done it before. FloodLAMP benefited from other groups sharing their actual EUA submission documents — these are not published, and they differ in important ways from the public-facing authorizations and IFUs that appear on the FDA website. Having real examples was helpful for understanding the level of detail and the conventions that the templates alone do not fully convey. If the FDA allowed or facilitated sharing of these submissions, for example, by simply letting developers choose to publish their submissions openly, some likely would, especially academics. This would meaningfully lower the barrier for new entrants.
Even with the FDA's templates available, the document preparation is a heavy lift for anyone who has not done it before. FloodLAMP benefited from other groups sharing their actual EUA submission documents — these are not published, and they differ in important ways from the public-facing authorizations and IFUs that appear on the FDA website. Having real examples was helpful for understanding the level of detail and the conventions that the templates alone do not fully convey. If the FDA allowed or facilitated sharing of these submissions, for example, by simply letting developers choose to publish their submissions openly, some likely would, especially academics. This would meaningfully lower the barrier for new entrants.
The new capabilities of AI could transform the document preparation burden. The EUA submission and IFU are highly structured, repetitive across test types, and draw heavily on standardized language. With progress on standardization and transparency from the FDA — such as machine-readable templates, published example submissions, and clearer guidance on what constitutes acceptable variations — AI tools could handle much of the drafting, cross-referencing, and consistency-checking that currently consumes weeks of a developer's time. The combination of AI and regulatory modernization could significantly reduce the cost and time to bring validated, innovative tests to market.
# 4,342 2020-11-06_Pre-EUA Sub - FloodLAMP Glass Milk LAMP Test.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2020-11-06_Pre-EUA Sub - FloodLAMP Glass Milk LAMP Test.md
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title: Pre-EUA Sub - FloodLAMP Glass Milk LAMP Test
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summary_short: The Pre-EUA Sub - FloodLAMP Glass Milk LAMP Test (Nov 6, 2020) is a Molecular Diagnostic Template submission for laboratory use that defines the intended use, measurand, and workflow for a pooled, colorimetric RT-LAMP SARS-CoV-2 test using chemical inactivation plus “glass milk” silica purification for saliva and anterior nares samples in high-complexity CLIA labs. It compiles key regulatory details, validated reagents and prepared solutions, step-by-step procedures, controls, result interpretation criteria, and early performance data (including LoD) to support an EUA pathway for asymptomatic screening and pooling.
CONTENT
***INTERNAL TITLE:*** Molecular Diagnostic Template for Laboratories
## A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for use of FloodLAMP to be performed for the in vitro qualitative detection of RNA from the SARS-CoV-2 in anterior nares swab specimens and saliva samples from individuals \[suspected of COVID-19 by their healthcare provider\]\[as recommended for testing by public health authority guidelines for screening of asymptomatic individuals\]. FloodLAMP will be performed in CLIA-certified, high-complexity laboratories. Additional testing and confirmation procedures should be performed in consultation with public health and/or other authorities to whom reporting is required. Positive results should also be reported in accordance with local, state, and federal regulations.
## B. MEASURAND
Specific nucleic acid sequences in the ORF1a and nucleocapsid genes of SARS-CoV-2, targeted by the As1e and N2 primer sets.
## C. LABORATORY/SPONSOR
Randall J. True
Founder and CEO
FloodLAMP Biotechnologies, a DE Public Benefit Corporation
Phone: (415) 269-2974
Email: randy@floodlamp.bio
Mailing Address:
4860 Alpine Rd.
Portola Valley, CA 94028
Laboratory Address:
FloodLAMP.bio at MBC Biolabs
San Carlos, CA 94070
## D. REGULATORY INFORMATION
***Approval/Clearance Status:***
FloodLAMP is not cleared, CLIA-waived, approved, or subject to an approved investigational device exemption.
***Product Code:***
QJR
## E. PROPOSED INTENDED USE
### 1) Intended Use:
The FloodLAMP Glass Milk Test is a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) test intended for the qualitative detection of RNA from SARS-CoV-2 in saliva and anterior nares (nasal) swab specimens. Testing is limited to screening of asymptomatic individuals. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories. Sample pooling is at a baseline level of 10, with on-site and at-home modalities. Pooling of pools to levels greater than 10 will be investigated pending LoD determination and validation studies.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information. FloodLAMP Glass Milk Test is intended to be used on normal and clear saliva that naturally forms in the mouth, not for other lower respiratory tract specimens such as sputum.
The assay is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of real-time PCR and in vitro diagnostic procedures. The assay is only for use under the Food and Drug Administration's Emergency Use Authorization.
Use of the FloodLAMP Glass Milk Test in a general, asymptomatic screening population is intended to be used as part of an infection control plan, that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. Negative results should be considered presumptive and do not preclude current or future infection obtained through community transmission or other exposures. Negative results must be considered in the context of an individual's recent exposures, history, presence of clinical signs and symptoms consistent with COVID-19.
### 2) Reagents Used with Test:
The FloodLAMP Glass Milk test is to be used with the following reagents and no specialized instruments. Only ordinary laboratory equipment such as pipettes, centrifuges, and heaters are needed.
#### Table 1: Validated reagents used with Test
|Item|Chemical Composition|Vendor|Catalog number|
|---|---|---|---|
|TCEP|tris(2-carboxyethyl)phosphine hydrochloride|Sigma-Aldrich Millipore Sigma|646547-10X1ML 580567|
|EDTA|Ethylenediaminetetraacetic acid|Thermo Fisher|15575020|
|NaOH|Sodium Hydroxide|Sigma-Aldrich|SX0607N-6|
|Ultrapure Water|Ultrapure Water, DNAse RNAse free|Thermo Fisher|10977015|
|Tris-HCl|TRIS hydrochloride, 1M pH 8.0|Thermo Fisher|AM9855G|
|TE Buffer|TRIS hydrochloride (10mM) and EDTA (1mM)|Sigma-Aldrich|93283|
|1X PBS|monobasic potassium phosphate, sodium chloride, and dibasic sodium phosphate|Thermo Fisher|10010049|
|NaI|Sodium iodide|Sigma-Aldrich|793558|
|HCl|Hydrochloric acid|Sigma-Aldrich|320331|
|Triton X-100|t-Octylphenoxypolyethoxyethanol|Sigma-Aldrich|T8787-50ML|
|Silica|Silicon Dioxide, 325 Mesh|Sigma-Aldrich|SI108|
|Guanidine|Guanidine Hydrochloride|Sigma-Aldrich|SRE0066|
|LAMP MM|Colorimetric LAMP Master Mix|NEB|M1804|
||
### 3) Prepared Solutions Used with Test:
#### Table 2: Inactivation Solution
|Component|Concentration|Volume|
|---|---|---|
|TCEP|0.5 M|10 mL|
|EDTA|0.5 M|4 mL|
|NaOH|10 N|2.3 mL|
|Ultrapure Water| |3.7 mL|
Final Volume 20 mL
||
#### Table 3: Binding Solution
|Component|Concentration|Volume / Mass|
|---|---|---|
|NaI| |45 g|
|Ultrapure Water| |to 48.5 mL|
|HCl|1 N|0.5 mL|
|Triton X-100| |1.0 mL|
Final Volume 50 mL
||
#### Table 4: Glass Milk - Under Development
|Component|Concentration|Volume / Mass|
|---|---|---|
|Silica| |500 g|
|HCl|10%|100 mL|
|dH20| |2400 mL|
|TE Buffer| |500 mL|
|Final Volume 200 mL|
||
#### Table 5: Primers used for FloodLAMP \"AN\" Primer Mix
|Target|Primer|Sequence|
|---|---|---|
|As1e|As1e_FIP|TCAGCACACAAAGCCAAAAATTTATTTTTCTGTGCAAAGGAAATTAAGGAG|
| |As1e_BIP|TATTGGTGGAGCTAAACTTAAAGCCTTTTCTGTACAATCCCTTTGAGTG|
| |As1_F3|CGGTGGACAAATTGTCAC|
| |As1_B3|TTACAAGCTTAAAGAATGTCTGAACACT|
| |As1_LF|TTACAAGCTTAAAGAATGTCTGAACACT|
| |As1_LB|TTGAATTTAGGTGAAACATTTGTCACG|
|N2|N2-FIP|TTCCGAAGAACGCTGAAGCGGAACTGATTACAAACATTGGCC|
| |N2-BIP|CGCATTGGCATGGAAGTCACAATTTGATGGCACCTGTGTA|
| |N2-F3|ACCAGGAACTAATCAGACAAG|
| |N2-B3|GACTTGATCTTTGAAATTTGGATCT|
| |N2-LF|GGGGGCAAATTGTGCAATTTG|
| |N2-LB|CTTCGGGAACGTGGTTGACC|
||
#### Table 6: 10X Primer Mix
|Primer|Volume (400 reactions)|
|---|---|
|As1e_FIP (100uM)|160 μL|
|As1e_BIP (100uM)|160 μL|
|As1_F3 (100uM)|20 μL|
|As1_B3 (100uM)|20 μL|
|As1_LF (100uM)|40 μL|
|As1_LB (100uM)|40 μL|
|N2-FIP (100uM)|160 μL|
|N2-BIP (100uM)|160 μL|
|N2-F3 (100uM)|20 μL|
|N2-B3 (100uM)|20 μL|
|N2-LF (100uM)|40 μL|
|N2-LB (100uM)|40 μL|
|Add Ultrapure Water|120 μL|
|Final Volume 1000 μL|
||
#### Table 7: Primer Solution
|Component|Volume (1 reaction)|Volume (100 reactions)|
|---|---|---|
|Ultrapure Water|7.5 μL|750 μL|
|Guanidine (400 mM)|2.5 μL|250 μL|
|10X Primer Mix|2.5 μL|250 μL|
|Final Volume 1250 mL|
||
## F. DEVICE DESCRIPTION AND TEST PRINCIPLE
### 1) Product Overview/Test Principle:
The FloodLAMP Glass Milk Test is a method for SARS-CoV-2 detection that comprises 3 steps: 1) sample inactivation and preservation, 2) nucleic acid purification and concentration, and 3) colorimetric RT-LAMP amplification. It can be broadly implemented as it (1) utilizes very low cost, readily available bulk reagents for inactivation and purification, (2) does not require any instrumentation for assay processing or readout, and (3) has high sensitivity enabling sample pooling to be utilized. Thus, the low cost and low barrier to deployment of the FloodLAMP Glass Milk Test means that it can scale quickly to very high levels.
### 2) Description of Test Steps:
#### Sample Inactivation
Starting with raw saliva or anterior nares swab extract:
1. 100X Inactivation Solution is added to sample.
2. Sample is vortexed to mix.
3. Sample is heated in 95°C water bath or dry heat block for 8 minutes.
4. Sample is placed on ice for at least 4 minutes.
5. Sample is spun in centrifuge at 5krpm for 4 minutes.
6. Top 90% of the sample is transferred to a new tube for subsequent processing and/or storage.
7. Store samples at 2-8°C until sample transport or processing (up to 72 hours) or at -20°C for 2-4 weeks, or at -80°C for longer term storage.
#### Glass Milk Purification
1. Glass Milk is added to the Binding Solution at a ratio of 1:50.
2. Glass Milk + Binding Solution is vortexed to mix.
3. 255 µL of Mixture is added to 500 µL of sample, in 1.5 mL microcentrifuge tubes or in wells of a deepwell plate.
4. Sample is incubated for 10 minutes, with periodic mixing.
5. Sample is spun down for 1 minute to pellet glass milk.
6. Supernatant is removed.
7. 80% Ethanol is added and then removed to wash pellet and perform liquid exchange.
8. 100 µL of 80% ethanol is added, pellet resuspended and resuspension transferred to 200 µL PCR tubes (either to strips of 8 PCR tubes or to a PCR plate).
9. Strips are capped (plates sealed) and spun down.
10. Supernatant is removed.
11. Tubes (plate) with nucleic acid bound silica pellet is placed on a 65°C heat block and heated for 5 minutes or until pellets have dry, chalky appearance.
#### LAMP Amplification
1. On ice or in cold block, prepare LAMP Reaction Mix by combining 12.5 µL per reaction LAMP Master Mix (NEB 1804) with 12.5 µL of Primer Solution (per reaction: 7.5 µL water, 2.5 µL 400 mM Guanidine Hydrochloride , 2.5 µL 10X Primer Mix).
2. 25 µL of LAMP Reaction Mix is added directly to dried pellet in each PCR tube.
3. Mix by pipette (avoid bubbles).
4. Cap strip tubes (seal plate).
5. Incubate on hot plate with PCR Tube dry block at 65°C for 25 minutes.
6. Remove strip tubes (plate) and let cool for 2 minutes.
7. Visually read the result by color of the PCR tube.
### 3) Control Material(s) to be Used:
Controls will be included with every batch of samples run.
#### Table 8: Purpose and frequency of controls to be used with Test
|Control|Purpose|Frequency|
|---|---|---|
|Negative Control|To monitor for contamination during sample processing|Every batch of up to 93 samples|
|Positive Control|To monitor functioning of reagents|Every PCR plate with up to 93 samples or batch of strip tubes|
||
1X Phosphate Buffered Saline + Inactivation Solution is used as a negative control (no template control). 1X Phosphate Buffered Saline + Inactivation Solution + Spike (Zeptometrix Inactivated Virions, BEI Cell Lysate, or Twist synthetic SARS-CoV-2 RNA) is used as positive control (**see Controls in Supporting Data**).
### 4) Assay results and interpretation:
All test controls should be examined prior to interpretation of patient results. If the controls are not valid, the sample results cannot be interpreted. Results will be interpreted according to **Table 9**.
#### Table 9: Test results and interpretation
|Outcome|Color|
|---|---|
|Positive|Yellow|
|Negative|Pink|
|Invalid|Orange|
||
#### Table 10: Image of Acceptable Binary Test results
_Photo showing acceptable binary test results with yellow (positive) and pink (negative) colorimetric LAMP reactions in PCR strip tubes._
Invalid test results will be retested by repeating the purification and amplification on the inactivated sample. Results from retested samples will follow the same interpretation as listed in **Table 9**.
## G. PERFORMANCE EVALUATION
### 1) Limit of Detection (LoD) - Analytical Sensitivity:
Specimens from presumed negative participants were collected and spiked with Zeptometrix inactivated virions prior to the inactivation step. This contrived positive sample was diluted in presumed negative inactivated samples to achieve the target concentrations for LoD assay runs (see **Table 10 and Supporting Data**).
#### Table 10: Limit of detection of Test
|Concentration (copies/µL)|Positive Samples Detected|
|---|---|
|4|100% (20/20)|
|2|100% (19/19)|
||
As a part of the Xprize Rapid Test Competition, \"proficiency plates\" consisting of 157 blinded samples were run with the FloodLAMP Glass Milk Test. Purification was performed in deepwell plates and processing was performed with multichannel pipettes. Hands-on time per plate was approximately 1 hour. The Xprize samples were smaller volumes (100-200 µL) than typically used for the FloodLAMP Glass Milk Test (500 µL) and were not inactivated with the same TCEP Inactivation Solution. Notwithstanding these caveats, LoD and cross reactivity determination will be available after the results data is scored.
Below is an image of a completed FloodLAMP Glass Milk Test plate, including 8 alternating positive and negative controls in well positions H5-12.
_Photo of a completed 96-well FloodLAMP Glass Milk Test plate showing yellow and pink colorimetric results with alternating positive and negative controls in positions H5-12._
### 2) Inclusivity (analytical sensitivity): TBD
In silico inclusivity analysis to be performed by mapping the primers and probes to the complete SARS-CoV-2 genomes that are available in the current GISAID (Global Initiative on Sharing All Influenza Data) database. The rate of mismatches will be calculated and potential for amplification failure analyzed.
### 3) Cross-reactivity (analytical specificity): TBD
In silico cross reactivity analysis to be performed by aligning the primer sequences against sequences of coronaviruses related to SARS-Cov-2, as well as commonrespiratory pathogens. If any organisms show \>80% overall match for the primer sets, wet testing of the following will be performed.
NR-52346 Quantitative PCR (qPCR) Control RNA from Inactivated SARS Coronavirus
NR-44228 Human respiratory syncytial virus , Genomic RNA from Human Respiratory Syncytial Virus, A1998/12-21
NR-45848 Genomic RNA from Influenza B Virus, B/Nevada/03/2011 (Victoria Lineage)
NR-49122 Genomic RNA from Human Metapneumovirus, TN/83-1211
HM-121 Streptococcus salivarius SK126
### 4) Clinical Evaluation:
**Clinical specimens**
The FloodLAMP Glass Milk Test has been performed on a single clinical positive saliva sample, however no concentration or comparator Ct values were available. The nucleic acid bound pellet was split evenly and the standard FloodLAMP Glass Milk Test colorimetric LAMP reaction was run on one set of 8 (duplicates of clinical positive and 6 controls) and the fluorimetric LAMP reaction (NEB E1700) was run on the 2nd set of 8 using an ABI QuantStudio 7 qPCR machine. SARS-CoV-2 was detected for the clinical positive samples in both sets, with expected results from all controls.
_Photo showing colorimetric and fluorimetric LAMP results from a clinical positive saliva sample with expected control results._
*thanks to collaborators at Montana St Univ, Chang & Keil
## H. UNMET NEED ADDRESSED BY THE PRODUCT
*This section will be completed by FDA.*
## I. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the detection of the SARS-CoV-2 have been approved/ cleared by FDA.
## J. BENEFITS AND RISKS
*This section will be completed by FDA.*
## K. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS
Include proposed Fact Sheets for Patients and Healthcare Providers - *see examples for authorized EUA tests on our website and templates will be made available.*
## L. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT
In lieu of a package insert or labeling please include your Laboratory SOP/protocol.
## M. RECORD KEEPING AND REPORTING INFORMATION TO FDA
The laboratory will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report on adverse events, and this website is referenced in the Fact Sheet for Health Care providers. The laboratory will maintain information on the performance of the test, and report to FDA any suspected change in performance of which they become aware. The laboratory will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
# 9,057 2021-03-22_EUA Submission - FloodLAMP EasyPCR COVID-19 Test v1.0.md
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last updated: 2026-03-05 by BA
file_name: 2021-03-22_EUA Submission - FloodLAMP EasyPCR COVID-19 Test v1.0.md
file_date: 2021-03-22
title: EUA Submission - FloodLAMP EasyPCR COVID-19 Test v1.0
category: regulatory
subcategory: fl-fda-submissions
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notes:
summary_short: The EUA Submission for the FloodLAMP EasyPCR COVID-19 Test v1.0 details an extraction-free, duplex RT-qPCR assay for qualitative SARS-CoV-2 detection in upper respiratory swab specimens, including proposed intended use for routine weekly screening in asymptomatic individuals. It specifies the CDC N1 and RNaseP targets, validated instruments, sample inactivation workflow, controls and interpretation criteria, and manufacturing/sourcing assumptions for an “open source” CLIA high-complexity lab deployment. It summarizes analytical and clinical performance claims including a 3,100 copies/mL LoD and clinical agreement results from an 80-specimen evaluation.
CONTENT
***INTERNAL TITLE:*** EUA Submission - FloodLAMP EasyPCR(TM) COVID-19 Test
## A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the **FloodLAMP EasyPCR(TM) COVID-19 Test** for the *in vitro* qualitative detection of RNA from the SARS-CoV-2 in in upper respiratory specimens including oropharyngeal and nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests.** Additional testing and confirmation procedures should be performed in consultation with public health and/or other authorities to whom reporting is required. Test results should be reported in accordance with local, state, and federal regulations.
## B. MEASURAND
Specific nucleic acid sequences from the genome of the SARS-CoV-2, targeted by the previously certified **2019-nCoV\_N1 primers and probe set as part of the CDC qPCR assay**. Primer names and sequences are listed in Table 1.
#### Table 1: Primers and probes
| | | |
|---------------|------------------|----------------------------------------|
| **Target** | **Primer/Probe** | **Sequence** |
| CDC-N1 | 2019-nCoV\_N1-F | GACCCCAAAATCAGCGAAAT |
| CDC-N1 | 2019-nCoV\_N1-R | TCTGGTTACTGCCAGTTGAATCTG |
| CDC-N1 | 2019-nCoV\_N1-P | **FAM**-ACCCCGCATTACGTTTGGTGGACC-**IBFQ** |
| Human RNAseP | RP-F | AGATTTGGACCTGCGAGCG |
| Human RNAseP | RP-R | GAGCGGCTGTCTCCACAAGT |
| Human RNAseP | RP-P | **Cy5**-TTCTGACCTGAAGGCTCTGCGCG-**IBRQ** |
||
## C. APPLICANT
FloodLAMP Biotechnologies, a DE Public Benefit Corporation
| Mailing Address: 4860 Alpine Rd. Portola Valley, CA 94028 | Laboratory Address: 930 Brittan Ave San Carlos, CA 94070 | Randall J. True, CSO Phone: (415) 269-2974 Email: randy@floodlamp.bio |
| :---- | :---- | :---- |
## D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name - **FloodLAMP EasyPCR(TM) COVID-19 Test**
Established Name - **FloodLAMP EasyPCR(TM) COVID-19 Test**
## E. REGULATORY INFORMATION
***Approval/Clearance Status:***
The **FloodLAMP EasyPCR(TM) COVID-19 Test** is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
***Product Code:***
QJR
## F. PROPOSED INTENDED USE
### 1) Intended Use:
**FloodLAMP EasyPCR(TM) COVID-19 Test** is a real-time reverse transcriptase polymerase chain reaction (RT-PCR) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests.** Testing is limited to **laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.**
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The **FloodLAMP EasyPCR(TM) COVID-19 Test** is intended for use by **qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of in vitro diagnostic procedures**. The **FloodLAMP EasyPCR(TM) COVID-19 Test** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
### 2) Special Conditions for Use Statements:
For Emergency Use Authorization (EUA) only
For prescription use only
For in vitro diagnostic use only
### 3) Special Instrument Requirements:
The **FloodLAMP EasyPCR(TM) COVID-19 Test** is to be used with the RT-PCR instruments listed in Table 2.
#### Table 2. RT-PCR Instruments validated for test
| | |
|----------------------|--------------------------------------------------|
| **Manufacturer** | **Instrument** |
| Thermo Fisher Scientific | Applied Biosystems QuantStudio(TM) 6 Flex |
| Thermo Fisher Scientific | Applied Biosystems QuantStudio(TM) 7 Pro |
| Bio-Rad | CFX96 Touch(TM) Real-Time PCR Detection System |
||
Designated laboratories will receive an FDA accepted instrument qualification protocol included as part of the **FloodLAMP EasyPCR(TM) Covid-19 Test** IFU and will be directed to execute the protocol prior to testing clinical samples. Designated laboratories must follow the authorized IFU, which includes the instrument qualification protocol, as per the letter of authorization.
## G. DEVICE DESCRIPTION AND TEST PRINCIPLE
### 1) Product Overview/Test Principle:
The **FloodLAMP EasyPCR(TM) COVID-19 Test** is a RNA extraction-free, duplexed RT-qPCR assay which indicates whether SARS-CoV-2 RNA is present. It can widely and rapidly be scaled because 1) it does not require nucleic acid extraction equipment, 2) it utilizes reagents and supplies readily available in large quantities, and 3) is a very straightforward protocol with minimal steps that can be executed quickly and reliably. It also utilizes the same streamlined sample preparation as the **FloodLAMP QuickColor(TM) COVID-19 Test**. Both are supply chain robust, "open source" protocol tests, meaning designated laboratories may obtain the test components directly from vendors. Further, the **FloodLAMP QuickColor(TM) COVID-19 Test** is isothermal, does not require any instrumentation and has a visual readout. Together, the two tests can be used in an integrated program for screening and rapid confirmation in large populations by a broad range of laboratories.
In the **FloodLAMP EasyPCR(TM) COVID-19 Test,** samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step, and the resulting inactivated sample is directly used as input in the duplexed RT-qPCR test. The test does not use new primers and probes for RT-qPCR testing, but rather uses previously validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC, which are readily available from multiple commercial suppliers. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a duplex assay, reducing the number of tests to 1 assay with 2 targets.
### 2) Description of Test Steps:
Specimens including **nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs** are collected in **sterile collection tubes.** Swabs are transported and stored dry prior to processing. At the laboratory, an inactivation solution at 1X containing TCEP (2.5 mM), EDTA (1 mM), and NaOH (11 mM) in 0.9% saline (154 mM) is added to the container with the swab, at the volume of 1 ml. Alternatively, for swabs that are collected or eluted in a saline solution or equivalent, the inactivation solution at 100X concentration should be added at 1/100th the sample solution volume.
The container with the specimen and inactivation solution is mixed by vortexing for 30 seconds. Subsequently, the container is heated in a 95°C water bath or dry heat block for 8 minutes. The now inactivated specimen container is allowed to cool at room temperature for 10 minutes and then stored on ice or at 4°C until amplification.
An amplification reaction mix (18 µl) is prepared per manufacturer's specifications, containing the New England Biolabs LunaⓇ PCR Master Mix (New England Biolabs E3006, 10 µl), New England Biolabs LunaⓇ RT (New England Biolabs E3006, 1 µl), a primer solution (4 µl of 5X PCR primer stock w/ N1-F & N1-R at 2 µM, N1-P & RP-P at 1 µM and RP-F & RP-R at 0.75 µM), and nuclease-free water (3 µl).
2µl of the inactivated sample is added to 18µl of the amplification reaction mix. The reaction is then run with the following thermocycler conditions in Table 3:
#### Table 3: Thermal cycling conditions and plate read steps
| | | | |
|----------|-----------------|----------|----------|
| **Step** | **Temperature** | **Time** | **Reps** |
| 1 | 52°C | 10 min | 1 |
| 2 | 95°C | 2 min | 1 |
| 3 | 95°C | 10 sec | 44 |
| 3 | 55°C\* | 30 sec | 44 |
||
*\* This step should be the optical read step*
### 3) Control Materials to be Used with FloodLAMP EasyPCR(TM) COVID-19 Test:
**One Positive Template Control and one Negative (No Template) Control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes. An **Internal Process Control** is included in every PCR reaction.
1. A **“No Template” (Negative) Control (NTC) is needed to assure the absence of cross-contamination from positive samples, positive controls, or amplicons** and is used **to determine if sample results are valid.** **It consists of nuclease-free water.**
2. A **Positive Template Control is needed to assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water.** Stock and working aliquots of the positive control are produced from the sources listed in Table 4 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at -80°C, or at most 1 month at -20°C.
3. **An Internal Process Control is needed to assure sufficient specimen quantity and quality**. It consists of a primer/probe set targeting the human RNaseP gene that is included in a single PCR amplification reaction. The RNAseP Internal Process Control uses a fluorescent reporter in a separate channel from the SARS-CoV-2 channel (i.e. in duplex).
#### Table 4. Components for Positive Template Control
| | | | |
|--------------------------------|---------------|----------------|------------|
| **Material** | **Supplier** | **Catalog \#** | **Volume** |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µL |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µL |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895 µL |
||
## H. INTERPRETATION OF RESULTS
### 1) FloodLAMP EasyPCR(TM) COVID-19 Test Controls
All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. Target results for the controls will be interpreted according to Table 5 below.
1. The “No Template” (Negative) Control (NTC) should yield a negative “not detected” result for both the N1 and RNaseP targets.
2. The Positive Template Control should yield a positive “detected” result for the N1 target and a negative “not detected” for the RNaseP control.
3. The Internal Process Control should yield a positive "detected" result for RNaseP. Detection of RNaseP is required to report a negative SARS-CoV-2 result.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and (optionally) RNAseZAP(TM) product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
### 2) Examination and Interpretation of Patient Specimen Results:
Assessment of clinical patient specimen test results should be performed after the positive, negative, and internal controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted. Patient specimen results will be interpreted according to Table 5 below.
#### Table 5: Interpretation of Patient Specimen Results
| ABI QuantStudio(TM) 7 Pro | | |
| :---: | :---: | :---: |
| **Result** | **Ct Value: N1** | **Ct Value: RP** |
| Positive | \<38.0 | Any Value |
| Negative | ≥38.0 | \<35.0 |
| Invalid | ≥38.0 | ≥35.0 |
| **Bio-Rad CFX96 Touch(TM) ABI QuantStudio(TM) 6 Flex** | | |
| **Result** | **Ct Value: N1** | **Ct Value: RP** |
| Positive | \<40.0 | Any Value |
| Negative | ≥40.0 | \<35.0 |
| \*Invalid | ≥40.0 | ≥35.0 |
||
\*Invalid test results will be repeated by rerunning the primary sample if available, otherwise by rerunning the inactivated sample. Results from retested samples will follow the same interpretation as listed in Table 5.
If the final interpretation of the test result is invalid, then "Invalid/Inconclusive" should be reported and retesting of the individual is recommended.
## I. PRODUCT MANUFACTURING
### 1) Overview of Manufacturing and Distribution:
The **FloodLAMP EasyPCR(TM) COVID-19 Test** utilizes standard chemicals available from multiple vendors, with the exception of the New England Biolabs LunaⓇ Universal Probe One-Step RT-qPCR Kit.
The **FloodLAMP EasyPCR(TM) COVID-19 Test** utilizes the same primer and probes as the EUA authorized SalivaDirect(TM) test, which derive from the CDC primer set. These are available in very large quantities with immediate distribution from multiple vendors including Eurofins Genomics, Integrated DNA Technologies, and LGC Biosearch.
New England Biolabs has expressed strong support for the **FloodLAMP EasyPCR(TM) COVID-19 Test** and FloodLAMP's other open source protocol EUA submissions that incorporate their products. New England Biolabs has very large quantities of the LunaⓇ Universal Probe One-Step RT-qPCR Kit prepared and ready for immediate distribution, typically with 24 hour shipping. Their manufacturing capacity is among the largest in the United States and can surge to meet increased demand.
**\*Under the Emergency Use Authorization (EUA) any of the 21 CFR Part 820 Quality System Regulation (QSR) requirements can be waived for the duration of the EUA but FDA recommends that developers follow comparable practices as much as possible if such requirements are waived. Among other things, FDA may consider previous compliance history when determining whether or not to waive certain QSR requirements for a specific product. Please note adverse events, as per 21 CFR Part 803, have to be reported for authorized devices (see Section P).**
### 2) Components Included with the Test
None. Designated CLIA labs may order components directly from vendors.
### 3) Components Required But Not Included with Test:
The **FloodLAMP EasyPCR(TM) COVID-19 Test** is to be used with the following reagents or equivalents listed in Table 6.
#### Table 6: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | ----- | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease-freeWater | | Ultrapure Water, DNAse RNAse free | Thermo Fisher | 10977015 |
| NaCl | 5M | Sodium Chloride | Thermo Fisher | 24740011 |
| PCR MasterMix \* | - | 2X PCR Master Mix (in LunaⓇ Universal Probe One-Step RT-qPCR Kit) | New England Biolabs | E3006 |
| PCR RT \* | - | Reverse Transcriptase (in LunaⓇ Universal Probe One-Step RT-qPCR Kit) | New England Biolabs | E3006 |
||
\* Item may not be substituted for equivalents. Only the specified vendor and catalog number may be utilized.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
The 100X Inactivation Solution is prepared by mixing the components in Table 7. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved.
#### Table 7: 100X Inactivation Solution
| | | | |
|------------------|--------------------|----------------|------------------|
| **Component** | **Source Concentration** | **Volume** | **100X Concentration** |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
For swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 8. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 8: 1X Inactivation Saline Solution
| | |
|----------------------------|-------------|
| **Component** | **Volume** |
| 0.9% Saline (154 mM NaCl) | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
The **FloodLAMP EasyPCR(TM) COVID-19 Test** uses the validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a duplex assay, detecting the 2 targets in a single well. This configuration is described in the SalivaDirect(TM) EUA Authorized test ([www.fda.gov/media/141192/download](http://www.fda.gov/media/141192/download)).
The complete set of 6 primers and probes may be purchased from the vendor Eurofins Genomics using the catalog number 12YS-010YST. This product contains primers and probes suspended at 100µM and is enough for 12,500 reactions. The contents can be mixed along with nuclease-free water to create the primer stocks used in the **FloodLAMP EasyPCR(TM) COVID-19 Test**. See Table 9 below for details. A large volume of primer-probe stock can be prepared in advance and stored at 4 oC for one month or -20 oC for up to 1 year. Vendors for the Primer and Probe sets are below in Table 10.
#### Table 9: 5X PCR Primer Stock Preparation from Eurofins Genomics Product
| | | |
|-----------------------------|----------------------|---------------------|
| **Component (final concentration)** | **Volume (1 reaction)** | **Volume (3,125 reactions)** |
| 2019-nCov\_N1-F (10 µM) | 0.4 µl | 1,250 µl |
| 2019-nCov\_N1-R (10 µM) | 0.4 µl | 1,250 µl |
| 2019-nCov\_N1-P (5 µM) | 0.2 µl | 625 µl |
| RP-F (3.75 µM) | 0.15 µl | 469 µl |
| RP-R (3.75 µM) | 0.15 µl | 469 µl |
| RP-P (5 µM) | 0.2 µl | 625 µl |
| Nuclease-free water | 2.5 µl | 7,813 µl |
| **TOTAL VOLUME** | **4 µl** | **12,500 µl** |
||
#### Table 10: Primer and Probe Set Products
| Vendor | Item | Catalog number | Quantity | # Reactions |
|---------|------|----------------|-----------|-------------|
| Order one of the following primer and probe sets |||||
| Eurofins Genomics | SalivaDirect™ complete set of the 6 primers and probes | 12YS-010YST | 50-100 nmol | 12,500 |
| Integrated DNA Technologies | nCoV_N1 Forward Primer Aliquot | 10006821 | 50 nmol | 6,2500 |
| Integrated DNA Technologies | nCoV_N1 Forward Primer Aliquot | 10006830 | 100 nmol | 12,500 |
| Integrated DNA Technologies | nCoV_N1 Reverse Primer Aliquot | 10006822 | 50 nmol | 6,250 |
| Integrated DNA Technologies | nCoV_N1 Reverse Primer Aliquot | 10006831 | 100 nmol | 12,500 |
| Integrated DNA Technologies | NCoV_N1 Probe Aliquot | 10006831 | 25 nmol | 6,250 |
| Integrated DNA Technologies | NCoV_N1 Probe Aliquot | 10006832 | 50 nmol | 12,500 |
| Integrated DNA Technologies | RNaseP Forward Primer Aliquot | 10006827 | 50 nmol | 16,600 |
| Integrated DNA Technologies | RNaseP Forward Primer Aliquot | 10006836 | 100 nmol | 33,300 |
| Integrated DNA Technologies | RNaseP Reverse Primer Aliquot | 10006828 | 50 nmol | 16,600 |
| Integrated DNA Technologies | RNaseP Reverse Primer Aliquot | 10006837 | 100 nmol | 33,300 |
| Integrated DNA Technologies | RNase P Probe | Custom order (Cy5) | 25 nmol | 6,250 |
| Integrated DNA Technologies | RNase P Probe | Custom order (Cy5) | 50 nmol | 12,500 |
| Integrated DNA Technologies | RNase P Probe | 10007061 (ATTO647) | 25 nmol | 6,250 |
| Integrated DNA Technologies | RNase P Probe | 10007062 (ATTO647) | 50 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Forward Primer | nCoV-N1-F-100 | 100 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Forward Primer | nCoV-N1-F-1000 | 1000 nmol | 125,000 |
| LGC Biosearch Technologies | nCoV_N1 Reverse Primer | nCoV-N1-R-100 | 100 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Reverse Primer | nCoV-N1-R-1000 | 1000 nmol | 125,000 |
| LGC Biosearch Technologies | NCoV_N1 Probe | nCoV-N1-P-25 | 25 nmol | 6,250 |
| LGC Biosearch Technologies | NCoV_N1 Probe | nCoV-N1-P-250 | 250 nmol | 62,500 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-20 | 20 nmol | 6,660 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-100 | 100 nmol | 33,300 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-1000 | 1000 nmol | 333,300 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-20 | 20 nmol | 6,660 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-100 | 100 nmol | 33,300 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-1000 | 1000 nmol | 333,300 |
| LGC Biosearch Technologies | RNase P Probe | RNP-PQ670-25 | 25 nmol | 6,250 |
| LGC Biosearch Technologies | RNase P Probe | RNP-PQ670-250 | 50 nmol | 12,500 |
||
The final amplification reaction components are listed in Table 11. PCR plates or strip tubes used for the amplification reactions should be maintained on ice or a cold block.
#### Table 11: PCR Amplification Reaction
| | | |
|----------------------------|---------------------|------------------------|
| **Component** | **Volume (1 reaction)** | **Volume (100 reactions)** |
| 5X PCR Primer Stock | 4 µL | 400 µL |
| New England Biolabs PCR MM | 10 µL | 1000 µL |
| New England Biolabs PCR RT | 1 µL | 100 µL |
| Nuclease-Free Water | 3 µL | 300 µL |
| **SUBTOTAL VOLUME** | **18 µL** | **2250 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **20 µL** | - |
||
### 4) Software Validation
The **FloodLAMP EasyPCR(TM) COVID-19 Test** has been validated on the RT-PCR instruments listed in Table 2 using the baseline threshold settings unless otherwise noted in the Instructions for Use. The test does not require any additional software.
### 5) Testing Capabilities
The **FloodLAMP EasyPCR(TM) COVID-19 Test** has been optimized for a robust, streamlined workflow and for rapid turnaround time on results. The total time to perform the test is dependent upon the following factors: number of lab technicians, batch size of samples, and in advance preparation of reaction mixes. The minimum turnaround time is approximately 1 hour and 45 minutes, of which approximately 1 hour and 20 minutes is the RT-PCR instrument run time. Automation can greatly increase overall throughput.
### 6) Reagent Stability:
A stability test plan for the components of the **FloodLAMP EasyPCR(TM) COVID-19 Test** will be developed during an interactive review. Briefly, the proposed study includes assessing all prepared solutions including: 100X Inactivation Solution, 1X Inactivation Saline Solution, 5X PCR Primer Stock, and the full PCR Amplification Mix. Prepared solutions will be assessed both for long term storage stability (typically 1-3 months at -20oC) and short term storage stability prior to usage (typically hours to several days at room temperature, 4oC or -20oC).
The proposed study uses a contrived positive sample consisting of gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative specimens at approximately 50,000 copies/mL (4X LoD). The contrived positive stability study samples will be prepared, aliquoted and stored at -80oC to permit repeated testing of the various solutions at the appropriate step of the test protocol.
For test components supplied by vendors, such as New England Biolab’s LunaⓇ Universal Probe One-Step RT-qPCR Kit, the manufacturer's recommended storage conditions and duration will be followed.
### 7) Sample Stability:
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
Samples can be stored at room temperature for 56 hours after collection prior to inactivation. For longer term storage, samples can be stored at ≤-70oC.
## J. PERFORMANCE EVALUATION
### 1) Limit of Detection (LoD) - Analytical Sensitivity:
The Limit of Detection (LoD) for the **FloodLAMP EasyPCR(TM) COVID-19 Test** was established using gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The gamma-irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 6,300, 3,100 and 1,600 copies/mL were selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 12. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 3,100 copies/mL.
#### Table 12: Confirmatory LoD Data Results
| | | | |
|----------------------|----------------|-----------------|------------------|
| **Instrument** | **LoD** | **Positive Replicates** | **Mean Ct Value (SD)** |
| ABI QuantStudio(TM) 7 Pro | 3,100 copies/mL | 95% (20/21) | 36.5 (.8) |
| ABI QuantStudio(TM) 6 Flex | 3,100 copies/mL | 100% (21/21) | 36.9 (1.1) |
| Bio-Rad CFX96 Touch(TM) | 3,100 copies/mL | 95% (20/21) | 37.2 (.9) |
||
### 2) Inclusivity (analytical sensitivity):
**FloodLAMP EasyPCR(TM) COVID-19 Test** includes a modified RT-qPCR assay by duplexing the previously authorized CDC N1 and human RNase P primer-probe sets. Inclusivity was tested in the original US CDC EUA with all publicly available SARS-CoV-2 genomes as of 1 February 2020. The initial analysis showed 100% homology between the N1 primer-probe set and available genomes, except for one low frequency mismatch with the N1 forward primer. However, this was not expected to affect performance of the primer-probe set due to annealing temperatures of 55°C which tolerate 1-2 mismatches. Indeed, performance of the N1 primer-probe set was shown to be high in the previous comparison of primer-probes sets (). GISAID continuously evaluates mismatches between newly available SARS-CoV-2 genomes and primer-probe sets and confirms a low frequency of nucleotide mismatches (<5%) with the N1 primer-probe set.
### 3) Cross-reactivity (Analytical Specificity):
The primer and probe sets used in the duplex assay were developed by the US CDC and have been EUA certified. The CDC reported no cross-reactivity with other human coronaviruses (229E, OC43, NL63, and HKU1), MERS-coronavirus, SARS-coronavirus, and 14 additional human respiratory viruses (see .
**Endogenous Interference Substances Studies:**
Exogenous and endogenous substances were tested for potential interference with the **FloodLAMP EasyPCR(TM) COVID-19 Test*.*** 10 µL of each stock of interfering substance was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. The gamma-irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived Positive Control Spiked comprised 20 µL of 8e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 160,000 copies/mL in the sample input into the amplification reaction.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 13 and Supporting Data.
#### Table 13: Interfering Substances Results
| Interfering Substance | Active Ingredient | Concentration | % Agreement with Expected Results | |
| :---: | :---: | :---: | :---: | :---: |
| | | | **Positive Control Spiked** | **Negative Control Unspiked** |
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
### 4) Clinical Evaluation
The clinical evaluation of the **FloodLAMP EasyPCR(TM) COVID-19 Test** utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The **FloodLAMP EasyPCR(TM) COVID-19 Tes**t showed a positive agreement of 97.5% and a negative agreement of 100%. The single false negative result was a specimen with a high Ct value as previously measured by the comparator test, indicating very low viral load. A summary of the clinical performance is below in Table 14.
Anterior nares swab specimens were collected from patients in phosphate buffered saline by the Stanford COVID-19 clinical testing program. Specimens were initially tested by the Stanford clinical laboratory using the Hologic Panther Fusion and Aptima SARS-CoV-2 Assays, which serves as the high sensitivity comparator test.
For the **FloodLAMP EasyPCR(TM) COVID-19 Test**, materials and the Instructions For Use were provided to the Stanford clinical laboratory. The materials provided consisted of the validated reagents listed in Table 6, the Eurofins Genomics primers and probes, and an aliquot of the positive control. The Bio-Rad CFX96 instrument was used to perform the RT-PCR. After thawing the frozen specimens, 1 mL of each specimen was transferred to 5mL tubes for the inactivation step. The positive and negative clinical specimens were assigned a new ID in a random order, then transferred to new tubes that were barcoded and labeled with the new ID. Line Item data are provided in the Supporting Data.
#### Table 14: Clinical Evaluation Results
| | | | |
|------------------------|----------------|----------------|-----------------|
| **FloodLAMP EasyPCR(TM) COVID-19 Test Results** | **Comparator - High Sensitivity EUA Authorized Test** | | |
| | **Positive** | **Negative** | **Total** |
| Positive | 39 | 0 | 39 |
| Negative | 1 | 40 | 41 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 97.5% (39/40) 95% CI: 86.8% to 99.9% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## K. UNMET NEED ADDRESSED BY THE PRODUCT
This section will be completed by FDA.
## L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the detection of the SARS-CoV-2 have been approved/cleared by FDA.
## M. BENEFITS AND RISKS:
This section will be completed by FDA.
## N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
Fact Sheets for Patients and Healthcare Providers attached.
## O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
Instructions for Use attached.
## P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
QuantStudio(TM) is a trademark of Thermo Fisher Scientific (NYSE: TMO)
Bio-Rad(TM) and Bio-Rad CFX96 Touch(TM) are trademarks of Bio-Rad Laboratories, Inc. (NYSE: BIO)
# 16,270 2021-03-22_EUA Submission - FloodLAMP QuickColor COVID-19 Test v1.0.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-03-22_EUA Submission - FloodLAMP QuickColor COVID-19 Test v1.0.md
file_date: 2021-03-22
title: EUA Submission - FloodLAMP QuickColor COVID-19 Test v1.0
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subcategory: fl-fda-submissions
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summary_short: The EUA Submission for the FloodLAMP QuickColor COVID-19 Test v1.0 describes an extraction-free, colorimetric RT-LAMP assay for qualitative SARS-CoV-2 detection using a visual pink-to-yellow readout and no specialized instrumentation. It details intended use for weekly screening of symptomatic and asymptomatic individuals, primer design targeting three viral genes, sample inactivation workflow, controls, and interpretation criteria for CLIA high-complexity labs. It reports analytical and clinical performance including a 12,500 copies/mL LoD and 90% positive agreement with 100% negative agreement in an 80-specimen clinical evaluation.
CONTENT
***INTERNAL TITLE:*** EUA Submission - FloodLAMP QuickColor(TM) COVID-19 Test
## A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the **FloodLAMP QuickColor(TM) COVID-19 Test** for the *in vitro* qualitative detection of RNA from the SARS-CoV-2 in in upper respiratory specimens including oropharyngeal and nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests.** Additional testing and confirmation procedures should be performed in consultation with public health and/or other authorities to whom reporting is required. Test results should be reported in accordance with local, state, and federal regulations.
## B. MEASURAND
Specific nucleic acid sequences from the genome of the SARS-CoV-2, targeted by **primers from the ORF1ab, N and E regions** of the virus. Primer names and sequences are listed in Table 1.
#### Table 1: Primer names and sequences
| | |
|----------------------|--------------------------------------------------|
| **Primer Name** | **Sequence (5'-3')** |
| **ORF1ab gene (AS1e)** | |
| Orf1ab\_FIP | TCAGCACACAAAGCCAAAAATTTATTTTTCTGTGCAAAGGAAATTAAGGAG |
| Orf1ab\_BIP | TATTGGTGGAGCTAAACTTAAAGCCTTTTCTGTACAATCCCTTTGAGTG |
| Orf1ab\_F3 | CGGTGGACAAATTGTCAC |
| Orf1ab\_B3 | CTTCTCTGGATTTAACACACTT |
| Orf1ab\_LF | TTACAAGCTTAAAGAATGTCTGAACACT |
| Orf1ab\_LB | TTGAATTTAGGTGAAACATTTGTCACG |
| **N Gene (N2)** | |
| N2\_FIP | TTCCGAAGAACGCTGAAGCGGAACTGATTACAAACATTGGCC |
| N2\_BIP | CGCATTGGCATGGAAGTCACAATTTGATGGCACCTGTGTA |
| N2\_F3 | ACCAGGAACTAATCAGACAAG |
| N2\_B3 | GACTTGATCTTTGAAATTTGGATCT |
| N2\_LF | GGGGGCAAATTGTGCAATTTG |
| N2\_LB | CTTCGGGAACGTGGTTGACC |
| **E Gene (E1)** | |
| E1\_FIP | ACCACGAAAGCAAGAAAAAGAAGTTCGTTTCGGAAGAGACAG |
| E1\_BIP | TTGCTAGTTACACTAGCCATCCTTAGGTTTTACAAGACTCACGT |
| E1\_F3 | TGAGTACGAACTTATGTACTCAT |
| E1\_B3 | TTCAGATTTTTAACACGAGAGT |
| E1\_LF | CGCTATTAACTATTAACG |
| E1\_LB | GCGCTTCGATTGTGTGCGT |
||
## C. APPLICANT
FloodLAMP Biotechnologies, a DE Public Benefit Corporation
| Mailing Address: 4860 Alpine Rd. Portola Valley, CA 94028 | Laboratory Address: 930 Brittan Ave San Carlos, CA 94070 | Randall J. True, CSO Phone: (415) 269-2974 Email: randy@floodlamp.bio |
| :---- | :---- | :---- |
## D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name - **FloodLAMP QuickColor(TM) COVID-19 Test**
Established Name - **FloodLAMP QuickColor(TM) COVID-19 Test**
## E. REGULATORY INFORMATION
***Approval/Clearance Status:***
The **FloodLAMP QuickColor(TM) COVID-19 Test** is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
***Product Code:***
QJR
## F. PROPOSED INTENDED USE
### 1) Intended Use:
**FloodLAMP QuickColor(TM) COVID-19 Test** is a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests.** Testing is limited to **laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.**
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The **FloodLAMP QuickColor(TM) COVID-19 Test** is intended for use by **qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures**. The **FloodLAMP QuickColor(TM) COVID-19 Test** is only for use under the Food and Drug Administration's Emergency Use Authorization.
### 2) Special Conditions for Use Statements:
For Emergency Use Authorization (EUA) only
For prescription use only
For *in vitro* diagnostic use only
### 3) Special Instrument Requirements:
The **FloodLAMP QuickColor(TM) COVID-19 Test** does not have special instrument requirements.
## G. DEVICE DESCRIPTION AND TEST PRINCIPLE
### 1) Product Overview/Test Principle:
The **FloodLAMP QuickColor(TM) COVID-19 Test** is a RNA extraction-free reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) molecular assay that indicates the presence of the SARS-CoV-2 viral RNA with a simple visual color change. It can widely and rapidly scale because 1) no special instrumentation of any kind is required, neither nucleic acid extraction equipment nor a RT-PCR instrument, 2) it utilizes reagents and supplies readily available in large quantities, and 3) is a very straightforward protocol with minimal steps that can be executed quickly and reliably. It also utilizes the same streamlined sample preparation as the **FloodLAMP EasyPCR(TM) COVID-19 Test**. Both are supply chain robust, "open source" protocol tests, meaning designated laboratories may obtain the test components directly from vendors. Together, the two tests can be used in an integrated program for screening and rapid confirmation in large populations by a broad range of laboratories.
The **FloodLAMP QuickColor(TM) COVID-19 Test** uses a set of specific primers that target ORF1ab, N and E genes for the detection of SARS-CoV-2 RNA. It uses Loop Mediated Isothermal Amplification (LAMP), a nucleic acid amplification technique wherein DNA amplification is carried out at a constant temperature of approximately 65°C. Samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step. The resulting inactivated sample is directly used as input in the LAMP reaction. The amplification reaction mix includes a reverse transcriptase (RT) polymerase to create complementary cDNA from RNA. The cDNA is subsequently amplified by a high strand displacement DNA polymerase. The amplified DNA products lower the pH of the reaction. A phenol red pH indicating dye is included in the amplification reaction mix, thus causing the reaction solution to visibly change from an initial bright pink to a bright yellow when sufficient amplification occurs. Reactions that change color to yellow indicate that SARS-CoV-2 RNA is present.
### 2) Description of Test Steps:
Specimens including **nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs** are collected in **sterile collection tubes.** Swabs are transported and stored dry prior to processing. At the laboratory, an inactivation solution at 1X containing TCEP (2.5 mM), EDTA (1 mM), and NaOH (11 mM) in 0.9% saline (154 mM) is added to the container with the swab, at the volume of 1 mL. Alternatively, for swabs that are collected or eluted in a saline solution or equivalent, the inactivation solution at 100X concentration should be added at 1/100th the sample solution volume.
The container with the specimen and inactivation solution is mixed by vortexing for 30 seconds. Subsequently, the container is heated for 8 minutes in a 95°C water bath or dry heat block. The now inactivated specimen container is allowed to cool at room temperature for 10 minutes and then stored on ice or at 4°C until amplification.
An amplification reaction mix (23 µl) is prepared per manufacturer's specifications, containing the Colorimetric LAMP master mix (NEB M1800, 12.5 µl) and a primer-guanidine solution (10.5 µl) comprising 10X primers mix (2.5 µl of 10X w FIP/BIP at 16 µM, F3/B3 at 2 µM, and LF/BF at 4 µM), guanidine hydrochloride (2.5 µl of 400 mM), and nuclease-free water (5.5 µl). The primer-guanidine solution may be prepared ahead of time and stored at -20°C for up to 1 month.
2 µl of the inactivated sample is added to 23µl of the amplification reaction mix. The reaction is incubated at 65°C for 25 minutes in a thermal cycler, dry heat block, or water bath. After removal from the heat, the reaction solution is allowed to cool at room temperature for 1 minute and then the test result is determined visually based on the color of the reaction solution.
### 3) Control Materials to be Used with test:
**One positive and one negative control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes on each heater:
1. A "no template" (negative) control (NTC) is needed to **assure the absence of cross contamination from positive samples, positive controls, or amplicons** and is used **to determine if sample results are valid.** **It consists of 100X Inactivation Solution diluted to 1X in 0.9% saline.** This NTC is the same solution added to dry swabs (see Section I below for the components).
2. A positive template control is needed to **assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water.** Stock and working aliquots of the positive control are produced from the sources listed in Table 2 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at -80°C, or at most 1 month at -20°C.
#### Table 2: Components for Positive Template Control
| | | | |
|--------------------------------|---------------|----------------|------------|
| **Material** | **Supplier** | **Catalog \#** | **Volume** |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µL |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µL |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895 µL |
||
## H. INTERPRETATION OF RESULTS
### 1) FloodLAMP QuickColor(TM) COVID-19 Test Controls
All test controls should be examined prior to interpretation of specimen results. If the controls are not valid, the specimen results cannot be interpreted. An example of the expected appearance of the negative and positive controls after amplification is shown in Figure 1.
_Photo showing negative control (pink, left) and positive control (yellow, right) after amplification._
#### Figure 1. Negative control (left) and positive control (right) after amplification.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and optionally RNAseZAP product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
### 2) Examination and Interpretation of Patient Specimen Results:
Assessment of clinical patient specimen test results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
Test results should be read at least 1 minute and no more than 8 hours after plates or tubes have been removed from heat. Test results may be determined directly from visual inspection of the color of the reaction tubes:
- yellow - result is positive
- bright pink or red - result is negative
- any other color - result is inconclusive.
Examples are shown below in Figure 2. Edge cases for positive and negative results are shown below in Figure 3. Any color variance stronger than the edge cases should be interpreted as inconclusive. In order to reduce the chance of both false negative and false positive results, this window for color variance is intentionally set to be small.
If the initial test is inconclusive, then one of the following should be performed:
1) repeat the Colorimetric LAMP Amplification Reaction on the inactivated sample. If the repeat test has a positive result then the final interpretation of the test is positive. If the repeat test has a negative or another inconclusive result, then the final interpretation is inconclusive.
2) follow-up test the inactivated sample with the FloodLAMP EasyPCR(TM) COVID-19 Test or another high sensitivity EUA authorized test that comprises the same inactivation protocol. The final interpretation is the result of the follow-up test.
For serial screening of individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, the initial inconclusive test result may be considered the final interpretation. If the final interpretation of the test result is inconclusive, then "Inconclusive" should be reported and retesting of the individual is recommended.
_Photos showing example test results (Figure 2: two negative pink and two positive yellow tubes) and edge case results (Figure 3: edge-case negative pink and edge-case positive yellow tubes)._
## I. PRODUCT MANUFACTURING
### 1) Overview of Manufacturing and Distribution:
The **FloodLAMP QuickColor(TM) COVID-19 Test** utilizes standard chemicals available in very large quantities from multiple vendors, with the exception of the LAMP Primers and New England Biolabs Colorimetric LAMP Master Mix.
FloodLAMP has partnered with LGC Biosearch for the LAMP Primers. LGC Biosearch has very large scale oligo production capacity and mature distribution capabilities. The first production scale lot of the LAMP Primers has been completed, with 1.2 million reactions ready for immediate distribution. FloodLAMP has purchased 600K reactions of the LAMP Primers. LGC Biosearch is supplying FloodLAMP for the **FloodLAMP QuickColor(TM) COVID-19 Test** and is also offering the LAMP Primers as a catalog product.
New England Biolabs has expressed strong support for the **FloodLAMP QuickColor(TM) COVID-19 Test** and FloodLAMP's other open source protocol EUA submissions that incorporate their products. New England Biolabs has very large quantities of the Colorimetric LAMP Master Mix product prepared and ready for immediate distribution, typically with 24 hour shipping within the U.S. Their manufacturing capacity is among the largest in the United States and can surge to meet increased demand.
**\*Under the Emergency Use Authorization (EUA) any of the 21 CFR Part 820 Quality System Regulation (QSR) requirements can be waived for the duration of the EUA but FDA recommends that developers follow comparable practices as much as possible if such requirements are waived. Among other things, FDA may consider previous compliance history when determining whether or not to waive certain QSR requirements for a specific product. Please note adverse events, as per 21 CFR Part 803, have to be reported for authorized devices (see Section P).**
### 2) Components Included with the Test
None. Designated CLIA labs may order components directly from vendors.
### 3) Components Required But Not Included with Test:
The **FloodLAMP QuickColor(TM) COVID-19 Test** is to be used with the reagents or equivalents listed in Table 3. No specialized instruments are needed. Only ordinary laboratory equipment such as pipettes, centrifuges, and heaters are needed.
#### Table 3: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog No. |
| :---------------------- | :-----------: | :---------------------------------------------------- | :-------------------- | :-------------------- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease- free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5 M | Sodium Chloride | Thermo Fisher | 24740011 |
| Guanidine | 6 M | Guanidine Hydrochloride | Sigma-Aldrich | SRE0066 |
| ColorimetricLAMP MM* | - | Colorimetric LAMP Master Mix | New England Biolabs | M1804 |
||
\* Item may not be substituted for equivalents. Only the specified vendor and catalog number may be utilized.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
A 100X Inactivation Solution is prepared by mixing the components in Table 4. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved. Aliquots of 100X Inactivation Solution should be stored in the dark at -20°C for up to 3 months. Upon thaw, working aliquots of 100X Inactivation Solution should be stored in the dark at room temperature for up to 1 month.
#### Table 4: 100X Inactivation Solution
| **Component** | **Source Concentration** | **Volume for 100X** | **100X Concentration** |
| ------------------ | -------------------- | ---------------- | ------------------ |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
For swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 5. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 5: 1X Inactivation Saline Solution
| | |
|-------------------------------------------|-------------|
| **Component** | **Volume** |
| 0.9% Saline (154 mM NaCl) in MilliQ Water | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
The **FloodLAMP QuickColor(TM) COVID-19 Test** uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. Primer names and sequences are shown above in Table 1. All 18 primers are mixed together and input into a single amplification reaction.
Primers may be purchased from the vendor LGC Biosearch Technologies as 3 pre-blended sets, or the primers may be purchased as 18 individual custom oligos. Table 6 below lists the primer products to be ordered.
The LGC Biosearch primer products are provided already blended for each target (6 primers per tube) and dried such that upon resuspension with 1 mL of nuclease-free water, the primers for each target are at 30X concentration. One resuspended tube for each of the 3 targets (i.e. primer blends) are mixed together to yield a 3 mL total volume that contains all individual primers at 10X concentration. This 3 mL of 10X LAMP Primer Mix provides for 1,200 reactions at 2.5 µL per reaction.
Alternatively to the pre-blended LGC Biosearch products, primers may be purchased as individual custom oligos. Custom oligos may be blended to form 30X Primer Set Mixes as intermediates or all mixed together for the 10X LAMP Primer Mix. The FIP and BIP primers for each target require purification by HPLC or an equivalent process. Appropriate validation of primer mixes from custom oligos is required. Primers may be stored at 4°C for up to one month, or at -20°C for up to 1 year.
#### Table 6: 10X LAMP Primer Mix Components
| Vendor | Item | Catalog number | Quantity | # Reactions |
|--------|------|----------------|-----------|-------------|
| Order one of the following primer sets |||||
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LB | Custom Order | 250 nmol | 25,000 |
||
The primers are mixed with guanidine hydrochloride to form an intermediate Primer-Guanidine Solution prior to combining with the sample and Colorimetric LAMP MM for the full amplification reaction. The components and volumes for the Primer-Guanidine Solution are listed in Table 7 and may be proportionally scaled for batch sizes of different numbers of reactions. The Primer-Guanidine Solution may be prepared in advance and should be stored at -20°C for up to 1 month.
#### Table 7: Primer-Guanidine Solution
| **Component** | **Volume (1 reaction)** | **Volume (100 reactions)** |
|-----------------------|-------------------------|----------------------------|
| 10X LAMP Primer Mix | 2.5 µL | 250 µL |
| Guanidine (400 mM) | 2.5 µL | 250 µL |
| Nuclease-free Water | 5.5 µL | 550 µL |
| **TOTAL VOLUME** | **10.5 µL** | **1050 µL** |
||
The final Colorimetric LAMP Amplification Reaction components are listed in Table 8. PCR plates or strip tubes used for the amplification reactions should be maintained on ice or a cold block until less than 5 minutes before incubation on the heater. Reaction plates/strip tubes comprising the Colorimetric LAMP Amplification Reaction Solution may be prepared in advance, capped/sealed, and stored at -20°C for up to 1 day prior to addition of the sample. A heated plate sealer is recommended. Alternatively, a manually applied foil or optical seal may be used.
#### Table 8: Colorimetric LAMP Amplification Reaction
| **Component** | **Volume (1 reaction)** | **Volume (100 reactions)** |
|-----------------------|-------------------------|----------------------------|
| Primer-Guanidine Solution | 10.5 µL | 1050 µL |
| Colorimetric LAMP MM | 12.5 µL | 1250 µL |
| **SUBTOTAL VOLUME** | **23 µL** | **2300 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **25 µL** | - |
||
### 4) Software Validation
No software is required for labs to run the **FloodLAMP QuickColor(TM) COVID-19 Test*.***
### 5) Testing Capabilities
The **FloodLAMP QuickColor(TM) COVID-19 Test** has been optimized for a robust, streamlined workflow and rapid turnaround time on results. The total time to perform the test is dependent upon the following factors: number of lab technicians, batch size of samples, and advance preparation of reaction mixes. **The minimum turnaround time is approximately 45 minutes.**
Since the **FloodLAMP QuickColor(TM) COVID-19 Test** does not require specialized instruments, it can be scaled up without the capital investment required for PCR machines or automated extraction. The number of tests capable of being performed per day by a laboratory is not constrained by PCR machines or extraction instruments. One technician can manually process approximately one plate (94 samples) per hour. This includes intake (debagging and barcode scanning), inactivation, and LAMP amplification. Automation can greatly increase throughput.
### 6) Reagent Stability
A stability test plan for the components of the **FloodLAMP QuickColor(TM) COVID-19 Test** will be developed during an interactive review. Briefly, the proposed study includes assessing all prepared solutions including: 100X Inactivation Solution, 1X Inactivation Saline Solution, 30X Primer Stock, 10X Primer Mix, Primer-Guanidine Solution, and the full Colorimetric LAMP Amplification Reaction Mix. Prepared solutions will be assessed both for long term storage stability (typically 1-3 months at -20°C) and short term storage stability prior to usage (typically hours to several days at room temperature, 4°C or -20°C).
The proposed study uses a contrived positive sample consisting of inactivated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative specimens at approximately 50,000 copies/mL (4X LoD). The contrived positive stability study samples will be prepared, aliquoted and stored at -80°C to permit repeated testing of the various solutions at the appropriate step of the test protocol.
For test components supplied by vendors, such as the Colorimetric LAMP Master Mix, the manufacturer's recommended storage conditions and duration will be followed.
### 7) Sample Stability
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
Samples can be stored at room temperature for 56 hours after collection prior to inactivation. For longer term storage, samples can be stored at ≤-70°C.
## J. PERFORMANCE EVALUATION
### 1) Limit of Detection (LoD) - Analytical Sensitivity:
The Limit of Detection (LoD) for the **FloodLAMP QuickColor(TM) COVID-19 Test** was established using gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The negative specimens were confirmed by PCR using the CDC primers. The gamma-irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 12,500 and 6,250 were selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 9. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 12,500 copies/mL.
#### Table 9: LoD Confirmatory Data Results
| **Concentration of Contrived Positive Sample** | **Replicates Detected** |
|-----------------------------------------------|-------------------------|
| 12,500 copies/mL | 95% (20/21) |
| 6,250 copies/mL | 52% (11/21) |
||
### 2) Inclusivity (analytical sensitivity):
An inclusivity study was conducted for the ORF1ab, N2, and E1 primer sets against all complete, high coverage SARS-CoV-2 sequences deposited at GISAID as of February 27, 2021. Table 10 summarizes the results of this in silico inclusivity analysis. A total of 498,224 sequences were considered. There are 10 sequence isolates that have 1mm to both As1e and E1 and had N2 excluded due to greater than 15 N's, with the other 498,214 sequence isolates all have at least 1 target region that is a complete match.
Each primer set matched at 100% similarity against the SARS-CoV-2 RefSeq reference genome (Wuhan-Hu-1; NC\_045512.1). All three primer sets differed by one or fewer mutations for 99.7% of GISAID sequences, indicating nominal primer hybridization for all SARS-CoV-2 variants under consideration.
#### Table 10: *In Silico* Inclusivity Analysis for LAMP Primers
| Primer | AS1e (ORF1ab gene) | | N2 (N gene) | | E1 (E gene) | |
| :---- | ----- | ----- | ----- | ----- | ----- | ----- |
| **Total Primer Length** | 195 | | 169 | | 168 | |
| **Total Number of Strains Evaluated** | 498,224 | | 498,224 | | 498,224 | |
| **100% Match** | 474,717 | 95.3% | 479,548 | 96.3% | 462,538 | 92.8% |
| **1 Mismatch** | 19,301 | 3.9% | 15,698 | 3.2% | 30,626 | 6.1% |
| **2 Mismatches** | 338 | 0.1% | 161 | 0.0% | 1,455 | 0.3% |
| **3 Mismatches** | 9 | 0.0% | 5 | 0.0% | 103 | 0.0% |
| **\> 3 Mismatches** | 0 | 0.0% | 0 | 0.0% | 1 | 0.0% |
| **Total Strains Removed** | 3,859 | 0.8% | 2,812 | 0.6% | 3,501 | 0.7% |
||
#### Evaluation of Impact of Viral Mutations
The As1e, E1 and N2 primer regions of all SARS-CoV-2 genomes present in GISAID as of 2/26/2021 were evaluated to assess the potential impact of genomic variants on LAMP primer binding. This analysis was performed with the Primer Monitoring Tool from New England Biolabs (), which continually monitors registered primer sets for overlapping variants in sequences from GISAID. Results are summarized by region and locus below in Table 11, including the 30 countries with most sequences in GISAID. Sequences were aligned to the SARS-CoV-2 reference sequence (NC\_045512.2) using minimap2 (minimap2 -t 16 -x asm5 -a). Variant sites (excluding Ns) were identified using samtools mpileup and summarized by region and genome position. Genomic positions having >= 40 global variant observations are shown (column labels). When present, box labels indicate the fraction of variants observed at a given locus.
The aggregate of current published mutations is not expected to reduce performance of the **FloodLAMP QuickColor(TM) COVID-19 Test** by more than 5% from that established by the performance evaluation in this EUA submission. Further, the use of 3 primer sets targeting different regions in the SARS-CoV-2 genome should make the test robust to new genetic variants.
#### Table 11: Variant Analysis of LAMP Primers
_Heatmap charts showing variant frequency at LAMP primer binding sites across 30 countries for AS1e, N2, and E1 primer sets, based on GISAID sequences aligned to the SARS-CoV-2 reference genome._
### 3) Cross-reactivity (Analytical Specificity):
*In silico* cross-reactivity analysis was performed by aligning the primer sequences of the **FloodLAMP QuickColor(TM) COVID-19 Test** against sequences of other coronaviruses and common respiratory flora using the BLASTn alignment tool from NCBI. Results of this analysis are presented in Tables 12A, 12B, and 12C.
The % identity range (# identical bases/ \# primer bases) is shown for each primer and organism. Darker font indicates % identity greater than 80%. Organisms with >= 50% identity primer hits are shown. This analysis is not intended to predict amplification. Near perfect homology across B3, F3, FIP and BIP is necessary to support successful amplification. With the exception of SARS-CoV, simultaneous homologies do not occur between any of the primers and microorganisms screened. With respect to clinical relevance of the in silico cross-reactivity analysis, there are no known circulating strains of SARS-CoV circulating in humans, thus the overall probability for the test to produce a cross-reactive signal is negligible.
#### Table 12A: *In Silico* Cross-Reactivity Analysis for AS1e Primers
| Organism Group | Organism Name | Organism ID | As1_B3 (22 bp) | As1e_BIP (49 bp) | As1_F3 (18 bp) | As1e_FIP (51 bp) | As1_LB (27 bp) | As1_LF (28 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 47%-55% | 100% | 43%-53% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| | SARS coronavirus | NC_004718 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 72%-89% | 29% | 52%-67% | |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 77% | | 89% | 37%-51% | 52%-89% | |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 59%-73% | 33%-35% | 89% | 33%-45% | 52% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-73% | 31% | 72%-83% | 29%-59% | 52% | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | 83% | | | |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 59%-82% | 39% | | 29%-41% | 67% | 61% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-82% | | 72% | 39%-87% | 59% | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 59%-82% | 31% | 72% | 31% | 52%-67% | |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | 72%-78% | | 70% | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | 72% | 29%-35% | 78% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.15 | NW_017264789.1 | 59% | | | 78% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.11 | NW_017264785.1 | 77% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 77% | | | 35% | 63% | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59% | 43%-49% | 72% | 29%-57% | 63%-74% | 68% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | 49% | 72% | 31%-41% | 56%-74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | 31%-43% | 74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 73% | | 72% | 29%-39% | 52% | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 59%-68% | 31%-37% | 72% | 29%-35% | 56%-67% | 57%-71% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | 37%-41% | 72% | 29%-41% | 52%-63% | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.14 | NW_017264788.1 | | | | 35% | | 71% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | | | | 29%-47% | 70% | 68% |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59%-68% | 35% | | 29%-43% | | 68% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 68% | 37% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 33%-49% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | 43% | | 38% | | 68% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 64% | | | | | 57% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | | | | 33%-35% | 59% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 59% | | | | | 50% |
| | Bordetella pertussis 18323 | NC_018518.1 | | | | | | 57% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | | 52% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | 39%-47% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.54 | NW_017264828.1 | | 47% | | | | |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | | 31% | | 31%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | | | | 33%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.19 | NW_017264793.1 | | | | 38% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | | | | 35% | | |
| | Respiratory syncytial virus | NC_001803.1 | | | | 33% | | |
||
#### Table 12B: *In Silico* Cross-Reactivity Analysis for N2 Primers
| Organism Group | Organism Name | Organism ID | N2_B3 (25 bp) | N2_BIP (40 bp) | N2_F3 (21 bp) | N2_FIP (42 bp) | N2_LB (20 bp) | N2_LF (21 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 53% | 100% | 48%-55% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 64% | 53% | 90% | 55% | 85% | 90% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 60%-80% | | 95% | | 75% | 62%-71% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | 40% | 75%-90% | |
| | Bordetella pertussis 18323 | NC_018518.1 | | 35% | | | 65%-80% | 81% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | 56%-72% | 43% | | | | 62%-81% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | 56%-76% | | 62%-71% | 45% | | 62%-81% |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 56%-80% | 35%-68% | 62% | | | 62%-81% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 60%-80% | 35%-45% | 71% | | | 62%-71% |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 60%-72% | 35%-45% | 71%-76% | | | 62%-76% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 56%-76% | | 76% | 36% | 65% | |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 60%-76% | 43% | | 36%-55% | | 62%-76% |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | 60% | | | | 65%-75% | 76% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 68%-64% | | | | | 76% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | 35% | | | 75% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 56%-72% | 48% | 62% | 40% | | 67%-71% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 56%-72% | | 71% | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.17 | NW_017264791.1 | 56%-72% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | 60%-72% | | 71% | | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 56%-68% | 35% | | | | 62%-71% |
| | Human parainfluenza virus 1 | NC_003461.1 | | | 71% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 60%-68% | | | | | 62%-71% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 60%-68% | 50% | | 43% | | 62%-67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 68% | | | | | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 60%-68% | | 62% | | | 62% |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 56% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 56%-60% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 64% | 35% | | | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 60%-64% | 43%-50% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 60% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.51 | NW_017264825.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.67 | NW_017264841.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 56% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.21 | NW_017264795.1 | 52% | | | | | |
||
#### Table 12C: *In Silico* Cross-Reactivity Analysis for E1 Primers
| Organism Group | Organism Name | Organism ID | E1_B3 (22 bp) | E1_BIP (44 bp) | E1_F3 (23 bp) | E1_FIP (42 bp) | E1_LB (19 bp) | E1_LF (18 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 45%-57% | 100% | 45%-62% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 95% | 55% | 100% | 43%-62% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | | | | 40%-50% | | 72%-89% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | | | | 84% | 72% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | | | 36%-40% | | 78%-83% |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-82% | | 43% | | | 72% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | | | | 43%-50% | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | | | | | | 78% |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | | 45% | | 43%-48% | | 72%-78% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 77% | | | 36%-43% | | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59%-73% | | | 38%-48% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-73% | | 65% | 43% | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 73% | 41% | | 48% | | 72% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 59% | | | 43%-48% | | 72% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | | 36%-50% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | | 65% | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | 59%-68% | | | | | 72% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | | | 40% | 68% | 72% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 70% | | 40%-50% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | | | 70% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 59%-64% | | | 40% | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59% | | | 40%-43% | | |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 0%-59% | 0% | 0% | 0%-36% | 0% | 0% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | 59% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.20 | NW_017264794.1 | 59% | | | | | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | 34% | 57% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.30 | NW_017264804.1 | | | | 50% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.69 | NW_017264843.1 | | | | 50% | | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | | 43% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | | | | 40% | | |
||
Wet testing was performed to demonstrate that the **FloodLAMP QuickColor(TM) COVID-19 Test** does not react with related pathogens, high prevalence disease agents and normal or pathogenic flora that are reasonably likely to be encountered in a clinical specimen. SARS-CoV, RSV, Flu, Human Metapneumovirus. and Streptococcus Salivarius were tested for potential cross-reactivity, as shown in Table 13 and Supporting Data. 5 µL of each stock of cross-reactivity organism was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and cross-reactivity organisms were spiked onto the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived positive had 38 µL of 1e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 38,000 copies/mL in the sample input into the amplification reaction.
All wet testing showed no cross-reactivity with the viral pathogens and common respiratory flora, as shown in Table 13.
#### Table 13: Wet Testing Cross-Reactivity Results
| **Organism** | **Description** | **BEI Number** | **Detected Replicates** |
|------------------------|-------------------------|---------------|-------------------------|
| SARS-CoV | UV-inactivated virus | NR-3882 | 0/3 |
| Human Metapneumovirus | Genomic RNA | NR-49122 | 0/3 |
| RSV | Genomic RNA | NR-43976 | 0/3 |
| Influenza B | Genomic RNA | NR-45848 | 0/3 |
| Streptococcus salivarius | Bacterial cell culture | HM-121 | 0/3 |
||
#### Endogenous Interference Substances Studies:
Exogenous and endogenous substances were tested for potential interference with the **FloodLAMP QuickColor(TM) COVID-19 Test.** 10 µL of each stock of interfering substance was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived Positive Control Spiked comprised 20 µL of 8e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 160,000 copies/mL in the sample input into the amplification reaction.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 14 and Supporting Data.
#### Table 14: Interfering Substances Results
| **Interfering Substance** | **Active Ingredient** | **Concentration** | **% Agreement (Positive)** | **% Agreement (Negative)** |
|---------------------------|---------------------------------------------|-------------------|---------------------------|---------------------------|
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen,
Guaifenesin,
Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
### 4) Clinical Evaluation
The clinical evaluation of the **FloodLAMP QuickColor(TM) COVID-19 Test** utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The **FloodLAMP QuickColor(TM) COVID-19 Test** showed a positive agreement of 90% and a negative agreement of 100%. The 4 false negative results were specimens with high Ct values as previously measured by the comparator test, indicating low viral load. A summary of the clinical performance is below in Table 15.
Anterior nares swab specimens were collected from patients in phosphate buffered saline by the Stanford COVID-19 clinical testing program. Specimens were initially tested by the Stanford clinical laboratory using the Hologic Panther Fusion and Aptima SARS-CoV-2 Assays, which serves as the high sensitivity comparator test.
For the **FloodLAMP QuickColor(TM) COVID-19 Test**, materials and the Instructions For Use were provided to the Stanford clinical laboratory. The materials provided consisted of the validated reagents listed in Table 3, the LGC primers and probes, and an aliquot of the positive control. After thawing the frozen specimens, 1 mL of each specimen was transferred to 5mL tubes for the inactivation step. The positive and negative clinical specimens were assigned a new ID in a random order, then transferred to new tubes that were barcoded and labeled with the new ID. The Bio-Rad C1000 Touch(TM) thermal cycler was used for the heating device to perform the isothermal amplification. Two different technicians independently interpreted the results visually per the Instructions For Use, with identical results. Line Item data are provided in the Supporting Data.
Of the 40 positive specimens, 7 specimens had initial inconclusive results due to color variation beyond the edge case examples. Per Section H2 above, the inactivated samples were follow-up tested with the FloodLAMP EasyPCR(TM) COVID-19 Test, for which all 7 inconclusive results were positive.
#### Table 15: Clinical Evaluation Results
| | **Comparator - High Sensitivity EUA Authorized Test** | | |
|------------------------------------|--------------------------------------------------------|-----|-----|
| **FloodLAMP QuickColor(TM) COVID-19 Test Results** | **Positive** | **Negative** | **Total** |
| Positive | 36 | 0 | 36 |
| Negative | 4 | 40 | 44 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 90.0% (36/40) 95% CI: 76.3% to 97.2% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## K. UNMET NEED ADDRESSED BY THE PRODUCT
This section will be completed by FDA.
## L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the detection of the SARS-CoV-2 have been approved/cleared by FDA.
## M. BENEFITS AND RISKS:
This section will be completed by FDA.
## N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
Fact Sheets for Patients and Healthcare Providers attached.
## O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
Instructions for Use attached.
## P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
# 13,972 2021-03-22_Instructions for Use - FloodLAMP EasyPCR COVID-19 Test v1.0.md
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title: Instructions for Use - FloodLAMP EasyPCR COVID-19 Test v1.0
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summary_short: The Instructions for Use for the FloodLAMP EasyPCR COVID-19 Test v1.0 provides CLIA high-complexity labs with the full workflow for an extraction-free, duplex RT-qPCR assay using CDC N1 and RNaseP targets after TCEP-based chemical plus heat inactivation. It specifies required reagents and equipment, contamination controls, instrument setup/templates, step-by-step plate and run procedures, and Ct-based result interpretation with control acceptance criteria. It also summarizes stated analytical/clinical performance (including a 3,100 copies/mL LoD and 97.5%/100% agreement in an 80-specimen evaluation) and required reporting/recordkeeping under EUA conditions.
CONTENT
***INTERNAL TITLE:*** FloodLAMP EasyPCR(TM) COVID-19 Test
Instructions for Use v1.0
IVD
COVID-19 Emergency Use Authorization Only
For *in vitro* diagnostic (IVD) Use
[www.floodlamp.bio](http://www.floodlamp.bio)
FloodLAMP Biotechnologies, PBC | 930 Brittan Ave. San Carlos, CA 94070 USA
## Table of Contents
| | |
|---------|------|
| Intended Use | 3 |
| Principles of Procedure | 3 |
| Materials Provided and Storage | 4 |
| Materials Required but Not Provided | 4 |
| • Standard Lab Equipment and Consumables | 5 |
| Warnings and Precautions | 6 |
| • General Precautions | 6 |
| • Contamination Precautions | 7 |
| Limitations | 7 |
| Conditions of Authorization for the Laboratory | 8 |
| Specimen Collection and Storage | 9 |
| Running Tests | 10 |
| • Reagent Preparation | 10 |
| • Controls Preparation | 11 |
| • PCR Primer Stock Preparation | 12 |
| • Sample Preparation | 14 |
| • Sample Inactivation | 14 |
| • Preparing to Run Assay for the First Time | 14 |
| • Create the Plate Layout Map | 16 |
| • PCR Amplification Reaction Preparation | 19 |
| • Sample Addition | 19 |
| • Run the Assay | 20 |
| • Analyzing Data | 22 |
| • Results Interpretation | 23 |
| • • Test Controls | 23 |
| • • Patient Specimen Results Interpretation | 23 |
| Performance Evaluation | 24 |
| • Analytical Sensitivity: Limit of Detection (LoD) | 24 |
| • Analytical Sensitivity: Inclusivity/Cross-Reactivity (in silico) | 24 |
| • Analytical Specificity: Cross-Reactivity | 25 |
| • Analytical Specificity: Interfering Substances | 25 |
| Clinical Evaluation | 26 |
| Support | 26 |
||
FloodLAMP EasyPCR(TM) COVID-19 Test
For COVID-19 Emergency Use Authorization Only
Instructions for Use
## Intended Use
FloodLAMP EasyPCR(TM) COVID-19 Test is a reverse transcriptase polymerase chain reaction (RT-PCR) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The FloodLAMP EasyPCR(TM) COVID-19 Test is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures. The FloodLAMP EasyPCR(TM) COVID-19 Test is only for use under the Food and Drug Administration’s Emergency Use Authorization.
## Principles of Procedure
The FloodLAMP EasyPCR(TM) COVID-19 Test is an RNA-extraction-free, dualplexed RT-qPCR assay which indicates whether SARS-CoV-2 RNA is present. It can widely and rapidly be scaled because 1) it does not require nucleic acid extraction equipment, 2) it utilizes reagents and supplies readily available in large quantities, and 3) is a very straightforward protocol with minimal steps that can be executed quickly and reliably. It also utilizes the same streamlined sample preparation as the FloodLAMP QuickColor(TM) test which is isothermal, does not require any instrumentation, and has a visual readout. Together the two tests can be used in an integrated program for screening and rapid confirmation in large populations by a broad range of laboratories.
In the FloodLAMP EasyPCR(TM) COVID-19 Test samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step, and the resulting inactivated sample is directly used as input in the dualplexed RT-qPCR test. The test does not use new primers and probes for RT-qPCR testing, but rather uses previously validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC, which are readily available from multiple commercial suppliers. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a dualplex assay, reducing the number of tests to 1 assay with 2 sets.
## Materials Provided and Storage
The FloodLAMP EasyPCR(TM) COVID-19 Test utilizes standard chemicals available from multiple vendors, with the exception of the PCR Master Mix. Designated CLIA labs may order components directly from vendors.
## Materials Required but Not Provided
The FloodLAMP EasyPCR(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1. The FloodLAMP EasyPCR(TM) COVID-19 Test is to be used with RT-PCR Instruments such as Applied Biosystems QuantStudio(TM) Systems and Bio-Rad CFX(TM) Systems.
#### Table 1: Validated reagents used with Test
| **Item** | **Concentration** | **Chemical Composition** | **Vendor** | **Catalog Number** |
|---|---|---|---|---|
| TCEP | 0.5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich / Millipore Sigma | 646547-10X1ML |
| EDTA | 0.5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease-free Water | | Ultrapure Water, nuclease free | Thermo Fisher | 10977015 |
| NaCl | 5 M | Sodium Chloride | Thermo Fisher | 24740011 |
| PCR Kit\* | | LunaⓇ Universal Probe One-Step RT-qPCR Kit | New England Biolabs | E3006 |
||
\* Item may not be substituted for equivalent.
The FloodLAMP EasyPCR(TM) COVID-19 Test uses the validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a dualplex assay, detecting the 2 targets in a single well. This configuration is described in the SalivaDirect(TM) EUA Authorized test ([www.fda.gov/media/141192/download](http://www.fda.gov/media/141192/download)).
All four primers for both CoV-19 and RNase P detection may be purchased from the vendor Eurofins Genomics using the catalog number 12YS-010YST. This product contains primers and probes suspended at 100μM and is enough for 12,500 reactions. This kit can be mixed along with nuclease-free water to create the primer stock used in the FloodLAMP EasyPCR(TM) COVID-19 Test. See Table 6 below for details. A larger volume of primer-probe stock can be prepared in advance and stored at -20°C for up to 1 year.
#### Table 2: Primers and probes
| **Target** | **Primer/Probe** | **Sequence** |
|---|---|---|
| CDC-N1 | 2019-nCoV\_N1-F | GACCCCAAAATCAGCGAAAT |
| CDC-N1 | 2019-nCoV\_N1-R | TCTGGTTACTGCCAGTTGAATCTG |
| CDC-N1 | 2019-nCoV\_N1-P | **FAM**-ACCCCGCATTACGTTTGGTGGACC-**IBFQ** |
| Human RNAseP | RP-F | AGATTTGGACCTGCGAGCG |
| Human RNAseP | RP-R | GAGCGGCTGTCTCCACAAGT |
| Human RNAseP | RP-P | **Cy5**-TTCTGACCTGAAGGCTCTGCGCG-**IBRQ** |
||
### Standard Lab Equipment and Consumables
- 70% ethanol
- 10% bleach, prepared daily
- 96-well PCR reaction plates (Applied Biosystems # 4346906, 4366932, 4346907, Eppendorf # 951020303 or equivalent)
- Optical strip caps (Applied Biosystems # 4323032 or equivalent)
- Optical plate seal (Applied Biosystems # 4311971 or equivalent)
- PCR strip tubes and caps (USA Scientific catalog # 1402-2500 or equivalent)
- 5 mL transport tubes or equivalent (sterile)
- 1.5 mL microcentrifuge tubes or equivalent (nuclease-free)
- Aerosol resistant micropipette tips (nuclease-free)
- Micropipettes (calibrated)
- Bottle top dispenser for 1 mL volume (optional, calibrated)
- 96-well cold block
- Cold blocks for 5 mL and 1.5 mL - 2.0 mL tubes, or ice
- Vortex mixer
- 96-well plate centrifuge or equivalent
- Mini centrifuge for 1.5 mL tubes or equivalent
- Thermal cycler, water bath, dry heat bath or equivalent (calibrated)
- Class II Biological Safety Cabinet (BSC)
- PCR Instrument (choose one)
- QuantStudio(TM) 6 Flex
- QuantStudio(TM) 7 Pro
- Bio-Rad CFX96 Touch(TM)
## Warnings and Precautions
Materials or chemicals required for the use of the FloodLAMP EasyPCR(TM) COVID-19 Test should be closely examined by the user. The user should carefully read all warnings, instructions or Safety Data Sheets provided by the supplier and follow the general safety precautions when handling biohazards, chemicals and other materials.
### General Precautions
- The FloodLAMP EasyPCR(TM) COVID-19 Test is for *in vitro* diagnostic use (IVD) only. Rx Only.
- For use under COVID-19 Emergency Use Authorization Only.
- Standard precautions and procedures should be taken when handling and disposing of human samples.
- This test has not been FDA cleared or approved; the test has been authorized by FDA under an Emergency Use Authorization (EUA) for use by laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA) of 1988, 42 U.S.C. §263a, to perform high complexity tests.
- This test has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens.
- This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of *in vitro* diagnostic tests for detection and/or diagnosis of COVID19 under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
- Standard precautions and procedures should be taken when handling and extracting human samples.
- Standard precautions and procedures should be taken when using laboratory equipment.
- Standard precautions and procedures should be taken when disposing of waste.
- Dispose of reagents according to local regulations.
- Do not use reagents after their recommended stability time frame.
- Ensure reagents are stored at the recommended temperatures as described below and in the vendor product information and manuals.
### Contamination Precautions
- Avoid contamination by following good laboratory practices, wearing proper personal protective equipment, segregating workflow, and decontaminating workspace appropriately.
- Ensure that surfaces and equipment used for all test steps have been properly cleaned with 10% bleach and 70% ethanol.
- Ensure all consumables are DNase and RNase free except for sample collection tubes which may be sterile.
- Use only calibrated pipettes and filter tips that are sterile and PCR clean.
- After completion of the test, dispose of the amplification reaction plates or tubes. Do not open tubes or remove the seals on plates after heating amplification reactions.
## Limitations
- The use of this assay as an *in vitro* diagnostic under the FDA COVID-19 Emergency Use Authorization (EUA) is limited to laboratories that are certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, to perform high complexity tests by Rx only.
- Use of this assay is limited to personnel who are trained in the procedure. Failure to follow these instructions may lead to erroneous results.
- The performance of the FloodLAMP EasyPCR(TM) COVID-19 Test was established using Nasopharyngeal Swab specimen type collected in saline. Nasal swabs, oropharyngeal swabs, mid-turbinate nasal swabs specimens are also considered acceptable specimen types for use with the test but performance has not been established.
- Samples must be collected according to recommended protocols and transported and stored as described herein.
- Samples should not be collected in U(TM) or V(TM) or Liquid Amies transport media.
- The effect of vaccines, antiviral therapeutics, antibiotics, chemotherapeutic or immunosuppressant drugs have not been evaluated.
- Detection of SARS-CoV-2 RNA may be affected by sample collection methods, patient factors (e.g., presence of symptoms), and/or stage of infection.
- False-positive results may arise from various reasons, including, but not limited to the following:
- Contamination during specimen collection, handling, or preparation
- Contamination during assay preparation
- Incorrect sample labeling
- False-negative results may arise from various reasons, including, but not limited to the following:
- Improper sample collection or storage
- Degradation of SARS-CoV-2 RNA
- Presence of inhibitory substances
- Use of extraction reagents or instrumentation not approved with this assay
- Incorrect sampling window
- Failure to follow instructions for use
- Mutations in SARS-CoV-2 target sequences
- Nucleic acid may persist even after the virus is no longer viable.
- This test cannot rule out diseases caused by other bacterial or viral pathogens.
- Performance has not yet been established in asymptomatic individuals and will be established during a post-authorization study.
- Use of the test in a general, asymptomatic population for serial screening is intended to be used as part of an infection control plan, that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. Negative results should not be treated as definitive and do not preclude current or future infection obtained through community transmission or other exposures. Negative results must be considered in the context of an individual’s recent exposures, history, and presence of clinical signs and symptoms consistent with COVID-19.
- This test should not be used within 30 minutes of administering nasal or throat sprays.
- Positive results must be reported to appropriate public health authorities, following state and national guidelines.
- The clinical performance of the test has not been established in all circulating variants, and test performance may vary depending on the prevalence of variants circulating at the time of patient testing.
- Negative test results do not exclude possibility of exposure to or infection with SARS-CoV-2 virus. Patient handling will be directed by healthcare professionals.
## Conditions of Authorization for the Laboratory
The FloodLAMP EasyPCR(TM) COVID-19 Test Letter of Authorization, along with the authorized Fact Sheet for Healthcare Providers, the authorized Fact Sheet for Patients, and authorized labeling are available on the FDA website: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas)
However, to assist clinical laboratories running the FloodLAMP EasyPCR(TM) COVID-19 Test, the relevant Conditions of Authorization are listed below:
- Authorized laboratories1 using the FloodLAMP EasyPCR(TM) COVID-19 Test will include all authorized Fact Sheets with test result reports. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
- Authorized laboratories1 using the FloodLAMP EasyPCR(TM) COVID-19 Test will use the FloodLAMP EasyPCR(TM) COVID-19 Test as outlined in the FloodLAMP EasyPCR(TM) COVID-19 Test Instructions for Use. Deviations from the authorized procedures, including the authorized clinical specimen types, authorized control materials, authorized other ancillary reagents and authorized materials required to perform the test are not permitted.
- Authorized laboratories must notify the relevant public health authorities of their intent to run the test prior to initiating testing.
- Authorized laboratories using the FloodLAMP EasyPCR(TM) COVID-19 Test will have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
- Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
- All laboratory personnel using the test must be appropriately trained in molecular assay techniques and use appropriate laboratory and personal protective equipment when handling these test components, and use the test in accordance with the authorized labeling.
- FloodLAMP Biotechnologies, PBC authorized distributors, and authorized laboratories using the FloodLAMP EasyPCR(TM) COVID-19 Test will ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
1 For ease of reference, this will refer to, “Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a certified laboratories with FDA Emergency Use Authorization FDA for performing SARS-CoV-2 testing”
## Specimen Collection and Storage
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19:
[https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html](https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html)
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
- Samples can be stored at room temperature for 56 hours after collection prior to inactivation.
- For longer term storage, samples can be stored at ≤-70°C.
Note: Specimens must be packaged, shipped, and transported according to the current edition of the International Air Transport Association Dangerous Goods Regulation. Follow shipping regulations for UN 3373 Biological Substance, Category B when sending potential 2019-nCoV specimens.
## Running Tests
### Reagent Preparation
The FloodLAMP EasyPCR(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1.
#### Table 1: Validated reagents used with Test
| **Item** | **Concentration** | **Chemical Composition** | **Vendor** | **Catalog Number** |
|---|---|---|---|---|
| TCEP | 0.5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich / Millipore Sigma | 646547-10X1ML |
| EDTA | 0.5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease-free Water | | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5M | Sodium Chloride | Thermo Fisher | 24740011 |
| PCR Kit\* | | LunaⓇ Universal Probe One-Step RT-qPCR Kit | New England Biolabs | E3006 |
||
\* Item may not be substituted for equivalent.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
A 100X Inactivation Solution is prepared by mixing the components in Table 3 and vortexing for 30 seconds. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved. Aliquots of 100X Inactivation Solution should be stored in the dark at -20° C for up to 3 months. Upon thaw, working aliquots of 100X Inactivation Solution should be stored in the dark at room temperature for up to 1 month.
#### Table 3: 100X Inactivation Solution
| **Component** | **Source Concentration** | **Volume** | **100X Concentration** |
|---|---|---|---|
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | | 3.7 mL | |
| **TOTAL VOLUME** | | **20 mL** | |
||
Swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 4. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 4: 1X Inactivation Saline Solution
| **Component** | **Volume** |
|---|---|
| 0.9% Saline (154 mM NaCl) in MilliQ Water | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
### Controls Preparation
One **Positive Template Control** and one **Negative (No Template) Control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes. An **Internal Process Control** is included in every PCR reaction.
1. A **“No Template” (Negative) Control (NTC)** is needed to assure the absence of cross-contamination from positive samples, positive controls, or amplicons and is used to determine if sample results are valid. It consists of nuclease-free water.
2. A **Positive Template Control** is needed to assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water. Stock and working aliquots of the positive control are produced from the sources listed in Table 5 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at -80°C, or at most 1 month at -20°C.
3. An **Internal Process Control** is needed to assure sufficient specimen quantity and quality. It consists of a primer/probe set targeting the human RNaseP gene that is included in a single PCR amplification reaction. The RNAseP Internal Process Control uses a fluorescent reporter in a separate channel from the SARS-CoV-2 channel (i.e. in duplex).
#### Table 5. Components for Positive Template Control
| **Material** | **Vendor** | **Catalog \#** | **Volume** |
|---|---|---|---|
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µl |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µl |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895 µl |
||
### PCR Primer Stock Preparation
The FloodLAMP EasyPCR(TM) COVID-19 Test uses the validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a dualplex assay, detecting the 2 targets in a single well. This configuration is described in the SalivaDirect(TM) EUA Authorized test (www.fda.gov/media/141192/download).
All four primers for both CoV-19 and RNase P detection may be purchased from the vendor Eurofins Genomics using the catalog number 12YS-010YST. This kit contains primers and probes suspended at 100μM and is enough for 12,500 reactions. This kit can be mixed along with nuclease-free water to create the primer stock used in the FloodLAMP EasyPCR(TM) COVID-19 Test. See Table 6 below for details.
#### Table 6: 5X PCR Primer Stock Preparation from Eurofins Genomics Primer and Probe Set
| **Component** | **5X PCR Primer Stock Concentration** | **Volume (1 reaction)** | **Volume (3,125 reactions)** |
|---|---|---|---|
| 2019-nCov_N1-F | 2 µM | 0.4 µl | 1250 µl |
| 2019-nCov_N1-R | 2 µM | 0.4 µl | 1250 µl |
| 2019-nCov_N1-P | 1 µM | 0.2 µl | 625 µl |
| RP-F | 0.75 µM | 0.15 µl | 469 µl |
| RP-R | 0.75 µM | 0.15 µl | 469 µl |
| RP-P | 1 µM | 0.2 µl | 625 µl |
| Nuclease-free water | - | 2.5 µl | 7813 µl |
| **Total Volume** | - | **4 µl** | **12500 µl** |
||
Alternatively to the Eurofins Genomics Kit, primers may be purchased as individual custom oligos. Table 7 below lists the primer products to be ordered. Appropriate validation of primer mixes from custom oligos is required. Primers may be stored at 4°C for up to one month, or at -20°C for up to 1 year.
#### Table 7: PCR Primer Stock Components
| Vendor | Item | Catalog number | Quantity | # Reactions |
|---------|------|----------------|-----------|-------------|
| Order one of the following primer and probe sets |||||
| Eurofins Genomics | SalivaDirect™ complete set of 6 primers and probes | 12YS-010YST | 50-100 nmol | 12,500 |
| Integrated DNA Technologies | nCoV_N1 Forward Primer Aliquot | 10006821 | 50 nmol | 6,2500 |
| Integrated DNA Technologies | nCoV_N1 Forward Primer Aliquot | 10006830 | 100 nmol | 12,500 |
| Integrated DNA Technologies | nCoV_N1 Reverse Primer Aliquot | 10006822 | 50 nmol | 6,250 |
| Integrated DNA Technologies | nCoV_N1 Reverse Primer Aliquot | 10006831 | 100 nmol | 12,500 |
| Integrated DNA Technologies | NCoV_N1 Probe Aliquot | 10006831 | 25 nmol | 6,250 |
| Integrated DNA Technologies | NCoV_N1 Probe Aliquot | 10006832 | 50 nmol | 12,500 |
| Integrated DNA Technologies | RNaseP Forward Primer Aliquot | 10006827 | 50 nmol | 16,600 |
| Integrated DNA Technologies | RNaseP Forward Primer Aliquot | 10006836 | 100 nmol | 33,300 |
| Integrated DNA Technologies | RNaseP Reverse Primer Aliquot | 10006828 | 50 nmol | 16,600 |
| Integrated DNA Technologies | RNaseP Reverse Primer Aliquot | 10006837 | 100 nmol | 33,300 |
| Integrated DNA Technologies | RNase P Probe | Custom order (cy5) | 25 nmol | 6,250 |
| Integrated DNA Technologies | RNase P Probe | Custom order (cy5) | 50 nmol | 12,500 |
| Integrated DNA Technologies | RNase P Probe | 10007061 (ATTO647) | 25 nmol | 6,250 |
| Integrated DNA Technologies | RNase P Probe | 10007062 (ATTO647) | 50 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Forward Primer | nCoV-N1-F-100 | 100 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Forward Primer | nCoV-N1-F-1000 | 1000 nmol | 125,000 |
| LGC Biosearch Technologies | nCoV_N1 Reverse Primer | nCoV-N1-R-100 | 100 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Reverse Primer | nCoV-N1-R-1000 | 1000 nmol | 125,000 |
| LGC Biosearch Technologies | NCoV_N1 Probe | nCoV-N1-P-25 | 25 nmol | 6,250 |
| LGC Biosearch Technologies | NCoV_N1 Probe | nCoV-N1-P-250 | 250 nmol | 62,500 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-20 | 20 nmol | 6,660 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-100 | 100 nmol | 33,300 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-1000 | 1000 nmol | 333,300 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-20 | 20 nmol | 6,660 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-100 | 100 nmol | 33,300 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-1000 | 1000 nmol | 333,300 |
| LGC Biosearch Technologies | RNase P Probe | RNP-PQ670-25 | 25 nmol | 6,250 |
| LGC Biosearch Technologies | RNase P Probe | RNP-PQ670-250 | 50 nmol | 12,500 |
||
### Sample Preparation
\* For wet swab specimens (swabs in saline or unprocessed swab elution):
1. If samples are frozen, thaw unless no ice crystals are present and then keep on ice, cold block or at 4°C.
2. Pulse vortex each sample and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
3. Wipe the outside of the sample tube with 70% ethanol.
For dry swab specimens:
1. Wipe the outside of the sample tube with 70% ethanol.
### Sample Inactivation
1. Place the inactivation heater (a thermal cycler, water bath, dry heat bath or equivalent) in the BSC, turn on, and set the temperature to hold at 100°C.
2. \* For wet swab specimens: transfer 1 mL or available volume of each sample to an appropriately labeled 1.5 mL or 5 mL tube and securely cap.
3. \* For wet swab specimens: add 10µL per 1 mL sample volume of 100X Inactivation Solution to each sample tube.
4. For dry swab specimens (DO NOT DO FOR WET SWAB SPECIMENS): add 1 mL of 1X Inactivation Solution to each sample tube.
5. Vortex for 30 seconds.
6. Place sample tubes into the inactivation heater for 8 minutes.
7. Remove sample tubes from the inactivation heater and let cool at room temperature for 10 minutes.
8. Place sample tubes on ice, in the refrigerator, or on a cold block at 4°C until ready to perform amplification reaction.
Note: Testing of inactivated specimens must be conducted the same day inactivation is performed. For long term storage, keep the original specimen at ≤-70°C.
### Preparing to Run Assay for the First Time
*Note: Any instrument running the FloodLAMP EasyPCR(TM) COVID-19 Test must be calibrated for the following dyes: FAM and Cy5.*
#### Download the Template Run File
The Template Run File contains all the parameters preconfigured to run the FloodLAMP EasyPCR(TM) COVID-19 Test. These parameters can be seen in more detail under “Create the Run File ...” headings below.
To download the Template Run File:
1. Go to [www.floodlamp.bio/ifus](http://www.floodlamp.bio/ifus)
2. Download the Template Run file(s) for the instrument type and assay to be run.
#### Table 7: RT-PCR Instrument Template Run Files
| **Instrument** | **Setup Template Filename** |
|---|-----------------------------------------------------------|
| ABI QuantStudio(TM) 7 Pro | FloodLAMP_QS7Pro_PCR_template_run.edt |
| ABI QuantStudio(TM) 6 Flex | FloodLAMP_QS6Flx_PCR_template_run.edt |
| Bio-Rad CFX96 Touch(TM) | FloodLAMP_BRCFX_PCR_protocol.prcl |
| Bio-Rad CFX96 Touch(TM) | FloodLAMP_BRCFX_PCR_template_run.pltd |
||
*Note: Template Run Files only need to be downloaded once upon first use.*
#### Alternatively Create the Template Run File on QuantStudio(TM) 6 Flex or 7 Pro
1. Open the Design and Analysis Software.
2. Select the “SET UP PLATE” option.
3. From the sidebar on the screen, select the following properties to filter:
- Instrument – choose the appropriate instrument
- Block – choose the appropriate block
- RunMode – Standard
- Analysis options are left blank
4. From the plate sections present on the screen, select the correct System Template and the system will automatically navigate to the "Run Method" tab.
- "Presence/Absence" for QuantStudio(TM) 7 Pro
- “Presence-Absence Standard Pre PCR Post” for QuantStudio(TM) 6 Flex
5. Change Run Parameters as shown below:
- **Run Method:**
- 20μL Rxn Vol.
- 105° C Heated Cover Temp
- Ramp Rate: 1.6° C/s
#### Table 8 : Thermal cycling and plate read steps for QuantStudio(TM) Systems for PCR
| **Stage** | **Temperature** | **Time** | **Reps** |
|---|---|---|---|
| 1 | 52° C | 10 min | 1 |
| 2 | 95° C | 2 min | 1 |
| 3 | 95° C | 10 sec | 44 |
| 3 | 55° C\* | 30 sec | 44 |
| 4 | 55° C\*\* | 30 sec | 1 |
||
\*This step should be the optical read step
\*\*This step is only required for QuantStudio(TM) 6 Flex
- **Plate Setup**
- Targets: FAM (N1) & Cy5 (RP)
- Quencher: None
- Passive Reference: ROX
1. Once done setting up the template, go to “Actions” in the top right corner and hit “Save As”:
- On Connect: Save to template folder.
- Offline: Save to preferred location.
#### Create the Template Run File on Bio-Rad CFX96 Touch(TM)
1. Launch the CFX96 Touch(TM) software package.
2. In the Startup Wizard pop-up window select the instrument “CFX96” from the drop down menu.
3. Under “Select Run Type” press the “User-defined” button.
4. Create a new thermocycler protocol by selecting “Create New” from the Run Setup window.
5. Under Tools in the top left toolbar select “Run Time Calculator” and check “96 Wells-All Channels”.
6. Make the following changes to the cycling conditions in the Protocol Editor:
- Sample Volume to 20 µL
- Lid Setting to 105°C
- Change cycles to be as shown below:
#### Table 9 : Thermal cycling and plate read steps for the Bio-Rad CFX96 Touch(TM)
| **Stage** | **Temperature** | **Time** | **Reps** |
|---|---|---|---|
| 1 | 52° C | 10 min | 1 |
| 2 | 95° C | 2 min | 1 |
| 3 | 95° C | 10 sec | 44 |
| 3 | 55° C\* | 30 sec | 44 |
||
\*This step should be the optical read step
7. Click “OK” to save the protocol as type Protocol File (\*.prcl) and return to the Protocol tab in Run Setup.
### Create the Plate Layout Map
#### QuantStudio(TM) 6 Flex or 7 Pro Option 2: Sample Name Input
For this option, sample names (i.e. specimen IDs) are directly input into the instrument software prior to starting the run.
1. Open template in Design and Analysis app and go to the “Plate Setup” tab.
2. On the right side of the screen ensure the “Samples” tab is highlighted and press the addition icon to add the number of samples being tested.
3. Click on the “Sample 1” box to rename the sample.
- Repeat this step for all subsequent samples being entered.
4. Click the well located in the plate map then check the box next to the sample name from the right side bar to associate the name to the well.
- There is also the option to highlight the well location in the plate map and click on the “Enter sample” box. Enter the sample ID and press tab to continue to the next well.
5. Once the sample names have been entered, the wells may be highlighted by left clicking the mouse over the starting well and dragging the mouse across all wells. The targets are then chosen by clicking the check boxes next to each target in the sidebar.
- FAM & Cy5 targets should be chosen and named “N1” and “RP” respectively.
6. Once done setting up the template, go to “Actions” in the top right corner and hit “Save As,” a pop-up window will appear directing the user to title the file according to information pertaining to the sample run.
- Connect: Save to the desired folder (only applicable for 7 Pro).
- Offline: Save to a USB that is inserted into the computer.
7. Use your plate layout to load your samples and controls after preparing the amplification reaction mix.
#### QuantStudio(TM) 6 Flex or 7 Pro Option 2: Lookup Based on Well Position
For this option, a single generic sample name is applied to all wells, and subsequently, outside of the instrument software, the results are linked to the actual sample name via a lookup table to the well position.
1. Open the template in the Design and Analysis app and go to the “Plate Setup” tab.
2. Highlight the entire plate and add 1 sample to all wells, with the same sample name in every well.
3. Once the sample name has been entered, the targets are chosen by clicking the check boxes next to each target in the sidebar.
- FAM & Cy5 targets should be chosen and named “N1” and “RP” respectively.
4. Go to “Actions” in the top right corner and hit “Save As” and name the Template Run File as desired. The software will automatically save as a .edt file.
- Connect: Save to desired location (only applicable for QuantStudio 7 Pro).
- Offline: Save to a USB that is inserted into the computer.
This process only needs to be done once – all subsequent runs can use the same Template Run File.
#### Bio-Rad CFX96 Touch(TM):
1. Launch the CFX96 Touch(TM) software package and open the correct protocol template.
2. Review the details of the protocol. If correct, click “Next” to proceed to the Plate tab.
3. On the Plate tab, click “Create New” and the Plate Editor appears.
4. Use the Plate Editor to create a new plate.
5. To ensure the correct plate size is selected, go to “Settings > Plate Size” and check that 96-well or 384-well is selected.
6. To set the plate type, select “Settings > Plate Type” and select “BR Clear” or “BR White” from the drop-down menu.
7. To set the scan mode, select the “All Channels” scan mode from the Scan Mode drop-down list.
8. Select the “Select Fluorophores” button on the upper right of the Plate Editor window.
- De-select all default fluorophores and select “FAM” and “Cy5” and click OK.
9. In the Plate Editor window highlight the whole plate and click the checkbox in front of FAM and Cy5.
10. Select the “Experiment Settings” button in order to define the Targets.
- In the lower left of the Experiment Settings window in the New box, type in “N1” and select “Add”.
- Repeat and type in “RP”.
- Select “OK”.
11. In the Plate Editor window next to FAM in the drop-down menu under Target Name select “N1” and for Cy5 select “RP”.
12. Click OK to save changes and close the “Select Fluorophores” dialog box.
#### Bio-Rad CFX96 Touch(TM) Option 1: Sample Name Input
1. Load the appropriate sample type to each well by selecting the well and selecting the appropriate Sample Type (Unknown, NTC, or Positive Control) from the drop-down menu.
2. Multiple wells can be selected at once to load the sample type.
- Note: The EC can be listed as an Unknown sample.
3. In the “Target Names” section confirm that the necessary fluorophores are assigned to each well.
4. Name each well by typing in the sample name and pressing “Enter” in the Sample Names dropdown list.
5. Click OK to save the Plate File (\*.pltd) and return to the Plate tab in Run Setup. When prompted, specify a name for the plate and a save location.
#### Bio-Rad CFX96 Touch(TM) Option 2: Lookup Based on Well Position
1. Name the file as desired and save as type “Plate File (\*.pltd)”.
2. Select “Save”, click “OK” in the Plate Editor window and exit the software.
This process only needs to be done once – all subsequent runs can use the same Template Plate File.
### PCR Amplification Reaction Preparation
1. Place a 96-well PCR plate or PCR strip tubes onto a cold block or ice.
2. Thaw frozen reagents until ice crystals are not present.
3. Pulse vortex thawed reagents for 3 seconds and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
4. Store on ice or in the refrigerator or on a cold block at 4°C until ready to use.
5. Prepare the PCR Amplification Reaction Mix by combining the components listed below in Table 10.
NOTE: Component volumes should be scaled proportionally for the number of reactions.
6. Vortex the PCR Amplification Reaction Solution for 10 seconds and briefly spin down in a centrifuge.
7. Add 18 µL of the PCR Amplification Reaction Solution into the wells of the PCR plate or PCR strip tubes.
#### Table 10: PCR Amplification Reaction Mix
| **Component** | **Volume (1 reaction)** | **Volume (1 reaction x 100)
1 x 96-plate w/ 4% overage** |
|---|---|---|
| 5X PCR Primer Stock | 4 µL | 400 µL |
| Nuclease-free Water | 3 µL | 300 µL |
| PCR Master Mix\* | 10 µL | 1000 µL |
| PCR RT\* | 1 µL | 100 µL |
| **SUBTOTAL VOLUME** | **18 µL** | **1800 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **20 µL** | - |
||
\* in LunaⓇ Universal Probe One-Step RT-qPCR Kit
### Sample Addition
NOTE: Ensure that positive and negative controls are included in each batch run (i.e. in each PCR plate or group of strip tubes that are heated together).
1. Add 2 μL of each sample into a separate tube in the amplification reaction PCR plate or strip tubes.
2. Mix by pipetting.
3. If using PCR plate, seal with optical film (optionally using heat sealer). If using PCR strip tubes, cap strips.
4. Pulse vortex and briefly spin down in a centrifuge to collect the liquid at the bottom.
5. Continue to section “Run the Assay”.
### Run the Assay
Refer to Specific Instrument User Manuals for full system usage and maintenance details.
#### On QuantStudio(TM) 6 Flex
1. To transfer templates from a USB drive, plug a USB drive into the USB port below the touchscreen.
2. If the instrument is in standby, touch the touchscreen to activate it and then press the green power icon.
3. In the Main Menu, press “View Templates”.
4. In the Browse Experiments screen, select the template:
- Press the Folder icon, then choose “USB”.
- Press the desired template, then press “Save”.
5. In the Save Experiment As screen, set the name for the file.
- Press the “New Template Name” field, then enter a name for the copied file.
- Press the “Save to Folder” field, then select the folder to receive the file.
- Hit “Save”.
6. Press the Home icon to return to the Main Menu.
7. Navigate to the Main Menu screen, then press the red eject icon.
8. When the side door opens, load the appropriate plate or PCR strips. Ensure that the consumable is properly aligned.
9. In the Main Menu, press “Browse Experiments”.
10. In the Experiments screen, choose the desired experiment and then click the Folder icon to choose where to save the experiment.
11. Then press “Start Run” to start the run immediately.
#### On QuantStudio(TM) 7 Pro
1. Log into user on instrument.
2. USB: Plug in USB with saved template on it.
3. From the options on the instrument’s screen press “Load plate file”.
- The QuantStudio(TM) 7 is a touchscreen device.
4. From the “Run Queue” screen,
- USB: press “USB drive” on the left side.
- Connect: press Cloud icon on the left side.
5. This will bring up any plate files saved.
6. Press the plate file associated with the run to be performed.
7. A new window will appear requesting location of results once the run is complete.
- Connect: Press the “Cloud Connect” icon, press again to verify location and then press “Done”.
- USB: Press the “USB drive Connected” if not already highlighted and press “Done”.
8. Press the double-arrow icon at the top right corner of the screen.
- The instrument drawer will open from the front.
9. Place the plate/strips into the plate holder ensuring proper orientation of the plate (A1 well top-left).
10. Press “Start Run” on the screen of the instrument.
- A pop-up window will appear asking the user to confirm the plate has been loaded.
- If the plate has been loaded, press “Start Run” again or press “Open Drawer” to place the plate into the block and then press “Start Run”.
#### On Bio-Rad CFX96 Touch(TM)
1. Open the correct .pcrl file and review the protocol details. If correct, click “Next” to proceed to the Plate tab.
2. When prompted, open the correct .pltd file and review the plate details in the Run Information section.
3. Select the checkbox for the appropriate block (CFX96 or CFX384) on which to perform the run.
4. To insert the plate or 8-tube strips into the block, click Open Lid.
5. Insert the plate or 8-tube strips into the block, ensuring proper orientation.
6. Click Close Lid.
7. Click Start Run at the bottom right of the screen.
8. When prompted, save the data file (.pcrd) to the desired location.
### Analyzing Data
#### Exporting Data from QuantStudio(TM) 6 Flex or 7 Pro
##### Using USB
1. Confirm Quant says “File Transferred - USB”.
2. Take USB from Quant and plug it into computer.
3. Export data off of USB onto computer.
##### Using Cloud Connect with QuantStudio(TM) 7 Pro
1. Go to [Cloud Connect](https://apps.thermofisher.com/apps/spa/#/dashboard) and log in.
2. Go to files and find the data that was just uploaded by the Quant, in the folder chosen previously.
3. Download .xlsx file.
#### Exporting Data from Bio-Rad CFX96 Touch(TM)
1. After the run has completed, open the data file (.pcrd) by going to Select File > Open > Data File in the Home window and locating the desired data file. Adjust the following settings as described below.
2. Select Settings > Cq Determination mode and select Single Threshold.
3. Select Settings > Baseline Setting and select Baseline Subtracted.
4. Select Settings > Analysis Mode and select analysis by fluorophore.
5. Select Settings > Cycles to Analyze and confirm that all cycles are analyzed, then click “OK”.
6. Cq values of each well are displayed in the Quantification Data tab.
7. Export .xlsx files and select Export > Export all Data Sheets to Excel (Cq values are in "Quantification Plate View Results").
#### Compiling Results Option 1: Lookup Based on Well Position
For this option, outside of the instrument software the results are linked to the actual sample name via a lookup table to the well position. An example spreadsheet to perform this lookup and results compilation is available with instructions at [www.floodlamp.bio/ifus](http://www.floodlamp.bio/ifus).
#### Compiling Results Option 2: Sample Name Input
For this option, sample names (i.e. specimen IDs) are directly input into the instrument software prior to starting the run. Open the results file and continue to “Analyzing Data” section to score results.
### Results Interpretation
#### Test Controls
All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. Target results for the controls will be interpreted according to Table 5 below.
1. The **No Template (Negative) Control (NTC)** should yield a negative “not detected” result for both the N1 and RNaseP targets.
2. The **Positive Template Control** should yield a positive “detected” result for the N1 target and a negative “not detected” for the RNaseP control.
3. The **Internal Process Control** should yield a positive "detected" result for RNaseP. Detection of RNaseP is required to report a negative SARS-CoV-2 result.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and (optionally) RNAseZAP™ product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
#### Patient Specimen Results Interpretation
NOTE: Results can only be interpreted if the positive and negative controls in the plate or group of strip tubes have the expected results.
Use Table 11 below to assign a result to each sample.
#### Table 11: Interpretation of Assay Results
| **ABI QuantStudio(TM) 7 Pro** | | |
|---|---|---|
| **Result** | **Ct Value: N1** | **Ct Value RP** |
| Positive | <38.0 | Any Value |
| Negative | ≥38.0 | <35.0 |
| *Invalid | ≥38.0 | ≥35.0 |
| **Bio-Rad CFX96 Touch(TM)** / **ABI QuantStudio(TM) 6 Flex** | | |
| **Result** | **Ct Value: N1** | **Ct Value RP** |
| Positive | <40.0 | Any Value |
| Negative | ≥40.0 | <35.0 |
| *Invalid | ≥40.0 | ≥35.0 |
||
\*Invalid test results should be repeated by rerunning the primary sample if available, otherwise the inactivated sample. Results from retested samples will follow the same interpretation.
If the final interpretation of the test result is invalid, then "Invalid/Inconclusive" should be reported and retesting of the individual is recommended.
## Performance Evaluation
### Analytical Sensitivity: Limit of Detection (LoD)
The Limit of Detection (LoD) for the FloodLAMP EasyPCR(TM) COVID-19 Test was established using gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The gamma-irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 3,100 and 1,600 were selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 12. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 3,100 copies/mL.
#### Table 12: Confirmatory LoD Data Results
| **Instrument** | **LoD** | **Positive Replicates** |
|---|---|---|
| ABI QuantStudio(TM) 7 Pro | 3,100 copies/mL | 95% (20/21) |
| ABI QuantStudio(TM) 6 Flex | 3,100 copies/mL | 100% (21/21) |
| Bio-Rad CFX96 Touch(TM) | 3,100 copies/mL | 95% (20/21) |
||
### Analytical Sensitivity: Inclusivity
FloodLAMP EasyPCR(TM) COVID-19 Test includes a modified RT-qPCR assay by dualplexing the previously authorized CDC N1 and human RNase P primer-probe sets. Inclusivity was tested in the original US CDC EUA with all publicly available SARS-CoV-2 genomes as of 1 February 2020. The initial analysis showed 100% homology between the N1 primer-probe set and available genomes, except for one low frequency mismatch with the N1 forward primer. However, this was not expected to affect performance of the primer-probe set due to annealing temperatures of 55°C which tolerate 1-2 mismatches. Indeed, performance of the N1 primer-probe set was shown to be high in the previous comparison of primer-probes sets ([https://www.nature.com/articles/s41564-020-0761-6](https://www.nature.com/articles/s41564-020-0761-6)). GISAID continuously evaluates mismatches between newly available SARS-CoV-2 genomes and primer-probe sets and confirms a low frequency of nucleotide mismatches (<5%) with the N1 primer-probe set.
### Analytical Specificity: Cross-Reactivity
The primer and probe sets used in FloodLAMP’s dualplex assay were developed by the US CDC and have been EUA certified. The CDC reported no cross-reactivity with other human coronaviruses (229E, OC43, NL63, and HKU1), MERS-coronavirus, SARS-coronavirus, and 14 additional human respiratory viruses (see [https://www.fda.gov/media/134922/download](https://www.fda.gov/media/134922/download)).
### Analytical Specificity: Interfering Substances
Exogenous and endogenous substances were tested for potential interference with the FloodLAMP EasyPCR(TM) COVID-19 Test. Gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) was spiked onto dried AN swab specimens to produce contrived Positive Controls. Negative Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 13.
#### Table 13: Interfering Substances Results
| **Interfering Substance** | **Active Ingredient** | **Concentration** | **% Agreement with Expected Results** (Positive Control) | **% Agreement with Expected Results** (Negative Control) |
|---|---|---|---|---|
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
## Clinical Evaluation
The clinical evaluation of the FloodLAMP EasyPCR(TM) COVID-19 Test utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The FloodLAMP EasyPCR(TM) COVID-19 Test showed a positive agreement of 97.5% and a negative agreement of 100%. The single false negative result was a specimen with a high Ct value as previously measured by the comparator test, indicating low viral load. A summary of the clinical performance is shown in Table 14.
#### Table 14: Clinical Evaluation Results
| **FloodLAMP EasyPCR(TM) COVID-19 Test Results** | **Comparator - High Sensitivity EUA Authorized Test** | | |
|---|---|---|---|
| | **Positive** | **Negative** | **Total** |
| Positive | 39 | 0 | 39 |
| Negative | 1 | 40 | 41 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 97.5% (39/40) 95% CI: 86.8% to 99.9% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## Support
FloodLAMP Biotechnologies, PBC support center
[eua.support@floodlamp.bio](mailto:eua.support@floodlamp.bio)
650-394-5233
QuantStudio is a trademark of Thermo Fisher Scientific (NYSE: TMO)
Bio-Rad and Bio-Rad CFX96 Touch is a trademark of Bio-Rad Laboratories, Inc. (NYSE: BIO)
# 17,430 2021-03-22_Instructions for Use - FloodLAMP QuickColor COVID-19 Test v1.0.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-03-22_Instructions for Use - FloodLAMP QuickColor COVID-19 Test v1.0.md
file_date: 2021-03-22
title: Instructions for Use - FloodLAMP QuickColor COVID-19 Test v1.0
category: regulatory
subcategory: fl-fda-submissions
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pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/fl-fda-submissions/2021-03-22_Instructions%20for%20Use%20-%20FloodLAMP%20QuickColor%20COVID-19%20Test%20v1.0.pdf
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notes:
summary_short: The Instructions for Use for the FloodLAMP QuickColor COVID-19 Test v1.0 provides CLIA high-complexity laboratories with the complete protocol for an extraction-free, colorimetric RT-LAMP assay with visual readout after chemical and heat inactivation. It details required reagents and equipment, primer preparation, step-by-step testing workflow, control requirements, result interpretation by color change, and contamination precautions. It also documents analytical and clinical performance claims, including a 12,500 copies/mL LoD and 90% positive agreement with 100% negative agreement in an 80-specimen evaluation.
CONTENT
***INTERNAL TITLE:*** FloodLAMP QuickColor(TM) COVID-19 Test
Instructions for Use v1.0
IVD
COVID-19 Emergency Use Authorization Only
For *in vitro* diagnostic (IVD) Use
www.floodlamp.bio
FloodLAMP Biotechnologies, PBC | 930 Brittan Ave. San Carlos, CA 94070 USA
## Table of Contents
| | |
|---------|------|
| Intended Use | 3 |
| Principles of Procedure | 3 |
| Materials Provided and Storage | 4 |
| Materials Required but Not Provided | 4 |
| • Standard Lab Equipment and Consumables | 6 |
| Warnings and Precautions | 6 |
| • General Precautions | 6 |
| • Contamination Precautions | 7 |
| Limitations | 7 |
| Conditions of Authorization for the Laboratory | 9 |
| Specimen Collection and Storage | 10 |
| Running Tests | 11 |
| • Reagent Preparation | 11 |
| • Controls Preparation | 12 |
| • 10X LAMP Primer Mix Preparation | 13 |
| • Sample Preparation | 15 |
| • Sample Inactivation | 15 |
| • Colorimetric LAMP Amplification Reaction Preparation | 15 |
| • Sample Addition and Heating | 16 |
| • Test Controls | 17 |
| • Patient Specimen Results Interpretation | 18 |
| Performance Evaluation | 19 |
| • Analytical Sensitivity: Limit of Detection (LoD) | 19 |
| • Analytical Sensitivity: Inclusivity (in silico) | 19 |
| • Evaluation of Impact of Viral Mutations | 20 |
| • Analytical Specificity: Cross-Reactivity (in silico) | 22 |
| • Analytical Specificity: Cross-Reactivity (wet testing) | 26 |
| • Analytical Specificity: Interfering Substances | 26 |
| Clinical Evaluation | 27 |
| Support | 29 |
||
FloodLAMP QuickColor(TM) COVID-19 Test
For COVID-19 Emergency Use Authorization Only
Instructions for Use
## Intended Use
FloodLAMP QuickColor(TM) COVID-19 Test is a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The FloodLAMP QuickColor(TM) COVID-19 Test is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures. The FloodLAMP QuickColor(TM) COVID-19 Test is only for use under the Food and Drug Administration’s Emergency Use Authorization.
## Principles of Procedure
The FloodLAMP QuickColor(TM) COVID-19 Test is an RNA-extraction free isothermal RT-LAMP assay that indicates the presence of the SARS-CoV-2 viral RNA with a simple visual color change. It can widely and rapidly be scaled because 1) no special instrumentation of any kind is required, neither nucleic acid extraction equipment nor a RT-PCR instrument, 2) it utilizes reagents and supplies readily available in large quantities, and 3) is a very straightforward protocol with minimal steps that can be executed quickly and reliably. It also utilizes the same streamlined sample preparation as the FloodLAMP EasyPCR(TM) Test which is also a supply chain robust, open source protocol test. Together the two tests can be used in an integrated program for screening and rapid confirmation in large populations by a broad range of laboratories.
The FloodLAMP QuickColor(TM) COVID-19 Test uses a set of specific primers that target ORF1ab, N and E genes for the detection of SARS-CoV-2 RNA. Loop Mediated Isothermal Amplification (LAMP) is a nucleic acid amplification technique wherein DNA amplification is carried out at a constant temperature of approximately 65°C. Samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step. The resulting inactivated sample is directly used as input in the LAMP reaction. The amplification reaction mix includes a reverse transcriptase (RT) polymerase to create complementary cDNA from RNA. The cDNA is subsequently amplified by a high strand displacement DNA polymerase. The amplified DNA products lower the pH of the reaction. A phenol red pH indicating dye is included in the amplification reaction mix, thus causing the reaction solution to visibly change from an initial bright pink to a bright yellow when sufficient amplification occurs. Reactions that change color to yellow indicate that SARS-CoV-2 RNA is present.
## Materials Provided and Storage
The FloodLAMP QuickColor(TM) COVID-19 Test utilizes standard chemicals available from multiple vendors, with the exception of the LAMP primers and Colorimetric LAMP master mix. Designated CLIA labs may order components directly from vendors.
## Materials Required but Not Provided
The FloodLAMP QuickColor(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1. No specialized instruments are needed. Only ordinary laboratory equipment such as pipettes, centrifuges, and heaters are needed.
#### Table 1: Validated reagents used with the Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | :---: | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease-free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5 M | Sodium Chloride | Thermo Fisher | 24740011 |
| Guanidine HCl | 6 M | Guanidine Hydrochloride | Sigma-Aldrich | SRE0066 |
| Colorimetric LAMP MM\* | - | Colorimetric LAMP Master Mix | New England Biolabs | M1804 |
||
\* Item may not be substituted for equivalent. Only the specified vendor and catalog number may be utilized.
The FloodLAMP QuickColor(TM) COVID-19 Test uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. All 18 primers are mixed together and are input into a single amplification reaction. Primer names and sequences are listed in Table 2. Primers may be purchased pre-blended from the vendor LGC Biosearch Technologies with the product names LAMP\_S2-As1e, LAMP\_S2-N2, LAMP\_S2-E1. Alternatively, primers may be purchased as individual custom oligos. Appropriate validation of primer mixes from custom oligos is required. See Primer Preparation below for more information.
#### Table 2: Primer names and sequences
| Primer Name | Sequence (5’-3’) |
| :---- | :---- |
| **ORF1ab gene (AS1e)** | |
| Orf1ab\_FIP | TCAGCACACAAAGCCAAAAATTTATTTTTCTGTGCAAAGGAAATTAAGGAG |
| Orf1ab\_BIP | TATTGGTGGAGCTAAACTTAAAGCCTTTTCTGTACAATCCCTTTGAGTG |
| Orf1ab\_F3 | CGGTGGACAAATTGTCAC |
| Orf1ab\_B3 | CTTCTCTGGATTTAACACACTT |
| Orf1ab\_LF | TTACAAGCTTAAAGAATGTCTGAACACT |
| Orf1ab\_LB | TTGAATTTAGGTGAAACATTTGTCACG |
| **N Gene (N2)** | |
| N2\_FIP | TTCCGAAGAACGCTGAAGCGGAACTGATTACAAACATTGGCC |
| N2\_BIP | CGCATTGGCATGGAAGTCACAATTTGATGGCACCTGTGTA |
| N2\_F3 | ACCAGGAACTAATCAGACAAG |
| N2\_B3 | GACTTGATCTTTGAAATTTGGATCT |
| N2\_LF | GGGGGCAAATTGTGCAATTTG |
| N2\_LB | CTTCGGGAACGTGGTTGACC |
| **E Gene (E1)** | |
| E1\_FIP | ACCACGAAAGCAAGAAAAAGAAGTTCGTTTCGGAAGAGACAG |
| E1\_BIP | TTGCTAGTTACACTAGCCATCCTTAGGTTTTACAAGACTCACGT |
| E1\_F3 | TGAGTACGAACTTATGTACTCAT |
| E1\_B3 | TTCAGATTTTTAACACGAGAGT |
| E1\_LF | CGCTATTAACTATTAACG |
| E1\_LB | GCGCTTCGATTGTGTGCGT |
||
### Standard Lab Equipment and Consumables
* 70% ethanol
* 10% bleach, prepared daily
* 96-well PCR reaction plates (Applied Biosystems \# 4346906, 4366932, 4346907, Eppendorf \# 951020303 or equivalent)
* Optical strip caps (Applied Biosystems \# 4323032 or equivalent)
* Optical plate seal (Applied Biosystems \# 4311971 or equivalent)
* PCR strip tubes and caps (USA Scientific catalog \# 1402-2500 or equivalent)
* 5 mL transport tubes or equivalent (sterile)
* 1.5 mL microcentrifuge tubes or equivalent (nuclease-free)
* Aerosol resistant micropipette tips (nuclease-free)
* Micropipettes (calibrated)
* Bottle top dispenser for 1 mL volume (optional, calibrated)
* 96-well cold block
* Cold blocks for 5 mL and 1.5 mL \- 2.0 mL tubes, or ice
* Vortex mixer
* 96-well plate centrifuge or equivalent
* Mini centrifuge for 1.5 mL tubes or equivalent
* 2 x Thermal cycler, water bath, dry heat bath or equivalent (calibrated)
* Class II Biological Safety Cabinet (BSC)
## Warnings and Precautions
Materials or chemicals required for the use of the FloodLAMP QuickColor(TM) COVID-19 Test should be closely examined by the user. The user should carefully read all warnings, instructions or Safety Data Sheets provided by the supplier and follow the general safety precautions when handling biohazards, chemicals and other materials.
### General Precautions
* The FloodLAMP QuickColor(TM) COVID-19 Test is for *in vitro* diagnostic use (IVD) only. Rx Only.
* For use under COVID-19 Emergency Use Authorization Only.
* Standard precautions and procedures should be taken when handling and disposing of human samples.
* This test has not been FDA cleared or approved; the test has been authorized by FDA under an Emergency Use Authorization (EUA) for use by laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA) of 1988, 42 U.S.C. §263a, to perform high complexity tests.
* This test has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens.
* This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of *in vitro* diagnostic tests for detection and/or diagnosis of COVID19 under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
* Standard precautions and procedures should be taken when handling and extracting human samples.
* Standard precautions and procedures should be taken when using laboratory equipment.
* Standard precautions and procedures should be taken when disposing of waste.
* Dispose of reagents according to local regulations.
* Do not use reagents after their recommended stability time frame.
* Ensure reagents are stored at the recommended temperatures as described below and in the vendor product information and manuals.
### Contamination Precautions
* Avoid contamination by following good laboratory practices, wearing proper personal protective equipment, segregating workflow, and decontaminating workspace appropriately.
* Ensure that surfaces and equipment used for all test steps have been properly cleaned with 10% bleach and 70% ethanol.
* Ensure all consumables are DNase and RNase free except for sample collection tubes which may be sterile.
* Use only calibrated pipettes and filter tips that are sterile and PCR clean.
* After completion of the test, dispose of the amplification reaction plates or tubes. **Do not open tubes** or remove the seals on plates after heating amplification reactions.
## Limitations
* The use of this assay as an *in vitro* diagnostic under the FDA COVID-19 Emergency Use Authorization (EUA) is limited to laboratories that are certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, to perform high complexity tests by Rx only.
* Use of this assay is limited to personnel who are trained in the procedure. Failure to follow these instructions may lead to erroneous results.
* The performance of the FloodLAMP QuickColor(TM) COVID-19 Test was established using Nasopharyngeal Swab specimen type collected in saline. Nasal swabs, oropharyngeal swabs, mid-turbinate nasal swabs specimens are also considered acceptable specimen types for use with the test but performance has not been established.
* Samples must be collected according to recommended protocols and transported and stored as described herein.
* Samples should not be collected in UTM or VTM or Liquid Amies transport media.
* The effect of vaccines, antiviral therapeutics, antibiotics, chemotherapeutic or immunosuppressant drugs have not been evaluated.
* Detection of SARS-CoV-2 RNA may be affected by sample collection methods, patient factors (e.g., presence of symptoms), and/or stage of infection.
* False-positive results may arise from various reasons, including, but not limited to the following:
* Contamination during specimen collection, handling, or preparation
* Contamination during assay preparation
* Incorrect sample labeling
* False-negative results may arise from various reasons, including, but not limited to the following:
* Improper sample collection or storage
* Degradation of SARS-CoV-2 RNA
* Presence of inhibitory substances
* Use of extraction reagents or instrumentation not approved with this assay
* Incorrect sampling window
* Failure to follow instructions for use
* Mutations In SARS-CoV-2 target sequences
* Nucleic acid may persist even after the virus is no longer viable.
* This test cannot rule out diseases caused by other bacterial or viral pathogens.
* Performance has not yet been established in asymptomatic individuals and will be established during a post-authorization study.
* Use of the test in a general, asymptomatic population for serial screening is intended to be used as part of an infection control plan, that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. Negative results should not be treated as definitive and do not preclude current or future infection obtained through community transmission or other exposures. Negative results must be considered in the context of an individual’s recent exposures, history, and presence of clinical signs and symptoms consistent with COVID-19.
* This test should not be used within 30 minutes of administering nasal or throat sprays.
* Positive results must be reported to appropriate public health authorities, following state and national guidelines.
* The clinical performance of the test has not been established in all circulating variants, and test performance may vary depending on the prevalence of variants circulating at the time of patient testing.
* Negative test results do not exclude possibility of exposure to or infection with SARS-CoV-2 virus. Patient handling will be directed by healthcare professionals.
## Conditions of Authorization for the Laboratory
The FloodLAMP QuickColor(TM) COVID-19 Test Letter of Authorization, along with the authorized Fact Sheet for Healthcare Providers, the authorized Fact Sheet for Patients, and authorized labeling are available on the FDA website: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas)
However, to assist clinical laboratories running the FloodLAMP QuickColor(TM) COVID-19 Test, the relevant Conditions of Authorization are listed below:
* Authorized laboratories1 using the FloodLAMP QuickColor(TM) COVID-19 Test will include all authorized Fact Sheets with test result reports. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
* Authorized laboratories1 using the FloodLAMP QuickColor(TM) COVID-19 Test will use the FloodLAMP QuickColor(TM) COVID-19 Test as outlined in the FloodLAMP QuickColor(TM) COVID-19 Test Instructions for Use. Deviations from the authorized procedures, including the authorized clinical specimen types, authorized control materials, authorized other ancillary reagents and authorized materials required to perform the test are not permitted.
* Authorized laboratories must notify the relevant public health authorities of their intent to run the test prior to initiating testing.
* Authorized laboratories using the FloodLAMP QuickColor(TM) COVID-19 Test will have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
* Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
* All laboratory personnel using the test must be appropriately trained in molecular assay techniques and use appropriate laboratory and personal protective equipment when handling these test components, and use the test in accordance with the authorized labeling.
* FloodLAMP Biotechnologies, PBC authorized distributors, and authorized laboratories using the FloodLAMP QuickColor(TM) COVID-19 Test will ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
1 For ease of reference, this will refer to, “Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a certified laboratories with FDA Emergency Use Authorization FDA for performing SARS-CoV-2 testing
## Specimen Collection and Storage
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19:
[https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html](https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html)
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
* Samples can be stored at room temperature for 56 hours after collection prior to inactivation.
* For longer term storage, samples can be stored at ≤-70oC.
Note: Specimens must be packaged, shipped, and transported according to the current edition of the International Air Transport Association Dangerous Goods Regulation. Follow shipping regulations for UN 3373 Biological Substance, Category B when sending potential 2019-nCoV specimens.
## Running Tests
### Reagent Preparation
The FloodLAMP QuickColor(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1.
#### Table 1: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | :---: | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease- free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5M | Sodium Chloride | Thermo Fisher | 24740011 |
| Guanidine HCl | 6M | Guanidine Hydrochloride | Sigma-Aldrich | SRE0066 |
| Colorimetric LAMP MM\* | - | Colorimetric LAMP Master Mix | New England Biolabs | M1804 |
||
\* Item may not be substituted for equivalent.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
A 100X Inactivation Solution is prepared by mixing the components in Table 3 and vortexing for 30 seconds. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved. Aliquots of 100X Inactivation Solution should be stored in the dark at \-20°C for up to 3 months. Upon thaw, working aliquots of 100X Inactivation Solution should be stored in the dark at room temperature for up to 1 month.
#### Table 3: 100X Inactivation Solution
| Component | Source Concentration | Volume | 100X Concentration |
| :---- | :---: | :---: | :---: |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
Swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 4. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 4: 1X Inactivation Saline Solution
| Component | Volume |
| :---- | :---: |
| 0.9% Saline (154 mM NaCl) in MilliQ Water | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
### Controls Preparation
**One positive and one negative control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes on each heater:
1) A “no template” (negative) control (NTC) is needed to **assure the absence of cross contamination from positive samples, positive controls, or amplicons** and is used **to determine if sample results are valid.** **It consists of 100X Inactivation Solution diluted to 1X in 0.9% saline. This NTC is the same solution added to dry swabs (see Table 3 and Table 4 above for the components).**
2) A positive template control is needed to **assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water.** Stock and working aliquots of the positive control are produced from the sources listed in Table 5 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at \-80°C, or at most 1 month at \-20°C.
#### Table 5: Components for Positive Template Control
| Material | Vendor | Catalog \# | Volume |
| ----- | :---: | :---: | :---: |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µl |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µl |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895 µl |
||
### 10X LAMP Primer Mix Preparation
The FloodLAMP QuickColor(TM) COVID-19 Test uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. Primer names and sequences are shown above in Table 2. All 18 primers are mixed together and input into a single amplification reaction.
Primers may be purchased from the vendor LGC Biosearch Technologies as 3 pre-blended sets, or the primers may be purchased as 18 individual custom oligos. Table 6 below lists the primer products to be ordered.
The LGC Biosearch primer products are provided already blended for each target (6 primers per tube) and dried such that upon resuspension with 1 mL of nuclease water, the primers for each target are at 30X concentration. One resuspended tube for each of the 3 targets (i.e. primer blends) are mixed together to yield a 3 mL total volume that contains all individual primers at 10X concentration. This 3 mL of 10X LAMP Primer Mix provides for 1,200 reactions at 2.5 µL per reaction.
Alternatively to the pre-blended LGC Biosearch products, primers may be purchased as individual custom oligos. Custom oligos may be blended to form 30X Primer Set Mixes as intermediates or all mixed together for the 10X LAMP Primer Mix. The FIP and BIP primers for each target require purification by HPLC or an equivalent process. Appropriate validation of primer mixes from custom oligos is required. Primers may be stored at 4°C for up to one month, or at \-20°C for up to 1 year.
#### Table 6: 10X LAMP Primer Mix Components
| Vendor | Item | Catalog number | Quantity | # Reactions |
|---------|------|----------------|-----------|-------------|
| Order one of the following primer sets |||||
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LB | Custom Order | 250 nmol | 25,000 |
||
### Sample Preparation
\* For wet swab specimens (swabs in saline or unprocessed swab elution):
1) If samples are frozen, thaw unless no ice crystals are present and then keep on ice, cold block or at 4°C.
2) Pulse vortex each sample and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
3) Wipe the outside of the sample tube with 70% ethanol.
For dry swab specimens:
1) Wipe the outside of the sample tube with 70% ethanol.
### Sample Inactivation
1) Place the inactivation heater (a thermal cycler, water bath, dry heat bath or equivalent) in the BSC, turn on, and set the temperature to hold at 100 °C.
2) \* For wet swab specimens: transfer 1 mL or available volume of each sample to an appropriately labeled 1.5 mL or 5mL tube and securely cap.
3) \* For wet swab specimens: add 10μL per 1 mL sample volume of 100X Inactivation Solution to each sample tube.
4) For dry swab specimens (DO NOT DO FOR WET SWAB SPECIMENS): add 1 mL of 1X Inactivation Solution to each sample tube.
5) Vortex for 30 seconds.
6) Place sample tubes into the inactivation heater for 8 minutes.
7) Remove sample tubes from the inactivation heater and let cool at room temperature for 10 minutes.
8) Place sample tubes on ice, in the refrigerator, or on a cold block at 4°C until ready to perform amplification reaction.
Note: Testing of inactivated specimens must be conducted the same day inactivation is performed. For long term storage, keep the original specimen at ≤-70°C.
### Colorimetric LAMP Amplification Reaction Preparation
1) Place a 96-well PCR plate or PCR strip tubes onto a cold block or ice.
2) Thaw frozen reagents until ice crystals are not present.
3) Pulse vortex thawed reagents and briefly spin down in a centrifuge.
4) Store on ice, in the refrigerator, or on a cold block at 4°C until ready to use.
5) Combine components of Primer-Guanidine Solution per volumes listed in Table 7, or proportionally scaled for the number of reactions to be run.
NOTE: Component volumes should be scaled proportionally for the number of reactions.
NOTE: The Primer-Guanidine Solution may be prepared in advance and stored at \-20°C
for up to 1 month.
6) Pulse vortex and briefly spin down in a centrifuge.
7) Prepare the Colorimetric LAMP Amplification Reaction Mix by adding the Colorimetric LAMP MM to the Primer-Guanidine Solution per the volumes listed in Table 8.
8) Vortex the Colorimetric LAMP Amplification Reaction Solution for 10 seconds and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
9) Add 23 µL of the Colorimetric LAMP Amplification Reaction Solution into the wells of the PCR plate or PCR strip tubes.
NOTE: Reaction plates/strip tubes comprising the Colorimetric LAMP Amplification Reaction Solution may be prepared in advance, capped/sealed, and stored at \-20°C for up to 3 days prior to addition of the sample. A heated plate sealer may be used to seal plates. Alternatively, a manually applied foil or optical seal may be used.
#### Table 7: Primer-Guanidine Solution
| Component | Volume (1 reaction) | Volume (1 reaction x 100) 1 x 96-plate w/ 4% overage |
| ----- | :---: | :---: |
| 10X LAMP Primer Mix | 2.5 µL | 250 µL |
| Guanidine HCl (400 mM) | 2.5 µL | - |
| Guanidine HCl (6 M) | - | 16.7 µL |
| Nuclease-free Water | 5.5 µL | 783 µL |
| **TOTAL VOLUME** | **10.5 µL** | **1050 µL** |
||
#### Table 8: Colorimetric LAMP Amplification Reaction
| Component | Volume (1 reaction) | Volume (100 reactions) |
| ----- | :---: | :---: |
| Primer-Guanidine Solution | 10.5 µL | 1050 µL |
| Colorimetric LAMP MM | 12.5 µL | 1250 µL |
| **SUBTOTAL VOLUME** | **23 µL** | **2300 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **25 µL** | - |
||
### Sample Addition and Heating
NOTE: Ensure that positive and negative controls are included in each batch run (i.e. in each PCR plate or group of strip tubes that are heated together).
1) Turn on the amplification heater (a thermal cycler, water bath, dry heat bath or equivalent) and set the temperature to hold at 65°C.
NOTE: Amplification heater should be located in a separate, dedicated BSC or area of the lab. Proper cross contamination prevention practices are required, such as glove changes, to prevent amplicon contamination.
2) Add 2 μL of each sample into a separate tube in the amplification reaction PCR plate or strip tubes.
3) Mix by pipetting.
4) If using PCR plate, seal with foil seal, optical seal (optionally using heat sealer). If using PCR strip tubes, cap strips.
5) Pulse vortex and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
6) Place the plate or strip tubes in the heater and set timer for 25 minutes (do not use heated lid).
7) Remove the plate or strip tubes from the heater after 25 minutes.
8) Let cool for 1 minute and then interpret the test results.
### Test Controls
All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. An example of the expected appearance of the negative and positive controls after amplification is shown in Figure 1.
_Photo showing negative control (pink, left) and positive control (yellow, right) after amplification._
#### Figure 1. Negative control (left) and positive control (right) after amplification.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and optionally RNAseZAP product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
### Patient Specimen Results Interpretation
NOTE: Results can only be interpreted if the positive and negative controls in the plate or group of strip tubes have the expected results.
Test results should be read at least 1 minute and no more than 8 hours after plates or tubes have been removed from heat. Test results may be determined directly from visual inspection of the color of the reaction tubes:
* yellow \- result is positive
* bright pink or red \- result is negative
* any other color \- result is invalid.
Examples are shown below in Figure 2. Edge cases for positive and negative results are shown below in Figure 3. Any color variance stronger than the edge cases should be interpreted as inconclusive. In order to reduce the chance of both false negative and false positive results, this window for color variance is intentionally set to be small.
If the initial test is inconclusive, then one of the following should be performed:
1) repeat the LAMP Amplification Reaction on the inactivated sample. If the repeat test has a positive result then the final interpretation of the test is positive. If the repeat test has a negative or another inconclusive result, then the final interpretation is inconclusive.
2) follow up test the inactivated sample with the FloodLAMP EasyPCR(TM) COVID-19 Test or another high sensitivity EUA authorized test that comprises the same inactivation protocol. The final interpretation is the result of the follow up test.
For serial screening of individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, the initial inconclusive test result may be considered the final interpretation.
If the final interpretation of the test result is inconclusive, then "Inconclusive" should be reported and retesting of the individual is recommended.
_Photo (Figure 2): Example of test results showing two negative (pink) and two positive (yellow) tubes. Photo (Figure 3): Edge case test results showing an edge-case negative (pink) and edge-case positive (yellow) tube._
## Performance Evaluation
### Analytical Sensitivity: Limit of Detection (LoD)
The Limit of Detection (LoD) for the FloodLAMP QuickColor(TM) COVID-19 Test was established using gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The negative specimens were confirmed by PCR using the CDC primers. The gamma-irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 12,500 and 6,250 were selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 9. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 12,500 copies/mL.
#### Table 9: LoD Confirmatory Data Results
| Concentration of Contrived Positive Sample | Replicates Detected |
| :---: | :---: |
| 12,500 copies/mL | 95% (20/21) |
| 6,250 copies/mL | 52% (11/21) |
||
### Analytical Sensitivity: Inclusivity (*in silico*)
An inclusivity study was conducted for the ORF1ab, N2, and E1 primer sets against all complete, high coverage SARS-CoV-2 sequences deposited at GISAID as of February 27, 2021. Table 10 summarizes the results of this *in silico* inclusivity analysis. A total of 498,224 sequences were considered. There are 10 sequence isolates that have 1mm to both As1e and E1 and had N2 excluded due to greater than 15 N's, with the other 498,214 sequence isolates all have at least 1 target region that is a complete match.
Each primer set matched at 100% similarity against the SARS-CoV-2 RefSeq reference genome (Wuhan-Hu-1; NC\_045512.1). All three primer sets differed by one or fewer mutations for 99.7% of GISAID sequences, indicating nominal primer hybridization for all SARS-CoV-2 variants under consideration.
#### Table 10: *In Silico* Inclusivity Analysis for LAMP Primers
| Primer | AS1e (ORF1ab gene) | | N2 (N gene) | | E1 (E gene) | |
| :---- | ----- | ----- | ----- | ----- | ----- | ----- |
| **Total Primer Length** | 195 | | 169 | | 168 | |
| **Total \# of Strains Evaluated** | 498,224 | | 498,224 | | 498,224 | |
| **100% Match** | 474,717 | 95.3% | 479,548 | 96.3% | 462,538 | 92.8% |
| **1 Mismatch** | 19,301 | 3.9% | 15,698 | 3.2% | 30,626 | 6.1% |
| **2 Mismatches** | 338 | 0.1% | 161 | 0.0% | 1,455 | 0.3% |
| **3 Mismatches** | 9 | 0.0% | 5 | 0.0% | 103 | 0.0% |
| **\> 3 Mismatches** | 0 | 0.0% | 0 | 0.0% | 1 | 0.0% |
| **Total Strains Removed** | 3,859 | 0.8% | 2,812 | 0.6% | 3,501 | 0.7% |
||
### Evaluation of Impact of Viral Mutations
The As1e, E1 and N2 primer regions of all SARS-CoV-2 genomes present in GISAID as of 2/26/2021 were evaluated to assess the potential impact of genomic variants on LAMP primer binding. This analysis was performed with the Primer Monitoring Tool from New England Biolabs ([primer-monitor.neb.com](http://primer-monitor.neb.com)), which continually monitors registered primer sets for overlapping variants in sequences from GISAID. Results are summarized by region and locus below in Table 11, including the 30 countries with most sequences in GISAID. Sequences were aligned to the SARS-CoV-2 reference sequence (NC\_045512.2) using minimap2 (minimap2 \-t 16 \-x asm5 \-a). Variant sites (excluding Ns) were identified using samtools mpileup and summarized by region and genome position. Genomic positions having \>= 40 global variant observations are shown (column labels). When present, box labels indicate the fraction of variants observed at a given locus.
The aggregate of current published mutations are not expected to reduce performance of the FloodLAMP QuickColor(TM) COVID-19 Test by more than 5% from that established by the performance evaluation in this EUA submission. Further, the use of 3 primer sets targeting different regions in the SARS-CoV-2 genome should make the test robust to new genetic variants.
#### Table 11: Variant Analysis of LAMP Primers
_Heatmap charts showing variant frequency at LAMP primer binding sites across 30 countries for AS1e, N2, and E1 primer sets, based on GISAID sequences aligned to the SARS-CoV-2 reference genome._
### Analytical Specificity: Cross-Reactivity (*in silico*)
*In silico* cross-reactivity analysis was performed by aligning the primer sequences of the FloodLAMP QuickColor(TM) COVID-19 Test against sequences of other coronaviruses and common respiratory flora using the BLASTn alignment tool from NCBI. Results of this analysis are presented in Tables 12A, 12B, and 12C.
The % identity range (\# identical bases/ \# primer bases) is shown for each primer and organism. Darker font indicates % identity greater than 80%. Organisms with \>= 50% identity primer hits are shown. This analysis is not intended to predict amplification. Near perfect homology across B3, F3, FIP and BIP is necessary to support successful amplification. With the exception of SARS-CoV, simultaneous homologies do not occur between any of the primers and microorganisms screened. With respect to clinical relevance of the *in silico* cross-reactivity analysis, there are no known circulating strains of SARS-CoV circulating in humans, thus the overall probability for the test to produce a cross-reactive signal is negligible.
#### Table 12A: *In Silico* Cross-Reactivity Analysis for AS1e Primers
| Organism Group | Organism Name | Organism ID | As1_B3 (22 bp) | As1e_BIP (49 bp) | As1_F3 (18 bp) | As1e_FIP (51 bp) | As1_LB (27 bp) | As1_LF (28 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 47%-55% | 100% | 43%-53% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| | SARS coronavirus | NC_004718 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 72%-89% | 29% | 52%-67% | |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 77% | | 89% | 37%-51% | 52%-89% | |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 59%-73% | 33%-35% | 89% | 33%-45% | 52% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-73% | 31% | 72%-83% | 29%-59% | 52% | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | 83% | | | |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 59%-82% | 39% | | 29%-41% | 67% | 61% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-82% | | 72% | 39%-87% | 59% | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 59%-82% | 31% | 72% | 31% | 52%-67% | |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | 72%-78% | | 70% | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | 72% | 29%-35% | 78% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.15 | NW_017264789.1 | 59% | | | 78% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.11 | NW_017264785.1 | 77% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 77% | | | 35% | 63% | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59% | 43%-49% | 72% | 29%-57% | 63%-74% | 68% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | 49% | 72% | 31%-41% | 56%-74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | 31%-43% | 74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 73% | | 72% | 29%-39% | 52% | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 59%-68% | 31%-37% | 72% | 29%-35% | 56%-67% | 57%-71% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | 37%-41% | 72% | 29%-41% | 52%-63% | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.14 | NW_017264788.1 | | | | 35% | | 71% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | | | | 29%-47% | 70% | 68% |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59%-68% | 35% | | 29%-43% | | 68% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 68% | 37% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 33%-49% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | 43% | | 38% | | 68% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 64% | | | | | 57% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | | | | 33%-35% | 59% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 59% | | | | | 50% |
| | Bordetella pertussis 18323 | NC_018518.1 | | | | | | 57% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | | 52% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | 39%-47% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.54 | NW_017264828.1 | | 47% | | | | |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | | 31% | | 31%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | | | | 33%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.19 | NW_017264793.1 | | | | 38% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | | | | 35% | | |
| | Respiratory syncytial virus | NC_001803.1 | | | | 33% | | |
||
#### Table 12B: *In Silico* Cross-Reactivity Analysis for N2 Primers
| Organism Group | Organism Name | Organism ID | N2_B3 (25 bp) | N2_BIP (40 bp) | N2_F3 (21 bp) | N2_FIP (42 bp) | N2_LB (20 bp) | N2_LF (21 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 53% | 100% | 48%-55% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 64% | 53% | 90% | 55% | 85% | 90% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 60%-80% | | 95% | | 75% | 62%-71% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | 40% | 75%-90% | |
| | Bordetella pertussis 18323 | NC_018518.1 | | 35% | | | 65%-80% | 81% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | 56%-72% | 43% | | | | 62%-81% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | 56%-76% | | 62%-71% | 45% | | 62%-81% |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 56%-80% | 35%-68% | 62% | | | 62%-81% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 60%-80% | 35%-45% | 71% | | | 62%-71% |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 60%-72% | 35%-45% | 71%-76% | | | 62%-76% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 56%-76% | | 76% | 36% | 65% | |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 60%-76% | 43% | | 36%-55% | | 62%-76% |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | 60% | | | | 65%-75% | 76% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 68%-64% | | | | | 76% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | 35% | | | 75% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 56%-72% | 48% | 62% | 40% | | 67%-71% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 56%-72% | | 71% | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.17 | NW_017264791.1 | 56%-72% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | 60%-72% | | 71% | | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 56%-68% | 35% | | | | 62%-71% |
| | Human parainfluenza virus 1 | NC_003461.1 | | | 71% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 60%-68% | | | | | 62%-71% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 60%-68% | 50% | | 43% | | 62%-67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 68% | | | | | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 60%-68% | | 62% | | | 62% |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 56% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 56%-60% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 64% | 35% | | | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 60%-64% | 43%-50% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 60% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.51 | NW_017264825.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.67 | NW_017264841.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 56% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.21 | NW_017264795.1 | 52% | | | | | |
||
#### Table 12C: *In Silico* Cross-Reactivity Analysis for E1 Primers
| Organism Group | Organism Name | Organism ID | E1_B3 (22 bp) | E1_BIP (44 bp) | E1_F3 (23 bp) | E1_FIP (42 bp) | E1_LB (19 bp) | E1_LF (18 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 45%-57% | 100% | 45%-62% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 95% | 55% | 100% | 43%-62% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | | | | 40%-50% | | 72%-89% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | | | | 84% | 72% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | | | 36%-40% | | 78%-83% |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-82% | | 43% | | | 72% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | | | | 43%-50% | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | | | | | | 78% |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | | 45% | | 43%-48% | | 72%-78% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 77% | | | 36%-43% | | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59%-73% | | | 38%-48% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-73% | | 65% | 43% | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 73% | 41% | | 48% | | 72% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 59% | | | 43%-48% | | 72% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | | 36%-50% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | | 65% | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | 59%-68% | | | | | 72% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | | | 40% | 68% | 72% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 70% | | 40%-50% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | | | 70% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 59%-64% | | | 40% | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59% | | | 40%-43% | | |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 0%-59% | 0% | 0% | 0%-36% | 0% | 0% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | 59% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.20 | NW_017264794.1 | 59% | | | | | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | 34% | 57% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.30 | NW_017264804.1 | | | | 50% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.69 | NW_017264843.1 | | | | 50% | | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | | 43% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | | | | 40% | | |
||
### Analytical Specificity: Cross-Reactivity (*wet testing*)
Wet testing was performed to demonstrate that the FloodLAMP QuickColor(TM) COVID-19 Test does not react with related pathogens, high prevalence disease agents and normal or pathogenic flora that are reasonably likely to be encountered in a clinical specimen. SARS-CoV, RSV, Flu, Human Metapneumovirus. and Streptococcus Salivarius were tested for potential cross-reactivity, as shown in Table 13. Gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) was spiked onto dried AN swab specimens to produce contrived Positve Controls. Negative Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and cross-reactivity organisms were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol.
All wet testing showed no cross-reactivity with the viral pathogens and common respiratory flora, as shown in Table 13.
#### Table 13: Wet Testing Cross-Reactivity Results
| Organism | Description | BEI Number | Detected Replicates |
| ----- | ----- | :---: | :---: |
| SARS-CoV | UV-inactivated virus | NR-3882 | 0/3 |
| Human Metapneumovirus | Genomic RNA | NR-49122 | 0/3 |
| RSV | Genomic RNA | NR-43976 | 0/3 |
| Influenza B | Genomic RNA | NR-45848 | 0/3 |
| Streptococcus salivarius | Bacterial cell culture | HM-121 | 0/3 |
||
### Analytical Specificity: Interfering Substances
Exogenous and endogenous substances were tested for potential interference with the FloodLAMP QuickColor(TM) COVID-19 Test. Gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) was spiked onto dried AN swab specimens to produce contrived Positve Controls. Negative Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 14 and Supporting Data.
#### Table 14: Interfering Substances Results
| Interfering Substance | Active Ingredient | Concentration | % Agreement with Expected Results | |
| :---: | :---: | :---: | :---: | :---: |
| | | | **Positive Control Spiked** | **Negative Control Unspiked** |
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
## Clinical Evaluation
The clinical evaluation of the FloodLAMP QuickColor(TM) COVID-19 Test utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The FloodLAMP QuickColor(TM) COVID-19 Test showed a positive agreement of 90% and a negative agreement of 100%. The 4 false negative results were specimens with high Ct values as previously measured by the comparator test, indicating low viral load. A summary of the clinical performance is below in Table 15.
#### Table 15: Clinical Evaluation Results
| FloodLAMP QuickColor(TM) COVID-19 Test Results | Comparator \- High Sensitivity EUA Authorized Test | | |
| :---: | :---: | :---: | :---: |
| | **Positive** | **Negative** | **Total** |
| Positive | 36 | 0 | 36 |
| Negative | 4 | 40 | 44 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 90.0% (36/40) 95% CI: 76.3% to 97.2% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## Support
FloodLAMP Biotechnologies, PBC support center
eua.support@floodlamp.bio
650-394-5233
# 15,555 2021-03-26_EUA Submission - FloodLAMP FLAMP COVID-19 Test NOT SUBMITTED.md
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last updated: 2026-03-05 by BA
file_name: 2021-03-26_EUA Submission - FloodLAMP FLAMP COVID-19 Test NOT SUBMITTED.md
file_date: 2021-03-26
title: EUA Submission - FloodLAMP FLAMP COVID-19 Test NOT SUBMITTED
category: regulatory
subcategory: fl-fda-submissions
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summary_short: The EUA Submission draft for the FloodLAMP QuickFluor COVID-19 Test (not submitted) describes an extraction-free, fluorimetric RT-LAMP assay using ORF1ab/N/E primer sets and real-time fluorescence readout on validated RT-PCR instruments (e.g., QuantStudio 7 Pro and Bio-Rad CFX96). It specifies the sample inactivation workflow, reaction setup, controls, and result interpretation criteria, along with proposed “open source” component sourcing for CLIA high-complexity labs. It summarizes stated performance claims including a 50,000 copies/mL LoD and clinical agreement results (80% positive agreement, 100% negative agreement) from an 80-specimen evaluation.
CONTENT
***INTERNAL TITLE:*** EUA Submission - FloodLAMP QuickFluor(TM) COVID-19 Test
## A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the **FloodLAMP QuickFluor(TM) COVID-19 Test** for the *in vitro* qualitative detection of RNA from the SARS-CoV-2 in upper respiratory specimens including oropharyngeal and nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests *.*** Additional testing and confirmation procedures should be performed in consultation with public health and/or other authorities to whom reporting is required. Test results should be reported in accordance with local, state, and federal regulations.
## B. MEASURAND
Specific nucleic acid sequences from the genome of the SARS-CoV-2, targeted by **primers from the ORF1ab, N & E regions** of the virus. Primer names and sequences are listed in Table 1.
#### Table 1: Primer names and sequences
| Primer Name | Sequence (5’-3’) |
| :---- | :---- |
| **ORF1ab gene (AS1e)** | |
| Orf1ab\_FIP | TCAGCACACAAAGCCAAAAATTTATTTTTCTGTGCAAAGGAAATTAAGGAG |
| Orf1ab\_BIP | TATTGGTGGAGCTAAACTTAAAGCCTTTTCTGTACAATCCCTTTGAGTG |
| Orf1ab\_F3 | CGGTGGACAAATTGTCAC |
| Orf1ab\_B3 | CTTCTCTGGATTTAACACACTT |
| Orf1ab\_LF | TTACAAGCTTAAAGAATGTCTGAACACT |
| Orf1ab\_LB | TTGAATTTAGGTGAAACATTTGTCACG |
| **N Gene (N2)** | |
| N2\_FIP | TTCCGAAGAACGCTGAAGCGGAACTGATTACAAACATTGGCC |
| N2\_BIP | CGCATTGGCATGGAAGTCACAATTTGATGGCACCTGTGTA |
| N2\_F3 | ACCAGGAACTAATCAGACAAG |
| N2\_B3 | GACTTGATCTTTGAAATTTGGATCT |
| N2\_LF | GGGGGCAAATTGTGCAATTTG |
| N2\_LB | CTTCGGGAACGTGGTTGACC |
| **E Gene (E1)** | |
| E1\_FIP | ACCACGAAAGCAAGAAAAAGAAGTTCGTTTCGGAAGAGACAG |
| E1\_BIP | TTGCTAGTTACACTAGCCATCCTTAGGTTTTACAAGACTCACGT |
| E1\_F3 | TGAGTACGAACTTATGTACTCAT |
| E1\_B3 | TTCAGATTTTTAACACGAGAGT |
| E1\_LF | CGCTATTAACTATTAACG |
| E1\_LB | GCGCTTCGATTGTGTGCGT |
||
## C. APPLICANT
FloodLAMP Biotechnologies, a DE Public Benefit Corporation
Mailing Address:
4860 Alpine Rd.
Portola Valley, CA 94028
Laboratory Address:
FloodLAMP at MBC Biolabs
930 Brittan Ave San Carlos, CA 94070
San Carlos, CA 94070
Randall J. True
Founder and CEO
Phone: (415) 269-2974
Email: randy@floodlamp.bio
## D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name \- **FloodLAMP QuickFluor(TM) COVID-19 Test**
Established Name \- **FloodLAMP QuickFluor(TM) COVID-19 Test**
## E. REGULATORY INFORMATION
***Approval/Clearance Status:***
The **FloodLAMP QuickFluor(TM) COVID-19 Test** is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
***Product Code:***
QJR
## F. PROPOSED INTENDED USE
### 1) Intended Use:
**FloodLAMP QuickFluor(TM) COVID-19 Test** is a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests.** Testing is limited to **laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.**
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis
for patient management decisions. Negative results must be combined with clinical observations,
patient history, and epidemiological information.
The **FloodLAMP QuickFluor(TM) COVID-19 Test** is intended for use by **qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures**. The **FloodLAMP QuickFluor(TM) COVID-19 Test** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
### 2) Special Conditions for Use Statements:
For Emergency Use Authorization (EUA) only
For prescription use only
For *in vitro* diagnostic use only
### 3) Special Instrument Requirements:
The **FloodLAMP QuickFluor(TM) PCR COVID-19 Test** test is to be used with the RT-PCR instruments listed in Table 2.
#### Table 2. RT-PCR Instruments validated for test
| Manufacturer | Instrument |
| :---: | :---: |
| ThermoFisher Scientific | Applied Biosystems QuantStudio 7 Pro |
| Bio-Rad | CFX96 Touch Real-Time PCR Detection System |
||
Designated laboratories will receive an FDA accepted instrument qualification protocol included as part of the **FloodLAMP QuickFluor(TM) Covid-19 Test** IFU and will be directed to execute the protocol prior to testing clinical samples. Designated laboratories must follow the authorized IFU, which includes the instrument qualification protocol, as per the letter of authorization.
## G. DEVICE DESCRIPTION AND TEST PRINCIPLE
### 1) Product Overview/Test Principle:
The **FloodLAMP QuickFluor(TM) COVID-19 Test** is an RNA-extraction free isothermal RT-LAMP assay which indicates that SARS-CoV-2 RNA is present. FloodLAMP’s test uses a set of specific primers that target ORF1ab, N and E genes for the detection of SARS-CoV-2 RNA. Loop Mediated Isothermal Amplification (LAMP) is a nucleic acid amplification technique wherein DNA amplification is carried out at a constant temperature of approximately 65°C. The amplification reaction mix includes a reverse transcriptase (RT) polymerase to create complementary cDNA from RNA. The cDNA is subsequently amplified by a high strand displacement DNA polymerase. An intercalating fluorescent dye is also included in the reaction mix, enabling the real time fluorescence detection of amplicons. A RT-PCR Instrument is utilized for the isothermal amplification incubation and real time fluorescence readout.
### 2) Description of Test Steps:
Specimens including **nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs** are collected in **sterile collection tubes.** Swabs are transported and stored dry prior to processing. At the laboratory, an inactivation solution at 1X containing TCEP (2.5 mM), EDTA (1 mM), and NaOH (11 mM) in 0.9% saline (154 mM) is added to the container with the swab, at the volume of 1ml. Alternatively, for swabs that are collected or eluted in a saline solution or equivalent, the inactivation solution at 100X concentration should be added at 1/100th the sample solution volume.
The container with the specimen and inactivation solution is mixed by vortexing for 30 seconds. Subsequently, the container is heated in a 95°C water bath or dry heat block for 8 minutes. The now inactivated specimen container is allowed to cool at room temperature for 10 minutes and then stored on ice or at 4°C until amplification.
An amplification reaction mix (23 µL) is prepared per manufacturer's specifications, containing the Fluorimetric LAMP master mix (New EB E1700, 12.5 µL), Fluorescent Dye (NEB E1700, .5 µL) a 10X LAMP Primer Mix (2.5 µL of 10X w FIP/BIP at 16 µM, F3/B3 at 2 µM, and LF/BF at 4 µM), and nuclease-free water (7.5 µL).
2µL of the inactivated sample is added to 23µL of the amplification reaction mix. The reaction is then run with the following thermocycler conditions in Table 3:
#### Table 3. Thermal cycling conditions and plate read steps
| Stage | Temperature | Time | Reps |
| :---: | :---: | :---: | :---: |
| 1 | 65 C | 10 sec | 1 |
| 2 | 65 C | 10 sec | 1 |
| 3 | 65 C | 30 sec | 25 |
| 3 | 65\* C | 30 sec | 25 |
||
*\* This step should be the optical read step*
### 3) Control Materials to be Used with FloodLAMP QuickFluor(TM) COVID-19 Test:
**One Positive Template Control and one Negative (No Template) Control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes.
1) A **“No Template” (Negative) Control (NTC) is needed to assure the absence of cross-contamination from positive samples, positive controls, or amplicons** and is used **to determine if sample results are valid.** **It consists of nuclease-free water.**
2) A **Positive Template Control is needed to assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water.** Stock and working aliquots of the positive control are produced from the sources listed in Table 4 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at \-80°C, or at most 1 month at \-20°C.
#### Table 4. Components for Positive Template Control
| Material | Supplier | Catalog \# | Volume |
| ----- | :---: | :---: | :---: |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µL |
| Total Human RNA | Thermo | 4307281 | 100 µL |
| Nuclease-free Water | Thermo | 10977015 | 4,895 µL |
||
## H. INTERPRETATION OF Results
### 1) FloodLAMP QuickFluor(TM) COVID-19 Test Controls
All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. Target results for the controls will be interpreted according to Table 5 below.
1) The “No Template” (Negative) Control (NTC) should yield a negative “not detected” result for the Sars target.
2) The Positive Template Control should yield a positive “detected” result for the Sars target.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and (optionally) RNAseZAP(TM) product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
### 2) Examination and Interpretation of Patient Specimen Results:
Assessment of clinical specimen test results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted. Patient specimen results will be interpreted according to Table 5 below.
#### Table 5: Test Results and Interpretation
| ABI QuantStudio(TM) 7 Pro Bio-Rad CFX96 Touch(TM) | |
| :---: | :---: |
| **Result** | **Ct Value: ORF1ab, N2 & E1** |
| Positive | ≤25.0 |
| Negative | Undetermined |
||
## I. PRODUCT MANUFACTURING
### 1) Overview of Manufacturing and Distribution:
The **FloodLAMP QuickFluor(TM) COVID-19 Test** utilizes standard chemicals available in very large quantities from multiple vendors, with the exception of the LAMP Primers and New England Biolabs Fluorimetric LAMP Master Mix.
FloodLAMP has partnered with LGC Biosearch for the LAMP Primers. LGC Biosearch has very large scale oligo production capacity and mature distribution capabilities. The first production scale lot of the LAMP Primers has been completed, with 1.2 million reactions ready for immediate distribution. FloodLAMP has purchased 600K reactions of the LAMP Primers. LGC Biosearch is supplying FloodLAMP for the **FloodLAMP QuickFluor(TM) COVID-19 Test** and is also offering the LAMP Primers as a catalog product.
New England Biolabs has expressed strong support for the **FloodLAMP QuickFluor(TM) COVID-19 Test** and FloodLAMP's other open source protocol EUA submissions that incorporate their products. New England Biolabs has very large quantities of the Fluorimetric LAMP Master Mix product prepared and ready for immediate distribution, typically with 24 hour shipping within the U.S. Their manufacturing capacity is among the largest in the United States and can surge to meet increased demand.
**\*Under the Emergency Use Authorization (EUA) any of the 21 CFR Part 820 Quality System Regulation (QSR) requirements can be waived for the duration of the EUA but FDA recommends that developers follow comparable practices as much as possible if such requirements are waived. Among other things, FDA may consider previous compliance history when determining whether or not to waive certain QSR requirements for a specific product. Please note adverse events, as per 21 CFR Part 803, have to be reported for authorized devices (see Section P).**
### 2) Components Included with the Test:
None. Designated CLIA labs may order components directly from vendors.
### 3) Components Required But Not Included with Test:
The **FloodLAMP QuickFluor(TM) COVID-19 Test** is to be used with the reagents or equivalents listed in Table 6.
#### Table 6: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog No. |
| :---- | ----- | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease- free Water | - | Ultrapure Water, nuclease free | Thermo | 10977015 |
| NaCl | 5M | Sodium Chloride | Thermo | 24740011 |
| Fluorimetric LAMP Kit\* | - | Fluorimetric LAMP Kit | New England Biolabs | E1700 |
||
\* Item may not be substituted for equivalents. Only the specified vendor and catalog number may be utilized.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
A 100X Inactivation Solution is prepared by mixing the components in Table 7. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved. Aliquots of 100X Inactivation Solution should be stored in the dark at \-20°C for up to 3 months. Upon thaw, working aliquots of 100X Inactivation Solution should be stored in the dark at room temperature for up to 1 month.
#### Table 7: 100X Inactivation Solution
| Component | Source Concentration | Volume for 100X | 100X Concentration |
| :---- | :---: | :---: | :---: |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
For swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 5. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 8: 1X Inactivation Saline Solution
| Component | Volume |
| :---- | :---: |
| 0.9% Saline (154 mM NaCl) in MilliQ Water | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
The **FloodLAMP QuickFluor(TM) COVID-19 Test** uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. Primer names and sequences are shown above in Table 1. All 18 primers are mixed together and input into a single amplification reaction.
Primers may be purchased from the vendor LGC Biosearch Technologies as 3 pre-blended sets, or the primers may be purchased as 18 individual custom oligos. Table 6 below lists the primer products to be ordered.
The LGC Biosearch primer products are provided already blended for each target (6 primers per tube) and dried such that upon resuspension with 1 mL of nuclease-free water, the primers for each target are at 30X concentration. One resuspended tube for each of the 3 targets (i.e. primer blends) are mixed together to yield a 3 mL total volume that contains all individual primers at 10X concentration. This 3 mL of 10X LAMP Primer Mix provides for 1,200 reactions at 2.5 µL per reaction.
Alternatively to the pre-blended LGC Biosearch products, primers may be purchased as individual custom oligos. Custom oligos may be blended to form 30X Primer Set Mixes as intermediates or all mixed together for the 10X LAMP Primer Mix. The FIP and BIP primers for each target require purification by HPLC or an equivalent process. Appropriate validation of primer mixes from custom oligos is required. Primers may be stored at 4°C for up to one month, or at \-20°C for up to 1 year.
#### Table 9: 10X LAMP Primer Mix Components
| Vendor | Item | Catalog number | Quantity | # Reactions |
|---------|------|----------------|-----------|-------------|
| Order one of the following primer sets |||||
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orflab_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LB | Custom Order | 250 nmol | 25,000 |
||
The final Fluorimetric LAMP Amplification Reaction components are listed in Table 9. PCR plates or strip tubes used for the amplification reactions should be maintained on ice or a cold block until less than 5 minutes before incubation on the heater. Reaction plates/strip tubes comprising the Fluorimetric LAMP Amplification Reaction Solution may be prepared in advance, capped/sealed, and stored at \-20°C for up to 1 day prior to addition of the sample. A heated plate sealer is recommended. Alternatively, a manually applied foil or optical seal may be used.
#### Table 10: Fluorimetric LAMP Amplification Reaction
| Component | Volume (1 reaction) | Volume (100 reactions) |
| :---- | :---: | :---: |
| 10X LAMP Primer Mix | 2.5 µL | 250 µL |
| Nuclease Free Water | 7.5 µL | 750 µL |
| Fluorimetric LAMP MM | 12.5 µL | 1250 µL |
| Fluorescent Dye | .5 µL | 50 µL |
| **SUBTOTAL VOLUME** | **23 µL** | **2300 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **25 µL** | - |
||
### 4) Software Validation:
The **FloodLAMP QuickFluor(TM) COVID-19 Test** has been validated on the RT-PCR instruments listed in Table 2 using the baseline threshold settings unless otherwise noted in the Instructions for Use. The test does not require any additional software.
### 5) Testing Capabilities:
The **FloodLAMP QuickFluor(TM) COVID-19 Test** has been optimized for a streamlined workflow and rapid turnaround time on results. The total time to perform the test is dependent upon the following factors: number of lab technicians, batch size of samples, and in advance preparation of reaction mixes as well as availability of RT-qPCR instruments. The minimum turnaround time is approximately 1 hour, of which approximately 30 minutes is the RT-PCR instrument run time. Automation can greatly increase overall throughput.
### 6) Reagent Stability:
A stability test plan for the components of the **FloodLAMP QuickFluor(TM) COVID-19 Test** will be developed during an interactive review. Briefly, the proposed study includes assessing all prepared solutions including: 100X Inactivation Solution, 1X Inactivation Saline Solution, 30X Primer Stock, 10X Primer Mix, and the full Fluorimetric LAMP Amplification Reaction Mix. Prepared solutions will be assessed both for long term storage stability (typically 1-3 months at \-20oC) and short term storage stability prior to usage (typically hours to several days at room temperature, 4oC or \-20oC).
The proposed study uses a contrived positive sample consisting of inactivated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative specimens at approximately 50,000 copies/mL (4X LoD). The contrived positive stability study samples will be prepared, aliquoted and stored at \-80oC to permit repeated testing of the various solutions at the appropriate step of the test protocol.
For test components supplied by vendors, such as the Fluorimetric LAMP Kit, the manufacturer's recommended storage conditions and duration will be followed.
### 7) Sample Stability:
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19: [www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html](https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html)
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
Samples can be stored at room temperature for 56 hours after collection prior to inactivation. For longer term storage, samples can be stored at ≤-70oC.
## J. PERFORMANCE EVALUATION
### 1) Limit of Detection (LoD) \- Analytical Sensitivity:
The Limit of Detection (LoD) for the **FloodLAMP QuickFluor(TM) COVID-19 Test** was established using gamma irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The negative specimens were confirmed by PCR using the CDC primers. The gamma irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LOD study. A preliminary LOD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 50,000, 25,000 and 12,500 copies/mL were selected for confirmatory LOD runs. LOD run details are provided in Supporting Data, with the results summarized below in Table 10. The LOD, defined as the concentration at which at least 95% of the samples are positive, was determined at 50,000 copies/mL.
#### Table 11: Confirmatory LOD Data Results
| Instrument | LOD | Positive Replicates | Mean Ct Value (SD) |
| ----- | :---: | :---: | :---: |
| ABI QuantStudio 7 Pro | 50,000 copies/mL | 95% (20/21) | 11.9 (1.5) |
| Bio-Rad CFX96 | - | - | - |
||
### 2) Inclusivity (analytical sensitivity):
An inclusivity study was conducted for the ORF1ab, N2, and E1 primer sets against all complete, high coverage SARS-CoV-2 sequences deposited at GISAID as of February 27, 2021. Table 11 summarizes the results of this in silico inclusivity analysis. A total of 498,224 sequences were considered. There are 10 sequence isolates that have 1mm to both As1e and E1 and had N2 excluded due to greater than 15 N's, with the other 498,214 sequence isolates all have at least 1 target region that is a complete match.
Each primer set matched at 100% similarity against the SARS-CoV-2 RefSeq reference genome (Wuhan-Hu-1; NC\_045512.1). All three primer sets differed by one or fewer mutations for 99.7% of GISAID sequences, indicating nominal primer hybridization for all SARS-CoV-2 variants under consideration.
#### Table 12: *In Silico* Inclusivity Analysis for LAMP Primers
| Primer | AS1e (ORF1ab gene) | | N2 (N gene) | | E1 (E gene) | |
| :---- | ----- | ----- | ----- | ----- | ----- | ----- |
| **Total Primer Length** | 195 | | 169 | | 168 | |
| **Total Number of Strains Evaluated** | 498,224 | | 498,224 | | 498,224 | |
| **100% Match** | 474,717 | 95.3% | 479,548 | 96.3% | 462,538 | 92.8% |
| **1 Mismatch** | 19,301 | 3.9% | 15,698 | 3.2% | 30,626 | 6.1% |
| **2 Mismatches** | 338 | 0.1% | 161 | 0.0% | 1,455 | 0.3% |
| **3 Mismatches** | 9 | 0.0% | 5 | 0.0% | 103 | 0.0% |
| **\> 3 Mismatches** | 0 | 0.0% | 0 | 0.0% | 1 | 0.0% |
| **Total Strains Removed** | 3,859 | 0.8% | 2,812 | 0.6% | 3,501 | 0.7% |
||
#### Evaluation of Impact of Viral Mutations
The As1e, E1 and N2 primer regions of all SARS-CoV-2 genomes present in GISAID as of 2/26/2021 were evaluated to assess the potential impact of genomic variants on LAMP primer binding. This analysis was performed with the Primer Monitoring Tool from New England Biolabs ([primer-monitor.neb.com](https://primer-monitor.neb.com/)), which continually monitors registered primer sets for overlapping variants in sequences from GISAID. Results are summarized by region and locus below in Table 12, including the 30 countries with most sequences in GISAID. Sequences were aligned to the SARS-CoV-2 reference sequence (NC\_045512.2) using minimap2 (minimap2 \-t 16 \-x asm5 \-a). Variant sites (excluding Ns) were identified using samtools mpileup and summarized by region and genome position. Genomic positions having \>= 40 global variant observations are shown (column labels). When present, box labels indicate the fraction of variants observed at a given locus.
The aggregate of current published mutations are not expected to reduce performance of the **FloodLAMP QuickFluor(TM) COVID-19 Test** by more than 5% from that established by the performance evaluation in this EUA submission. Further, the use of 3 primer sets targeting different regions in the SARS-CoV-2 genome should make the test robust to new genetic variants.
#### Table 13: Variant Analysis of LAMP Primers
_Heatmap charts showing variant frequency at LAMP primer binding sites across 30 countries for AS1e, N2, and E1 primer sets, based on GISAID sequences aligned to the SARS-CoV-2 reference genome._
### 3) Cross-reactivity (Analytical Specificity):
*In silico* cross-reactivity analysis was performed by aligning the primer sequences of the **FloodLAMP QuickFluor(TM) COVID-19 Test** against sequences of other coronaviruses and common respiratory flora using the BLASTn alignment tool from NCBI. Results of this analysis are presented in Tables 14A, 14B, and 14C.
The % identity range (\# identical bases/ \# primer bases) is shown for each primer and organism. Darker font indicates % identity greater than 80%. Organisms with \>= 50% identity primer hits are shown. This analysis is not intended to predict amplification. Near perfect homology across B3, F3, FIP and BIP is necessary to support successful amplification. With the exception of SARS-CoV, simultaneous homologies do not occur between any of the primers and microorganisms screened. With respect to clinical relevance of the in silico cross-reactivity analysis, there are no known circulating strains of SARS-CoV circulating in humans, thus the overall probability for the test to produce a cross-reactive signal is negligible.
#### Table 14A: *In Silico* Cross-Reactivity Analysis for AS1e Primers
| Organism Group | Organism Name | Organism ID | As1_B3 (22 bp) | As1e_BIP (49 bp) | As1_F3 (18 bp) | As1e_FIP (51 bp) | As1_LB (27 bp) | As1_LF (28 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 47%-55% | 100% | 43%-53% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| | SARS coronavirus | NC_004718 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 72%-89% | 29% | 52%-67% | |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 77% | | 89% | 37%-51% | 52%-89% | |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 59%-73% | 33%-35% | 89% | 33%-45% | 52% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-73% | 31% | 72%-83% | 29%-59% | 52% | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | 83% | | | |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 59%-82% | 39% | | 29%-41% | 67% | 61% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-82% | | 72% | 39%-87% | 59% | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 59%-82% | 31% | 72% | 31% | 52%-67% | |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | 72%-78% | | 70% | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | 72% | 29%-35% | 78% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.15 | NW_017264789.1 | 59% | | | 78% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.11 | NW_017264785.1 | 77% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 77% | | | 35% | 63% | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59% | 43%-49% | 72% | 29%-57% | 63%-74% | 68% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | 49% | 72% | 31%-41% | 56%-74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | 31%-43% | 74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 73% | | 72% | 29%-39% | 52% | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 59%-68% | 31%-37% | 72% | 29%-35% | 56%-67% | 57%-71% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | 37%-41% | 72% | 29%-41% | 52%-63% | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.14 | NW_017264788.1 | | | | 35% | | 71% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | | | | 29%-47% | 70% | 68% |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59%-68% | 35% | | 29%-43% | | 68% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 68% | 37% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 33%-49% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | 43% | | 38% | | 68% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 64% | | | | | 57% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | | | | 33%-35% | 59% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 59% | | | | | 50% |
| | Bordetella pertussis 18323 | NC_018518.1 | | | | | | 57% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | | 52% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | 39%-47% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.54 | NW_017264828.1 | | 47% | | | | |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | | 31% | | 31%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | | | | 33%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.19 | NW_017264793.1 | | | | 38% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | | | | 35% | | |
| | Respiratory syncytial virus | NC_001803.1 | | | | 33% | | |
||
#### Table 14B: *In Silico* Cross-Reactivity Analysis for N2 Primers
| Organism Group | Organism Name | Organism ID | N2_B3 (25 bp) | N2_BIP (40 bp) | N2_F3 (21 bp) | N2_FIP (42 bp) | N2_LB (20 bp) | N2_LF (21 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 53% | 100% | 48%-55% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 64% | 53% | 90% | 55% | 85% | 90% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 60%-80% | | 95% | | 75% | 62%-71% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | 40% | 75%-90% | |
| | Bordetella pertussis 18323 | NC_018518.1 | | 35% | | | 65%-80% | 81% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | 56%-72% | 43% | | | | 62%-81% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | 56%-76% | | 62%-71% | 45% | | 62%-81% |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 56%-80% | 35%-68% | 62% | | | 62%-81% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 60%-80% | 35%-45% | 71% | | | 62%-71% |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 60%-72% | 35%-45% | 71%-76% | | | 62%-76% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 56%-76% | | 76% | 36% | 65% | |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 60%-76% | 43% | | 36%-55% | | 62%-76% |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | 60% | | | | 65%-75% | 76% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 68%-64% | | | | | 76% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | 35% | | | 75% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 56%-72% | 48% | 62% | 40% | | 67%-71% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 56%-72% | | 71% | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.17 | NW_017264791.1 | 56%-72% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | 60%-72% | | 71% | | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 56%-68% | 35% | | | | 62%-71% |
| | Human parainfluenza virus 1 | NC_003461.1 | | | 71% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 60%-68% | | | | | 62%-71% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 60%-68% | 50% | | 43% | | 62%-67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 68% | | | | | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 60%-68% | | 62% | | | 62% |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 56% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 56%-60% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 64% | 35% | | | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 60%-64% | 43%-50% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 60% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.51 | NW_017264825.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.67 | NW_017264841.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 56% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.21 | NW_017264795.1 | 52% | | | | | |
||
#### Table 14C: *In Silico* Cross-Reactivity Analysis for E1 Primers
| Organism Group | Organism Name | Organism ID | E1_B3 (22 bp) | E1_BIP (44 bp) | E1_F3 (23 bp) | E1_FIP (42 bp) | E1_LB (19 bp) | E1_LF (18 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 45%-57% | 100% | 45%-62% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 95% | 55% | 100% | 43%-62% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | | | | 40%-50% | | 72%-89% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | | | | 84% | 72% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | | | 36%-40% | | 78%-83% |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-82% | | 43% | | | 72% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | | | | 43%-50% | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | | | | | | 78% |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | | 45% | | 43%-48% | | 72%-78% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 77% | | | 36%-43% | | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59%-73% | | | 38%-48% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-73% | | 65% | 43% | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 73% | 41% | | 48% | | 72% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 59% | | | 43%-48% | | 72% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | | 36%-50% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | | 65% | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | 59%-68% | | | | | 72% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | | | 40% | 68% | 72% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 70% | | 40%-50% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | | | 70% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 59%-64% | | | 40% | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59% | | | 40%-43% | | |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 0%-59% | 0% | 0% | 0%-36% | 0% | 0% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | 59% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.20 | NW_017264794.1 | 59% | | | | | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | 34% | 57% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.30 | NW_017264804.1 | | | | 50% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.69 | NW_017264843.1 | | | | 50% | | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | | 43% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | | | | 40% | | |
||
Wet testing was performed to demonstrate that the **FloodLAMP QuickFluor(TM) COVID-19 Test** does not react with related pathogens, high prevalence disease agents and normal or pathogenic flora that are reasonably likely to be encountered in a clinical specimen. SARS-CoV, RSV, Flu, Human Metapneumovirus, and Streptococcus Salivarius were tested for potential cross-reactivity, as shown in Table 15 and Supporting Data. 5 µL of each stock of cross-reactivity organism was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma irradiated SARS-CoV-2 virus and cross-reactivity organisms were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived positive had 38 µL of 1e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 38,000 copies/mL in the sample input into the amplification reaction.
All wet testing showed no cross-reactivity with the viral pathogens and common respiratory flora, as shown in Table 15.
#### Table 15: Wet Testing Cross-Reactivity Results
| Organism | Description | BEI Number | Detected Replicates |
| ----- | ----- | :---: | :---: |
| SARS-CoV | UV-inactivated virus | NR-3882 | 0/3 |
| Human Metapneumovirus | Genomic RNA | NR-49122 | 0/3 |
| RSV | Genomic RNA | NR-43976 | 0/3 |
| Influenza B | Genomic RNA | NR-45848 | 0/3 |
| Streptococcus salivarius | Bacterial cell culture | HM-121 | 0/3 |
||
#### Endogenous Interference Substances Studies:
Exogenous and endogenous substances were tested for potential interference with the **FloodLAMP QuickFluor(TM) COVID-19 Test*.***10 µL of each stock of interfering substance was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived Positive Control Spiked comprised 20 µL of 8e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 160,000 copies/mL in the sample input into the amplification reaction.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 16 and Supporting Data.
#### Table 16: Interfering Substances Results
| Interfering Substance | Active Ingredient | Concentration | % Agreement with Expected Results | |
| :---: | :---: | :---: | :---: | :---: |
| | | | **Positive Control Spiked** | **Negative Control Unspiked** |
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
### 4) Clinical Evaluation:
The clinical evaluation of the **FloodLAMP QuickFluor(TM) COVID-19 Test** utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The **FloodLAMP QuickFluor(TM) COVID-19 Test** showed a positive agreement of 80% and a negative agreement of 100%. The 6 false negative results were specimens with high Ct values as previously measured by the comparator test, indicating low viral load. A summary of the clinical performance is below in Table 16.
Anterior nares swab specimens were collected from patients in phosphate buffered saline by the Stanford COVID-19 clinical testing program. Specimens were initially tested by the Stanford clinical laboratory using the Hologic Panther Fusion and Aptima SARS-CoV-2 Assays, which serves as the high sensitivity comparator test.
For the **FloodLAMP QuickFluor(TM) COVID-19 Test**, materials and the Instructions For Use were provided to the Stanford clinical laboratory. The materials provided consisted of the validated reagents listed in Table 3, the LGC primers and probes, and an aliquot of the positive control. After thawing the frozen specimens, 1 mL of each specimen was transferred to 5mL tubes for the inactivation step. The positive and negative clinical specimens were assigned a new ID in a random order, then transferred to new tubes that were barcoded and labeled with the new ID. The Bio-Rad CFX96 instrument was used to perform the isothermal amplification. Line Item data are provided in the Supporting Data.
#### Table 16: Clinical Evaluation Results
| FloodLAMP QuickFluorr(TM) COVID-19 Test Results | Comparator \- High Sensitivity EUA Authorized Test | | |
| :---: | :---: | :---: | :---: |
| | **Positive** | **Negative** | **Total** |
| Positive | 34 | 0 | 34 |
| Negative | 6 | 40 | 46 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 80.0% (34/40) 95% CI: 70.2% to 94.3% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## K. UNMET NEED ADDRESSED BY THE PRODUCT
This section will be completed by FDA.
## L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the detection of the SARS-CoV-2 have been approved/cleared by FDA.
## M. BENEFITS AND RISKS:
This section will be completed by FDA.
## N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
Fact Sheets for Patients and Healthcare Providers attached.
## O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
Instructions for Use attached.
## P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
QuantStudio is a trademark of Thermo Fisher Scientific (NYSE: TMO)
Bio-Rad and Bio-Rad CFX96 Touch is a trademark of Bio-Rad Laboratories, Inc. (NYSE: BIO)
# 20,466 2021-03-26_Instructions for Use - FloodLAMP FLAMP COVID-19 Test NOT SUBMITTED.md
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file_name: 2021-03-26_Instructions for Use - FloodLAMP FLAMP COVID-19 Test NOT SUBMITTED.md
file_date: 2021-03-26
title: Instructions for Use - FloodLAMP FLAMP COVID-19 Test NOT SUBMITTED
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summary_short: The draft Instructions for Use for the FloodLAMP QuickFluor COVID-19 Test describe an extraction-free, fluorimetric RT-LAMP assay with real-time fluorescence detection on RT-PCR instruments following chemical and heat inactivation. It provides detailed procedures for reagent and primer preparation, instrument setup, workflow execution, controls, and Ct-based result interpretation for CLIA high-complexity laboratories. It also documents proposed analytical and clinical performance, including a 50,000 copies/mL LoD and 80–85% positive agreement with 100% negative agreement in an 80-specimen clinical evaluation, for a test that was not submitted for EUA.
CONTENT
***INTERNAL TITLE:*** FloodLAMP QuickFluor(TM) COVID-19 Test
Instructions for Use v1.0 \*\*DRAFT\*\*
IVD
COVID-19 Emergency Use Authorization Only
For *in vitro* diagnostic (IVD) Use
www.floodlamp.bio
FloodLAMP Biotechnologies, PBC | 930 Brittan Ave. San Carlos, CA 94070 USA
## Table of Contents
| | |
|---------|------|
| Intended Use | 3 |
| Principles of Procedure | 3 |
| Materials Provided and Storage | 4 |
| Materials Required but Not Provided | 4 |
| • Standard Lab Equipment and Consumables | 5 |
| Warnings and Precautions | 6 |
| • General Precautions | 6 |
| • Contamination Precautions | 7 |
| Limitations | 7 |
| Conditions of Authorization for the Laboratory | 8 |
| Specimen Collection and Storage | 9 |
| Running Tests | 10 |
| • Reagent Preparation | 10 |
| • Controls Preparation | 11 |
| • 10X LAMP Primer Mix Preparation | 12 |
| • Sample Preparation | 13 |
| • Sample Inactivation | 14 |
| • Preparing to Run Assay for the First Time | 14 |
| • Create the Plate Layout Map | 16 |
| • Fluorimetric LAMP Amplification Reaction Preparation | 18 |
| • Sample Addition | 19 |
| • Run the Assay | 19 |
| • Analyzing Data | 21 |
| • Results Interpretation | 22 |
| • Patient Specimen Results Interpretation | 22 |
| Performance Evaluation | 23 |
| • Analytical Sensitivity: Limit of Detection (LoD) | 23 |
| • Analytical Sensitivity: Inclusivity (*in silico*) | 23 |
| • Evaluation of Impact of Viral Mutations | 24 |
| • Analytical Specificity: Cross-Reactivity (*in silico*) | 26 |
| • Analytical Specificity: Cross-Reactivity (wet testing) | 30 |
| • Analytical Specificity: Interfering Substances | 31 |
| Clinical Evaluation | 32 |
| Support | 32 |
||
FloodLAMP QuickFluor(TM) COVID-19 Test
For COVID-19 Emergency Use Authorization Only
Instructions for Use
## Intended Use
FloodLAMP QuickFluor(TM) COVID-19 Test is a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The FloodLAMP QuickFluor(TM) COVID-19 Test is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures. The FloodLAMP QuickFluor(TM) COVID-19 Test is only for use under the Food and Drug Administration’s Emergency Use Authorization.
## Principles of Procedure
The FloodLAMP QuickFluor(TM) COVID-19 Test uses a set of specific primers that target ORF1ab, N and E genes for the detection of SARS-CoV-2 RNA. It uses Loop Mediated Isothermal Amplification (LAMP), a nucleic acid amplification technique wherein DNA amplification is carried out at a constant temperature of approximately 65°C. Samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step. The resulting inactivated sample is directly used as input in the LAMP reaction. The amplification reaction mix includes a reverse transcriptase (RT) polymerase to create complementary cDNA from RNA. The cDNA is subsequently amplified by a high strand displacement DNA polymerase. An intercalating fluorescent dye is also included in the reaction mix, enabling the real-time fluorescence detection of amplicons. An RT-PCR Instrument is utilized for the isothermal amplification incubation and real-time fluorescence readout.
## Materials Provided and Storage
The FloodLAMP QuickFluor(TM) COVID-19 Test utilizes standard chemicals available from multiple vendors, with the exception of the LAMP primers and Fluorimetric LAMP master mix. Designated CLIA labs may order components directly from vendors.
## Materials Required but Not Provided
The FloodLAMP QuickFluor(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1. The FloodLAMP QuickFluor(TM) COVID-19 Test is to be used with RT-PCR Instruments such as Applied Biosystems QuantStudio(TM) Systems and Bio-Rad CFX(TM) Systems.
#### Table 1: Validated reagents used with the Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | ----- | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease- free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5M | Sodium Chloride | Thermo Fisher | 24740011 |
| LAMP Kit\* | - | Fluorimetric LAMP Kit | New England Biolabs | E1700 |
||
\* Item may not be substituted for equivalent. Only the specified vendor and catalog number may be utilized.
The FloodLAMP QuickFluor(TM) COVID-19 Test uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. All 18 primers are mixed together and are input into a single amplification reaction. Primer names and sequences are listed in Table 2. Primers may be purchased pre-blended from the vendor LGC Biosearch Technologies with the product names LAMP\_S2-As1e, LAMP\_S2-N2, LAMP\_S2-E1. Alternatively, primers may be purchased as individual custom oligos. Appropriate validation of primer mixes from custom oligos is required. See Primer Preparation below for more information.
#### Table 2: Primer names and sequences
| Primer Name | Sequence (5’-3’) |
| :---- | :---- |
| **ORF1ab gene (AS1e)** | |
| Orf1ab\_FIP | TCAGCACACAAAGCCAAAAATTTATTTTTCTGTGCAAAGGAAATTAAGGAG |
| Orf1ab\_BIP | TATTGGTGGAGCTAAACTTAAAGCCTTTTCTGTACAATCCCTTTGAGTG |
| Orf1ab\_F3 | CGGTGGACAAATTGTCAC |
| Orf1ab\_B3 | CTTCTCTGGATTTAACACACTT |
| Orf1ab\_LF | TTACAAGCTTAAAGAATGTCTGAACACT |
| Orf1ab\_LB | TTGAATTTAGGTGAAACATTTGTCACG |
| **N Gene (N2)** | |
| N2\_FIP | TTCCGAAGAACGCTGAAGCGGAACTGATTACAAACATTGGCC |
| N2\_BIP | CGCATTGGCATGGAAGTCACAATTTGATGGCACCTGTGTA |
| N2\_F3 | ACCAGGAACTAATCAGACAAG |
| N2\_B3 | GACTTGATCTTTGAAATTTGGATCT |
| N2\_LF | GGGGGCAAATTGTGCAATTTG |
| N2\_LB | CTTCGGGAACGTGGTTGACC |
| **E Gene (E1)** | |
| E1\_FIP | ACCACGAAAGCAAGAAAAAGAAGTTCGTTTCGGAAGAGACAG |
| E1\_BIP | TTGCTAGTTACACTAGCCATCCTTAGGTTTTACAAGACTCACGT |
| E1\_F3 | TGAGTACGAACTTATGTACTCAT |
| E1\_B3 | TTCAGATTTTTAACACGAGAGT |
| E1\_LF | CGCTATTAACTATTAACG |
| E1\_LB | GCGCTTCGATTGTGTGCGT |
||
### Standard Lab Equipment and Consumables
* 70% ethanol
* 10% bleach, prepared daily
* 96-well PCR reaction plates (Applied Biosystems \# 4346906, 4366932, 4346907, Eppendorf \# 951020303 or equivalent)
* Optical strip caps (Applied Biosystems \# 4323032 or equivalent)
* Optical plate seal (Applied Biosystems \# 4311971 or equivalent)
* PCR strip tubes and caps (USA Scientific catalog \# 1402-2500 or equivalent)
* 5 mL transport tubes or equivalent (sterile)
* 1.5 mL microcentrifuge tubes or equivalent (nuclease-free)
* Aerosol resistant micropipette tips (nuclease-free)
* Micropipettes (calibrated)
* Bottle top dispenser for 1 mL volume (optional, calibrated)
* 96-well cold block
* Cold blocks for 5 mL and 1.5 mL \- 2.0 mL tubes, or ice
* Vortex mixer
* 96-well plate centrifuge or equivalent
* Mini centrifuge for 1.5 mL tubes or equivalent
* Thermal cycler, water bath, dry heat bath or equivalent (calibrated)
* Class II Biological Safety Cabinet (BSC)
* PCR Instrument (Choose 1)
* QuantStudio(TM) 7 Pro
* Bio-Rad CFX96 Touch(TM)
## Warnings and Precautions
Materials or chemicals required for the use of the FloodLAMP QuickFluor(TM) COVID-19 Test should be closely examined by the user. The user should carefully read all warnings, instructions or Safety Data Sheets provided by the supplier and follow the general safety precautions when handling biohazards, chemicals and other materials.
### General Precautions
* The FloodLAMP QuickFluor(TM) COVID-19 Test is for *in vitro* diagnostic use (IVD) only. Rx Only.
* For use under COVID-19 Emergency Use Authorization Only.
* Standard precautions and procedures should be taken when handling and disposing of human samples.
* This test has not been FDA cleared or approved; the test has been authorized by FDA under an Emergency Use Authorization (EUA) for use by laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA) of 1988, 42 U.S.C. §263a, to perform high complexity tests.
* This test has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens.
* This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of *in vitro* diagnostic tests for detection and/or diagnosis of COVID19 under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
* Standard precautions and procedures should be taken when handling and extracting human samples.
* Standard precautions and procedures should be taken when using laboratory equipment.
* Standard precautions and procedures should be taken when disposing of waste.
* Dispose of reagents according to local regulations.
* Do not use reagents after their recommended stability time frame.
* Ensure reagents are stored at the recommended temperatures as described below and in the vendor product information and manuals.
### Contamination Precautions
* Avoid contamination by following good laboratory practices, wearing proper personal protective equipment, segregating workflow, and decontaminating workspace appropriately.
* Ensure that surfaces and equipment used for all test steps have been properly cleaned with 10% bleach and 70% ethanol.
* Ensure all consumables are DNase and RNase free except for sample collection tubes which may be sterile.
* Use only calibrated pipettes and filter tips that are sterile and PCR clean.
* After completion of the test, dispose of the amplification reaction plates or tubes. **Do not open tubes** or remove the seals on plates after heating amplification reactions.
## Limitations
* The use of this assay as an *in vitro* diagnostic under the FDA COVID-19 Emergency Use Authorization (EUA) is limited to laboratories that are certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, to perform high complexity tests by Rx only.
* Use of this assay is limited to personnel who are trained in the procedure. Failure to follow these instructions may lead to erroneous results.
* The performance of the FloodLAMP QuickFluor(TM) COVID-19 Test was established using Nasopharyngeal Swab specimen type collected in saline. Nasal swabs, oropharyngeal swabs, mid-turbinate nasal swabs specimens are also considered acceptable specimen types for use with the test but performance has not been established.
* Samples must be collected according to recommended protocols and transported and stored as described herein.
* Samples should not be collected in UTM or VTM or Liquid Amies transport media.
* The effect of vaccines, antiviral therapeutics, antibiotics, chemotherapeutic or immunosuppressant drugs have not been evaluated.
* Detection of SARS-CoV-2 RNA may be affected by sample collection methods, patient factors (e.g., presence of symptoms), and/or stage of infection.
* False-positive results may arise from various reasons, including, but not limited to the following:
* Contamination during specimen collection, handling, or preparation
* Contamination during assay preparation
* Incorrect sample labeling
* False-negative results may arise from various reasons, including, but not limited to the following:
* Improper sample collection or storage
* Degradation of SARS-CoV-2 RNA
* Presence of inhibitory substances
* Use of extraction reagents or instrumentation not approved with this assay
* Incorrect sampling window
* Failure to follow instructions for use
* Mutations In SARS-CoV-2 target sequences
* Nucleic acid may persist even after the virus is no longer viable.
* This test cannot rule out diseases caused by other bacterial or viral pathogens.
* Performance has not yet been established in asymptomatic individuals and will be established during a post-authorization study.
* Use of the test in a general, asymptomatic population for serial screening is intended to be used as part of an infection control plan, that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. Negative results should not be treated as definitive and do not preclude current or future infection obtained through community transmission or other exposures. Negative results must be considered in the context of an individual’s recent exposures, history, and presence of clinical signs and symptoms consistent with COVID-19.
* This test should not be used within 30 minutes of administering nasal or throat sprays.
* Positive results must be reported to appropriate public health authorities, following state and national guidelines.
* The clinical performance of the test has not been established in all circulating variants, and test performance may vary depending on the prevalence of variants circulating at the time of patient testing.
* Negative test results do not exclude possibility of exposure to or infection with SARS-CoV-2 virus. Patient handling will be directed by healthcare professionals.
## Conditions of Authorization for the Laboratory
The FloodLAMP QuickFluor(TM) COVID-19 Test Letter of Authorization, along with the authorized Fact Sheet for Healthcare Providers, the authorized Fact Sheet for Patients, and authorized labeling are available on the FDA website: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas)
However, to assist clinical laboratories running the FloodLAMP QuickFluor(TM) COVID-19 Test, the relevant Conditions of Authorization are listed below:
* Authorized laboratories1 using the FloodLAMP QuickFluor(TM) COVID-19 Test will include all authorized Fact Sheets with test result reports. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
* Authorized laboratories1 using the FloodLAMP QuickFluor(TM) COVID-19 Test will use the FloodLAMP QuickFluor(TM) COVID-19 Test as outlined in the FloodLAMP QuickFluor(TM) COVID-19 Test Instructions for Use. Deviations from the authorized procedures, including the authorized clinical specimen types, authorized control materials, authorized other ancillary reagents and authorized materials required to perform the test are not permitted.
* Authorized laboratories must notify the relevant public health authorities of their intent to run the test prior to initiating testing.
* Authorized laboratories using the FloodLAMP QuickFluor(TM) COVID-19 Test will have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
* Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
* All laboratory personnel using the test must be appropriately trained in molecular assay techniques and use appropriate laboratory and personal protective equipment when handling these test components, and use the test in accordance with the authorized labeling.
* FloodLAMP Biotechnologies, PBC authorized distributors, and authorized laboratories using the FloodLAMP QuickFluor(TM) COVID-19 Test will ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
1 For ease of reference, this will refer to, “Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a certified laboratories with FDA Emergency Use Authorization FDA for performing SARS-CoV-2 testing
## Specimen Collection and Storage
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19:
[https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html](https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html)
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
* Samples can be stored at room temperature for 56 hours after collection prior to inactivation.
* For longer term storage, samples can be stored at ≤-70oC.
Note: Specimens must be packaged, shipped, and transported according to the current edition of the International Air Transport Association Dangerous Goods Regulation. Follow shipping regulations for UN 3373 Biological Substance, Category B when sending potential 2019-nCoV specimens.
## Running Tests
### Reagent Preparation
The FloodLAMP QuickFluor(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1.
#### Table 1: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | ----- | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease- free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5 M | Sodium Chloride | Thermo Fisher | 24740011 |
| LAMP Kit\* | - | Fluorimetric LAMP Kit | New England Biolabs | E1700 |
||
\* Item may not be substituted for equivalent.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
A 100X Inactivation Solution is prepared by mixing the components in Table 3 and vortexing for 30 seconds. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved. Aliquots of 100X Inactivation Solution should be stored in the dark at \-20°C for up to 3 months. Upon thaw, working aliquots of 100X Inactivation Solution should be stored in the dark at room temperature for up to 1 month.
#### Table 3: 100X Inactivation Solution
| Component | Source Concentration | Volume | 100X Concentration |
| :---- | :---: | :---: | :---: |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
For swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 4. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 4: 1X Inactivation Saline Solution
| Component | Volume |
| :---- | :----: |
| 0.9% Saline (154 mM NaCl) in MilliQ Water | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
### Controls Preparation
**One positive and one negative control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes on each heater:
1) A “no template” (negative) control (NTC) is needed to **assure the absence of cross contamination from positive samples, positive controls, or amplicons** and is used **to determine if sample results are valid.** **It consists of nuclease-free water.**
2) A positive template control is needed to **assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water.** Stock and working aliquots of the positive control are produced from the sources listed in Table 5 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at \-80°C, or at most 1 month at \-20°C.
#### Table 5: Components for Positive Template Control
| Material | Vendor | Catalog \# | Volume |
| :---- | :----: | :----: | :----: |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µl |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µl |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895 µl |
||
### 10X LAMP Primer Mix Preparation
The FloodLAMP QuickFluor(TM) COVID-19 Test uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. Primer names and sequences are shown above in Table 2. All 18 primers are mixed together and input into a single amplification reaction.
Primers may be purchased from the vendor LGC Biosearch Technologies as 3 pre-blended sets, or the primers may be purchased as 18 individual custom oligos. Table 6 below lists the primer products to be ordered.
The LGC Biosearch primer products are provided already blended for each target (6 primers per tube) and dried such that upon resuspension with 1 mL of nuclease-free water, the primers for each target are at 30X concentration. One resuspended tube for each of the 3 targets (i.e. primer blends) are mixed together to yield a 3 mL total volume that contains all individual primers at 10X concentration. This 3 mL of 10X LAMP Primer Mix provides for 1,200 reactions at 2.5 µL per reaction.
Alternatively to the pre-blended LGC Biosearch products, primers may be purchased as individual custom oligos. Custom oligos may be blended to form 30X Primer Set Mixes as intermediates or all mixed together for the 10X LAMP Primer Mix. The FIP and BIP primers for each target require purification by HPLC or an equivalent process. Appropriate validation of primer mixes from custom oligos is required. Primers may be stored at 4°C for up to one month, or at \-20°C for up to 1 year.
#### Table 6: 10X LAMP Primer Mix Components
| Vendor | Item | Catalog number | Quantity | # Reactions |
|--------|------|----------------|-----------|-------------|
| Order one of the following primer sets |||||
| LGC Biosearch Technologies | SARS-CoV-2 LAMP ASIe 6 primer set at 30X (ORF1ab gene) | LAMP_S2-ASIe-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP ASIe 6 primer set at 30X (ORF1ab gene) | LAMP_S2-ASIe-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LB | Custom Order | 250 nmol | 25,000 |
||
### Sample Preparation
\* For wet swab specimens (swabs in saline or unprocessed swab elution):
1) If samples are frozen, thaw unless no ice crystals are present and then keep on ice, cold block or at 4°C.
2) Pulse vortex each sample and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
3) Wipe the outside of the sample tube with 70% ethanol.
For dry swab specimens:
1) Wipe the outside of the sample tube with 70% ethanol.
### Sample Inactivation
1) Place the inactivation heater (a thermal cycler, water bath, dry heat bath or equivalent) in the BSC, turn on, and set the temperature to hold at 100°C.
2) \* For wet swab specimens: transfer 1 mL or available volume of each sample to an appropriately labeled 1.5 mL or 5 mL tube and securely cap.
3) \* For wet swab specimens: add 10 µL per 1 mL sample volume of 100X Inactivation Solution to each sample tube.
4) For dry swab specimens (DO NOT DO FOR WET SWAB SPECIMENS): add 1 mL of 1X Inactivation Solution to each sample tube.
5) Vortex for 30 seconds.
6) Place sample tubes into the inactivation heater for 8 minutes.
7) Remove sample tubes from inactivation heater and let cool at room temperature for 10 minutes.
8) Place sample tubes on ice, in the refrigerator, or on a cold block at 4°C until ready to perform amplification reaction.
Note: Testing of inactivated specimens must be conducted the same day inactivation is performed. For long term storage, keep the original specimen at ≤-70°C.
### Preparing to Run Assay for the First Time
*Note: Any instrument running the FloodLAMP QuickFluor(TM) COVID-19 Test must be calibrated for the following dye: FAM*
#### Download the Template Run File
The Template Run File contains all the parameters preconfigured to run the FloodLAMP QuickFluor(TM) COVID-19 Test. These parameters can be seen in more detail under “Create the Run File ...” headings below.
To download the Template Run File:
1) Go to www.floodlamp.bio/euas
2) Download the Template Run file(s) for the instrument type and assay to be run.
#### Table 7: Fluorescence LAMP Instrument Template Run File
| Instrument | Setup Template Filename |
| ----- | ----- |
| ABI QuantStudio(TM) 7 Pro | FloodLAMP\_QS7Pro\_Fluor\_template\_run.edt |
| Bio-Rad CFX96 Touch(TM) | FloodLAMP\_BRCFX\_Fluor\_protocol.prcl |
| Bio-Rad CFX96 Touch(TM) | FloodLAMP\_BRCFX\_Fluor\_template\_run.pltd |
||
*Note: Template Run Files only need to be downloaded once upon first use.*
#### Alternatively, Create the Template Run File on QuantStudio(TM) 7 Pro
1) Open the Design and Analysis Software
2) Select the “SET UP PLATE” option
3) From the sidebar on the screen, select the following properties to filter:
1. Instrument – choose the appropriate instrument
2. Block – choose the appropriate block
3. RunMode – Standard
4. Analysis options are left blank
4. From the plate sections present on the screen, select the correct System Template and the system will automatically navigate to the "Run Method" tab
1. "Presence/Absence" for QuantStudio(TM) 7 Pro
5. Change run template parameters as shown below:
Run Parameters
- **Run Method:**
- 25 µL Rxn Vol.
- 95°C Heated Cover Temp
- Ramp Rate: 1.6°C/s
#### Table 8: Fluorimetric LAMP Run Parameters
| Stage | Temperature | Time | Reps |
| :---: | :---: | :---: | :---: |
| 1 | 65°C | 10 sec | 1 |
| 2 | 65°C | 10 sec | 1 |
| 3 | 65°C | 30 sec | 25 |
| 3 | 65°C \* | 30 sec | 25 |
||
*\* This step should be the optical read step*
- **Plate Setup**
- Target: FAM (Sars)
- Quencher: None
- Passive Reference: None
6. Once done editing the template, go to “Actions” in the top right corner, hit “Save As”
1. On Connect: Save to template folder
2. Offline: Save to preferred location
#### Alternatively, Create the Template Run File on Bio-Rad CFX96 Touch™
1. Launch the CFX96 Touch software package.
2. In the Startup Wizard pop-up window select the instrument “CFX96” from the drop down menu.
3. Under “Select Run Type” press the “User-defined” button.
4. Create a new thermocycler protocol by selecting “Create New” from the Run Setup window.
5. Under Tools in the top left toolbar select “Run Time Calculator” and check “96 Wells-All Channels”.
6. Make the following changes to the cycling conditions in the Protocol Editor:
a. Change the Sample Volume to 25 μL
b. Change the Lid Setting to 95°C
c. Change cycles to be as shown below:
#### Table 9: Thermal cycling conditions and plate read steps (BioRad CFX96)
| Stage | Temperature | Time | Reps |
| :---: | :---: | :---: | :---: |
| 1 | 65 C | 30 sec | 25 |
| 1 | 65\* C | 30 sec | 25 |
||
*\* This step should be the optical read step*
7. Click “OK” to save the protocol as type Protocol File (\*.prcl) and return to the Protocol tab in Run Setup
### Create the Plate Layout Map
#### QuantStudio(TM) 7 Pro Option 1: Sample Name Input
For this option, sample names (i.e. specimen IDs) are directly input into the instrument software prior to starting the run.
1. Open template in Design and Analysis app and go to the “Plate Setup” tab
2. On the right side of the screen ensure the “Samples” tab is highlighted and press the addition icon to add the number of samples being tested.
3. Click on the “Sample 1” box to rename the sample
1. Repeat this step for all subsequent samples being entered
4. Click the well located in the plate map then check the box next to the sample name from the right side bar to associate the name to the well
1. There is also the option to highlight the well location in the plate map and click on the “Enter sample” box. Enter the sample ID and press tab to continue to the next well in the plate map. This will automatically load the sample name into the sidebar.
5. Once the sample names have been entered, the wells may be highlighted by left clicking the mouse over the starting well and dragging the mouse across all wells associated in run. The targets are then chosen by clicking the check boxes next to each target in the sidebar
1. FAM should be chosen and named “Sars”
6. Once done setting up the template, go to “Actions” in the top right corner and hit “Save As,” a pop-up window will appear directing the user to title the file according to information pertaining to the sample run
1. Connect: save to the desired folder (only applicable for 7 Pro)
2. Offline: save to a USB that is inserted into the computer
7. Use your plate layout to load your samples and controls after preparing the amplification reaction mix.
#### QuantStudio(TM) 7 Pro Option 2: Lookup Based on Well Position
For this option, a single generic sample name is applied to all wells, and subsequently, outside of the instrument software, the results are linked to the actual sample name via a lookup table to the well position.
1. Open template in Design and Analysis app and go to the “Plate Setup” tab
2. Highlight the entire plate and add 1 sample to all wells, with the same sample name in every well.
3. Highlight entire plate and add FAM to all wells
4. Go to “Actions” in the top right corner and hit “Save As” and name the template as desired.
1. Connect: save to desired location
2. Offline: save to a USB that is inserted into the computer
This process only needs to be done once – all subsequent runs can use the same Template Run File.
#### Bio-Rad CFX96 Touch(TM):
1. Launch the CFX96 Touch software package and open the correct protocol template
2. Review the details of the protocol. If correct, click “Next” to proceed to the Plate tab
3. On the Plate tab, click “Create New” and the Plate Editor appears.
4. Use the Plate Editor to create a new plate.
5. To ensure the correct plate size is selected, go to “Settings \> Plate Size” and check that 96-well or 384-well is selected from the drop-down menu.
1. The plate size selected must correspond to the block size of the instrument being used.
6. To set the plate type, select” Settings \> Plate Type” and select “BR Clear” or “BR White” from the drop-down menu.
1. The plate type selected should match the plate type used in the run.
7. To set the scan mode, select the “All Channels” scan mode from the Scan Mode drop-down list in the Plate Editor toolbar.
8. Select the “Select Fluorophores” button on the upper right of the Plate Editor window
1. De-select all default fluorophores and select “FAM”and click OK
9. In the Plate Editor window highlight the whole plate and click the checkbox in front of FAM
10. Select the “Experiment Settings” button in order to define the Targets
1. In the lower left of the Experiment Settings window in the New box type in “N1” and select “Add”
2. Select “OK”
11. In the Plate Editor window next to FAM in the drop-down menu under Target Name select “Sars”
12. Click OK to save changes and close the “Select Fluorophores” dialog box.
#### Bio-Rad CFX96 Touch(TM) Option 1: Sample Name Input
For this option, sample names (i.e. specimen IDs) are directly input into the instrument software prior to starting the run.
1. Load the appropriate sample type to each well by selecting the well and selecting the appropriate Sample Type (Unknown, NTC, or Positive Control) from the drop-down menu.
2. Multiple wells can be selected at once to load the sample type
1. Note: the EC can be listed as an Unknown sample.
3. In the “Target Names” section confirm that the necessary fluorophores are assigned to each well.
4. Name each well as desired by typing in the sample name and pressing “Enter” in the Sample Names dropdown list in the right pane.
5. Click OK to save the Plate File (\*.pltd)and return to the Plate tab in Run Setup. When prompted, specify a name for the plate and a save location
#### Bio-Rad CFX96 Touch(TM) Option 2: Lookup Based on Well Position
For this option, a single generic sample name is applied to all wells, and subsequently, outside of the instrument software, the results are linked to the actual sample name via a lookup table to the well position.
1. Name the file as desired and save as type “Plate File (\*.pltd)”
2. Select “Save”, click “OK” in the Plate Editor window and exit the software
For this method of creating a Plate Layout Map, this process only needs to be repeated once – all subsequent runs can use the same template.
### Fluorimetric LAMP Amplification Reaction Preparation
1) Place a 96-well PCR plate or PCR strip tubes onto a cold block or ice.
2) Thaw frozen reagents until ice crystals are not present.
3) Pulse vortex thawed reagents for 3 seconds and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
4) Store on ice, in the refrigerator, or on a cold block at 4°C until ready to use.
5) Prepare the Fluorimetric LAMP Amplification Reaction Mix by combining the components listed below in Table 10.
NOTE: Component volumes should be scaled proportionally for the number of reactions.
6) Vortex the Fluorimetric LAMP Amplification Reaction Solution for 10 seconds and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
7) Add 23 µL of the Fluorimetric LAMP Amplification Reaction Solution into the wells of the PCR plate or PCR strip tubes.
#### Table 10: Fluorimetric LAMP Amplification Reaction
| Component | Volume (1 reaction) | Volume (100 reactions) |
| ----- | :---: | :---: |
| 10X LAMP Primer Mix | 2.5 µL | 250 µL |
| Nuclease-Free Water | 7.5 µL | 750 µL |
| Fluorimetric LAMP MM | 12.5 µL | 1250 µL |
| Fluorescent Dye | .5 µL | 50 µL |
| **SUBTOTAL VOLUME** | **23 µL** | **2300 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **25 µL** | - |
|||
### Sample Addition
NOTE: Ensure that positive and negative controls are included in each batch run (i.e. in each PCR plate or group of strip tubes that are heated together).
1) Add 2 µL of each sample into a separate tube in the amplification reaction PCR plate or strip tubes.
2) Mix by pipetting.
3) If using PCR plate optical seal (optionally using heat sealer). If using PCR strip tubes, cap strips.
4) Pulse vortex and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
5) Continue to section “Run the Assay”
### Run the Assay
Refer to Specific Instrument User Manuals for full system usage and maintenance details.
#### On QuantStudio(TM) 7 Pro
1. Log into user on instrument.
2. USB: Plug in USB with saved template on it.
3. From the options on the instrument’s screen press “Load plate file”.
1. The QuantStudio(TM) 7 Pro is a touchscreen device.
4. From the “Run Queue” screen,
1. USB: press “USB drive” on the left side.
2. Connect: press Cloud icon on the left side.
5. This will bring up any plate files saved.
6. Press the plate file associated with the run to be performed.
7. A new window will appear requesting location of results once the run is complete.
1. Connect: Press the “Cloud Connect” icon, press again to verify location the files will be uploaded to and then press “Done”.
2. USB: Press the “USB drive Connected” if the icon is not already highlighted and press “Done”.
8. Press the double-arrow icon located at the top right sided corner of the screen on the instrument.
1. The instrument drawer will open from the front.
9. Place the plate/strips into the plate holder ensuring proper orientation of the plate.
1. A1 well should be in the position of the top left corner.
2. The plate/strips will appear slightly suspended above the block due to two silicone strips above and below this plate. This is to be expected and the instrument lid will press the plate down once the drawer has closed.
10. Press “Start Run” on the screen of the instrument.
1. A pop-up window will appear asking the user to confirm the plate has been loaded.
2. If the plate has been loaded, press “StartRun” again or press “Open Drawer” to place the plate into the block and then press “Start Run”.
#### On Bio-Rad CFX96 Touch(TM)
1) Open the correct .pcrl file and review the protocol details. If correct click “Next” to proceed to the Plate tab.
2) When prompted, open the correct .pltd file and review the plate details in the Run Information section.
3) Select the checkbox for the appropriate block (CFX96 or CFX384) on which to perform the run.
4) To insert the plate or 8-tube strips into the block, click Open Lid.
5) Insert the plate or 8-tube strips into the block. Ensure the plate or 8-tube strips are properly oriented.
6) Click Close Lid.
7) Click Start Run at the bottom right of the screen.
8) When prompted, save the data file (.pcrd) to the desired location.
### Analyzing Data
#### Exporting Data from QuantStudio(TM) 7 Pro
##### Using USB
1) Confirm Quant says “File Transferred \- USB”
2) Take USB from Quant and plug it into computer
3) Export data off of USB onto computer
##### Using Cloud Connect with QuantStudio(TM) 7 Pro
1) Go to [Cloud Connect](https://apps.thermofisher.com/apps/spa/#/dashboard%20%20) and log in.
2) Go to files and find the data that was just uploaded by the Quant, it will be in the folder chosen previously chosen while running the Quant
3) Download .xlsx file
#### Exporting Data from Bio-Rad CFX96 Touch(TM)
1) After the run has completed, open the data file (.pcrd) by going to Select File \> Open \> Data File in the Home window and locating the desired data file. Adjust the following settings as described below.
2) Select Settings \> Cq Determination mode and select Single Threshold.
3) Select Settings \> Baseline Setting and select Baseline Subtracted.
4) Select Settings \> Analysis Mode and select analysis by fluorophore.
5) Select Settings \> Cycles to Analyze and the Cycles to Analyze dialog box appears. Confirm that all cycles are being analyzed and click “OK”.
6) Cq values of each well are displayed in the Quantification Data tab.
7) Export .xlsx files and select Export \> Export all Data Sheets to Excel (Cq values are available in "Quantification Plate View Results").
#### Compiling Results Option 1: Lookup Based on Well Position
For this option, outside of the instrument software the results are linked to the actual sample name via a lookup table to the well position. An example spreadsheet to perform this lookup and results compilation is available with instructions at [www.floodlamp.bio/euas](http://www.floodlamp.bio/ifus).
#### Compiling Results Option 2: Sample Name Input
For this option, sample names (i.e. specimen IDs) are directly input into the instrument software prior to starting the run. Open the results file and continue to “Analyzing Data” section to score results.
### Results Interpretation
#### Test Controls
All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. Target results for the controls will be interpreted according to Table 11 below.
1) The “No Template” (Negative) Control (NTC) should yield a negative “not detected” result for the SARS target
2) The Positive Template Control should yield a positive “detected” result for the SARS target
3) The Internal Process Control is required to report a negative SARS-CoV-2 result.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and (optionally) RNAseZAP(TM) product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
### Patient Specimen Results Interpretation
NOTE: Patient specimen results can only be interpreted if the positive and negative controls in the plate or group of strip tubes have the expected results.
Use Table 11 below to assign a result to each sample.
#### Table 11: Interpretation of Assay Results
| ABI QuantStudio(TM) 7 Pro Bio-Rad CFX96 Touch(TM) | | |
| :---: | :---: | :---: |
| **Result** | **Ct Value: N1** | |
| Positive | ≤25.0 | |
| Negative | Undetermined | |
|||
## Performance Evaluation
### Analytical Sensitivity: Limit of Detection (LoD)
The Limit of Detection (LoD) for the FloodLAMP QuickFluor(TM) COVID-19 Test was established using gamma irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The negative specimens were confirmed by PCR using the CDC primers. The gamma irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 50,000, 25,000 and 12,500 copies/mL were selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 12. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 50,000 copies/mL.
#### Table 12: LoD Confirmatory Data Results
| Instrument | LoD | Positive Replicates | Mean Ct Value (SD) |
| ----- | ----- | :---: | :---: |
| ABI QuantStudio(TM) 7 Pro | 50,000 copies/mL | 95% (20/21) | 11.9 (1.5) |
| ABI QuantStudio(TM) 7 Pro | 25,000 copies/mL | 76% (16/21) | 13.8 (2.3) |
||
### Analytical Sensitivity: Inclusivity (*in silico*)
An inclusivity study was conducted for the ORF1ab, N2, and E1 primer sets against all complete, high coverage SARS-CoV-2 sequences deposited at GISAID as of February 27, 2021. Table 13 summarizes the results of this *in silico* inclusivity analysis. A total of 498,224 sequences were considered. There are 10 sequence isolates that have 1mm to both As1e and E1 and had N2 excluded due to greater than 15 N's, with the other 498,214 sequence isolates all have at least 1 target region that is a complete match.
Each primer set matched at 100% similarity against the SARS-CoV-2 RefSeq reference genome (Wuhan-Hu-1; NC\_045512.1). All three primer sets differed by one or fewer mutations for 99.7% of GISAID sequences, indicating nominal primer hybridization for all SARS-CoV-2 variants under consideration.
#### Table 13: *In Silico* Inclusivity Analysis for LAMP Primers
| Primer | AS1e (ORF1ab gene) | | N2 (N gene) | | E1 (E gene) | |
| :---- | ----- | ----- | ----- | ----- | ----- | ----- |
| **Total Primer Length** | 195 | | 169 | | 168 | |
| **Total \# of Strains Evaluated** | 498,224 | | 498,224 | | 498,224 | |
| **100% Match** | 474,717 | 95.3% | 479,548 | 96.3% | 462,538 | 92.8% |
| **1 Mismatch** | 19,301 | 3.9% | 15,698 | 3.2% | 30,626 | 6.1% |
| **2 Mismatches** | 338 | 0.1% | 161 | 0.0% | 1,455 | 0.3% |
| **3 Mismatches** | 9 | 0.0% | 5 | 0.0% | 103 | 0.0% |
| **\> 3 Mismatches** | 0 | 0.0% | 0 | 0.0% | 1 | 0.0% |
| **Total Strains Removed** | 3,859 | 0.8% | 2,812 | 0.6% | 3,501 | 0.7% |
||
### Evaluation of Impact of Viral Mutations
The As1e, E1 and N2 primer regions of all SARS-CoV-2 genomes present in GISAID as of 2/26/2021 were evaluated to assess the potential impact of genomic variants on LAMP primer binding. This analysis was performed with the Primer Monitoring Tool from New England Biolabs ([primer-monitor.neb.com](http://primer-monitor.neb.com)), which continually monitors registered primer sets for overlapping variants in sequences from GISAID. Results are summarized by region and locus below in Table 14, including the 30 countries with most sequences in GISAID. Sequences were aligned to the SARS-CoV-2 reference sequence (NC\_045512.2) using minimap2 (minimap2 \-t 16 \-x asm5 \-a). Variant sites (excluding Ns) were identified using samtools mpileup and summarized by region and genome position. Genomic positions having \>= 40 global variant observations are shown (column labels). When present, box labels indicate the fraction of variants observed at a given locus.
The aggregate of current published mutations are not expected to reduce performance of the FloodLAMP QuickFluor(TM) COVID-19 Test by more than 5% from that established by the performance evaluation in this EUA submission. Further, the use of 3 primer sets targeting different regions in the SARS-CoV-2 genome should make the test robust to new genetic variants.
#### Table 14: Variant Analysis of LAMP Primers
_Heatmap charts showing variant frequency at LAMP primer binding sites across 30 countries for AS1e, N2, and E1 primer sets, based on GISAID sequences aligned to the SARS-CoV-2 reference genome._
### Analytical Specificity: Cross-Reactivity (*in silico*)
*In silico* cross-reactivity analysis was performed by aligning the primer sequences of the FloodLAMP QuickFluor(TM) COVID-19 Test against sequences of other coronaviruses and common respiratory flora using the BLASTn alignment tool from NCBI. Results of this analysis are presented in Tables 15A, 15B, and 15C.
The % identity range (\# identical bases/ \# primer bases) is shown for each primer and organism. Darker font indicates % identity greater than 80%. Organisms with \>= 50% identity primer hits are shown. This analysis is not intended to predict amplification. Near perfect homology across B3, F3, FIP and BIP is necessary to support successful amplification. With the exception of SARS-CoV, simultaneous homologies do not occur between any of the primers and microorganisms screened. With respect to clinical relevance of the *in silico* cross-reactivity analysis, there are no known circulating strains of SARS-CoV circulating in humans, thus the overall probability for the test to produce a cross-reactive signal is negligible.
#### Table 15A: *In Silico* Cross-Reactivity Analysis for AS1e Primers
| Organism Group | Organism Name | Organism ID | As1_B3 (22 bp) | As1e_BIP (49 bp) | As1_F3 (18 bp) | As1e_FIP (51 bp) | As1_LB (27 bp) | As1_LF (28 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 47%-55% | 100% | 43%-53% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| | SARS coronavirus | NC_004718 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 72%-89% | 29% | 52%-67% | |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 77% | | 89% | 37%-51% | 52%-89% | |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 59%-73% | 33%-35% | 89% | 33%-45% | 52% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-73% | 31% | 72%-83% | 29%-59% | 52% | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | 83% | | | |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 59%-82% | 39% | | 29%-41% | 67% | 61% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-82% | | 72% | 39%-87% | 59% | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 59%-82% | 31% | 72% | 31% | 52%-67% | |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | 72%-78% | | 70% | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | 72% | 29%-35% | 78% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.15 | NW_017264789.1 | 59% | | | 78% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.11 | NW_017264785.1 | 77% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 77% | | | 35% | 63% | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59% | 43%-49% | 72% | 29%-57% | 63%-74% | 68% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | 49% | 72% | 31%-41% | 56%-74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | 31%-43% | 74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 73% | | 72% | 29%-39% | 52% | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 59%-68% | 31%-37% | 72% | 29%-35% | 56%-67% | 57%-71% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | 37%-41% | 72% | 29%-41% | 52%-63% | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.14 | NW_017264788.1 | | | | 35% | | 71% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | | | | 29%-47% | 70% | 68% |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59%-68% | 35% | | 29%-43% | | 68% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 68% | 37% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 33%-49% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | 43% | | 38% | | 68% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 64% | | | | | 57% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | | | | 33%-35% | 59% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 59% | | | | | 50% |
| | Bordetella pertussis 18323 | NC_018518.1 | | | | | | 57% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | | 52% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | 39%-47% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.54 | NW_017264828.1 | | 47% | | | | |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | | 31% | | 31%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | | | | 33%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.19 | NW_017264793.1 | | | | 38% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | | | | 35% | | |
| | Respiratory syncytial virus | NC_001803.1 | | | | 33% | | |
||
#### Table 15B: *In Silico* Cross-Reactivity Analysis for N2 Primers
| Organism Group | Organism Name | Organism ID | N2_B3 (25 bp) | N2_BIP (40 bp) | N2_F3 (21 bp) | N2_FIP (42 bp) | N2_LB (20 bp) | N2_LF (21 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 53% | 100% | 48%-55% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 64% | 53% | 90% | 55% | 85% | 90% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 60%-80% | | 95% | | 75% | 62%-71% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | 40% | 75%-90% | |
| | Bordetella pertussis 18323 | NC_018518.1 | | 35% | | | 65%-80% | 81% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | 56%-72% | 43% | | | | 62%-81% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | 56%-76% | | 62%-71% | 45% | | 62%-81% |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 56%-80% | 35%-68% | 62% | | | 62%-81% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 60%-80% | 35%-45% | 71% | | | 62%-71% |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 60%-72% | 35%-45% | 71%-76% | | | 62%-76% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 56%-76% | | 76% | 36% | 65% | |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 60%-76% | 43% | | 36%-55% | | 62%-76% |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | 60% | | | | 65%-75% | 76% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 68%-64% | | | | | 76% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | 35% | | | 75% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 56%-72% | 48% | 62% | 40% | | 67%-71% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 56%-72% | | 71% | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.17 | NW_017264791.1 | 56%-72% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | 60%-72% | | 71% | | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 56%-68% | 35% | | | | 62%-71% |
| | Human parainfluenza virus 1 | NC_003461.1 | | | 71% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 60%-68% | | | | | 62%-71% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 60%-68% | 50% | | 43% | | 62%-67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 68% | | | | | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 60%-68% | | 62% | | | 62% |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 56% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 56%-60% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 64% | 35% | | | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 60%-64% | 43%-50% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 60% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.51 | NW_017264825.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.67 | NW_017264841.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 56% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.21 | NW_017264795.1 | 52% | | | | | |
||
#### Table 15C: *In Silico* Cross-Reactivity Analysis for E1 Primers
| Organism Group | Organism Name | Organism ID | E1_B3 (22 bp) | E1_BIP (44 bp) | E1_F3 (23 bp) | E1_FIP (42 bp) | E1_LB (19 bp) | E1_LF (18 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 45%-57% | 100% | 45%-62% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 95% | 55% | 100% | 43%-62% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | | | | 40%-50% | | 72%-89% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | | | | 84% | 72% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | | | 36%-40% | | 78%-83% |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-82% | | 43% | | | 72% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | | | | 43%-50% | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | | | | | | 78% |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | | 45% | | 43%-48% | | 72%-78% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 77% | | | 36%-43% | | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59%-73% | | | 38%-48% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-73% | | 65% | 43% | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 73% | 41% | | 48% | | 72% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 59% | | | 43%-48% | | 72% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | | 36%-50% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | | 65% | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | 59%-68% | | | | | 72% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | | | 40% | 68% | 72% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 70% | | 40%-50% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | | | 70% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 59%-64% | | | 40% | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59% | | | 40%-43% | | |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 0%-59% | 0% | 0% | 0%-36% | 0% | 0% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | 59% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.20 | NW_017264794.1 | 59% | | | | | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | 34% | 57% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.30 | NW_017264804.1 | | | | 50% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.69 | NW_017264843.1 | | | | 50% | | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | | 43% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | | | | 40% | | |
||
### Analytical Specificity: Cross-Reactivity (*wet testing*)
Wet testing was performed to demonstrate that the FloodLAMP QuickFluor(TM) COVID-19 Test does not react with related pathogens, high prevalence disease agents and normal or pathogenic flora that are reasonably likely to be encountered in a clinical specimen. SARS-CoV, RSV, Flu, Human Metapneumovirus. and Streptococcus Salivarius were tested for potential cross-reactivity, as shown in Table 16 and Supporting Data. 5 µL of each stock of cross-reactivity organism was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma irradiated SARS-CoV-2 virus and cross-reactivity organisms were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived positive had 38 µL of 1e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 38,000 copies/mL in the sample input into the amplification reaction.
All wet testing showed no cross-reactivity with the viral pathogens and common respiratory flora, as shown in Table 16.
#### Table 16: Wet Testing Cross-Reactivity Results
| Organism | Description | BEI Number | Detected Replicates |
| ----- | ----- | :---: | :---: |
| SARS-CoV | UV-inactivated virus | NR-3882 | 0/3 |
| Human Metapneumovirus | Genomic RNA | NR-49122 | 0/3 |
| RSV | Genomic RNA | NR-43976 | 0/3 |
| Influenza B | Genomic RNA | NR-45848 | 0/3 |
| Streptococcus salivarius | Bacterial cell culture | HM-121 | 0/3 |
||
### Analytical Specificity: Interfering Substances
Exogenous and endogenous substances were tested for potential interference with the FloodLAMP QuickFluor(TM) COVID-19 Test. 10 µL of each stock of interfering substance was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived Positive Control Spiked comprised 20 µL of 8e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 160,000 copies/mL in the sample input into the amplification reaction.
Exogenous and endogenous substances were tested for potential interference with the FloodLAMP QuickFluor(TM) COVID-19 Test. 10 µL of each stock of interfering substance was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived Positive Control Spiked comprised 20 µL of 8e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 160,000 copies/mL in the sample input into the amplification reaction.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 17 and Supporting Data.
#### Table 17: Interfering Substances Results
| Interfering Substance | Active Ingredient | Concentration | % Agreement with Expected Results | |
| :---: | :---: | :---: | :---: | :---: |
| | | | **Positive Control Spiked** | **Negative Control Unspiked** |
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
## Clinical Evaluation
The clinical evaluation of the FloodLAMP QuickFluor(TM) COVID-19 Test utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The FloodLAMP QuickFluor(TM) COVID-19 Test showed a positive agreement of 80.0% and a negative agreement of 100%. The six false negative results were specimen with high Ct values as previously measured by the comparator test, indicating low viral load. A summary of the clinical performance is shown below in Table 18.
#### Table 18: Clinical Evaluation Results
| FloodLAMP QuickFluor(TM) COVID-19 Test Results | Comparator \- High Sensitivity EUA Authorized Test | | |
| :---: | :---: | :---: | :---: |
| | **Positive** | **Negative** | **Total** |
| Positive | 34 | 0 | 34 |
| Negative | 6 | 40 | 46 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 85.0% (34/40) 95% CI: 70.2% to 94.3% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## Support
FloodLAMP Biotechnologies, PBC support center
eua.support@floodlamp.bio
650-394-5233
QuantStudio(TM) is a trademark of Thermo Fisher Scientific (NYSE: TMO)
Bio-Rad(TM) and Bio-Rad CFX96 Touch(TM) are trademarks of Bio-Rad Laboratories, Inc. (NYSE: BIO)
# 8,979 2021-05-18_EUA Submission - FloodLAMP EasyPCR COVID-19 Test v1.1.md
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last updated: 2026-03-05 by BA
file_name: 2021-05-18_EUA Submission - FloodLAMP EasyPCR COVID-19 Test v1.1.md
file_date: 2021-05-18
title: EUA Submission - FloodLAMP EasyPCR COVID-19 Test v1.1
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subcategory: fl-fda-submissions
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summary_short: The EUA Submission for the FloodLAMP EasyPCR COVID-19 Test v1.1 describes an extraction-free, duplex RT-qPCR assay using CDC N1 and RNaseP targets after chemical plus heat inactivation, designed for CLIA high-complexity labs running routine screening programs (e.g., schools and workplaces) with at least weekly testing. It details intended use, validated instruments, workflow, controls, and component sourcing for an open-protocol deployment. It summarizes performance claims including a 3,100 copies/mL LoD and 97.5% positive agreement with 100% negative agreement in an 80-specimen clinical evaluation.
CONTENT
***INTERNAL TITLE:*** EUA Submission - FloodLAMP EasyPCR(TM) COVID-19 Test
## A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the **FloodLAMP EasyPCR(TM) COVID-19 Test** for the *in vitro* qualitative detection of RNA from the SARS-CoV-2 in in upper respiratory specimens including oropharyngeal and nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week, such as those implemented by schools, workplaces and community groups**. Additional testing and confirmation procedures should be performed in consultation with public health and/or other authorities to whom reporting is required. Test results should be reported in accordance with local, state, and federal regulations.
## B. MEASURAND
Specific nucleic acid sequences from the genome of the SARS-CoV-2, targeted by the previously certified **2019-nCoV\_N1 primers and probe set as part of the CDC qPCR assay**. Primer names and sequences are listed in Table 1.
#### Table 1: Primers and probes
| Target | Primer/Probe | Sequence |
| :---- | :---- | :---- |
| CDC-N1 | 2019-nCoV\_N1-F | GACCCCAAAATCAGCGAAAT |
| CDC-N1 | 2019-nCoV\_N1-R | TCTGGTTACTGCCAGTTGAATCTG |
| CDC-N1 | 2019-nCoV\_N1-P | **FAM**\-ACCCCGCATTACGTTTGGTGGACC-**IBFQ** |
| Human RNAseP | RP-F | AGATTTGGACCTGCGAGCG |
| Human RNAseP | RP-R | GAGCGGCTGTCTCCACAAGT |
| Human RNAseP | RP-P | **Cy5**\-TTCTGACCTGAAGGCTCTGCGCG-**IBRQ** |
||
## C. APPLICANT
FloodLAMP Biotechnologies, a DE Public Benefit Corporation
| Mailing Address: 4860 Alpine Rd. Portola Valley, CA 94028 | Laboratory Address: 930 Brittan Ave San Carlos, CA 94070 | Randall J. True, CSO Phone: (415) 269-2974 Email: randy@floodlamp.bio |
| :---- | :---- | :---- |
## D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name \- **FloodLAMP EasyPCR(TM) COVID-19 Test**
Established Name \- **FloodLAMP EasyPCR(TM) COVID-19 Test**
## E. REGULATORY INFORMATION
***Approval/Clearance Status:***
The **FloodLAMP EasyPCR(TM) COVID-19 Test** is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
***Product Code:***
QJR
## F. PROPOSED INTENDED USE
### 1) Intended Use:
**FloodLAMP EasyPCR(TM) COVID-19 Test** is a real-time reverse transcriptase polymerase chain reaction (RT-qPCR) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week**. Testing is limited to **laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.**
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis
for patient management decisions. Negative results must be combined with clinical observations,
patient history, and epidemiological information.
The **FloodLAMP EasyPCR(TM) COVID-19 Test** is intended for use by **qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of in vitro diagnostic procedures**. The **FloodLAMP EasyPCR(TM) COVID-19 Test** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
### 2) Special Conditions for Use Statements:
For Emergency Use Authorization (EUA) only
For prescription use only
For in vitro diagnostic use only
### 3) Special Instrument Requirements:
The **FloodLAMP EasyPCR(TM) COVID-19 Test** test is to be used with the RT-PCR instruments listed in Table 2.
#### Table 2. RT-PCR Instruments validated for test
| Manufacturer | Instrument |
| :---: | :---: |
| Thermo Fisher Scientific | Applied Biosystems QuantStudio(TM) 6 Flex |
| Thermo Fisher Scientific | Applied Biosystems QuantStudio(TM) 7 Pro |
| Bio-Rad | CFX96 Touch(TM) Real-Time PCR Detection System |
||
Designated laboratories will receive an FDA accepted instrument qualification protocol included as part of the **FloodLAMP EasyPCR(TM) Covid-19 Test** IFU and will be directed to execute the protocol prior to testing clinical samples. Designated laboratories must follow the authorized IFU, which includes the instrument qualification protocol, as per the letter of authorization.
## G. DEVICE DESCRIPTION AND TEST PRINCIPLE
### 1) Product Overview/Test Principle:
The **FloodLAMP EasyPCR(TM) COVID-19 Test** is a RNA extraction-free, duplexed RT-qPCR assay which indicates whether SARS-CoV-2 RNA is present. It can widely and rapidly scale because 1) it does not require nucleic acid extraction equipment, 2) it utilizes reagents and supplies readily available in large quantities, and 3) is a very straightforward protocol with minimal steps that can be executed quickly and reliably. It also utilizes the same streamlined sample preparation as the **FloodLAMP QuickColor(TM) COVID-19 Test**. Both are supply chain robust, "open source" protocol tests, meaning designated laboratories may obtain the test components directly from vendors. Further, the **FloodLAMP QuickColor(TM) COVID-19 Test** is isothermal, does not require any instrumentation and has a visual readout. Together, the two tests can be used in an integrated program for screening and rapid confirmation in large populations by a broad range of laboratories.
In the **FloodLAMP EasyPCR(TM) COVID-19 Test,** samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step, and the resulting inactivated sample is directly used as input in the duplexed RT-qPCR test. The test does not use new primers and probes for RT-qPCR testing, but rather uses previously validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC, which are readily available from multiple commercial suppliers. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a duplex assay, reducing the number of tests to 1 assay with 2 sets.
### 2) Description of Test Steps:
Specimens including **nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs** are collected in **sterile collection tubes.** Swabs are transported and stored dry prior to processing. At the laboratory, an inactivation solution at 1X containing TCEP (2.5 mM), EDTA (1 mM), and NaOH (11 mM) in 0.9% saline (154 mM) is added to the container with the swab, at the volume of 1 ml. Alternatively, for swabs that are collected or eluted in a saline solution or equivalent, the inactivation solution at 100X concentration should be added at 1/100th the sample solution volume.
The container with the specimen and inactivation solution is mixed by vortexing for 30 seconds. Subsequently, the container is heated in a 95°C water bath or dry heat block for 8 minutes. The now inactivated specimen container is allowed to cool at room temperature for 10 minutes and then stored on ice or at 4°C until amplification.
An amplification reaction mix (18 µl) is prepared per manufacturer's specifications, containing the New England Biolabs LunaⓇ PCR Master Mix (New England Biolabs E3006, 10 µl), New England Biolabs LunaⓇ RT (New England Biolabs E3006, 1 µl), a primer solution (4 µl of 5X PCR primer stock w/ N1-F & N1-R at 2 µM, N1-P & RP-P at 1 µM and RP-F & RP-R at 0.75 µM), and nuclease-free water (3 µl).
2µl of the inactivated sample is added to 18µl of the amplification reaction mix. The reaction is then run with the following thermocycler conditions in Table 3:
#### Table 3: Thermal cycling conditions and plate read steps
| Step | Temperature | Time | Reps |
| :---: | :---: | :---: | :---: |
| 1 | 52°C | 10 min | 1 |
| 2 | 95°C | 2 min | 1 |
| 3 | 95°C | 10 sec | 44 |
| 3 | 55°C\* | 30 sec | 44 |
||
*\* This step should be the optical read step*
### 3) Control Materials to be Used with FloodLAMP EasyPCR(TM) COVID-19 Test:
**One Positive Template Control and one Negative (No Template) Control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes. An **Internal Process Control** is included in every PCR reaction.
1) A **“No Template” (Negative) Control (NTC) is needed to assure the absence of cross-contamination from positive samples, positive controls, or amplicons** and is used **to determine if sample results are valid.** **It consists of nuclease-free water.**
2) A **Positive Template Control is needed to assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water.** Stock and working aliquots of the positive control are produced from the sources listed in Table 4 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at \-80°C, or at most 1 month at \-20°C.
3) **An Internal Process Control is needed to assure sufficient specimen quantity and quality**. It consists of a primer/probe set targeting the human RNaseP gene that is included in a single PCR amplification reaction. The RNAseP Internal Process Control uses a fluorescent reporter in a separate channel from the SARS-CoV-2 channel (i.e. in duplex).
#### Table 4. Components for Positive Template Control
| Material | Supplier | Catalog \# | Volume |
| ----- | :---: | :---: | :---: |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µL |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µL |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895 µL |
||
## H. INTERPRETATION OF RESULTS
### 1) FloodLAMP EasyPCR(TM) COVID-19 Test Controls
All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. Target results for the controls will be interpreted according to Table 5 below.
1) The “No Template” (Negative) Control (NTC) should yield a negative “not detected” result for both the N1 and RNaseP targets.
2) The Positive Template Control should yield a positive “detected” result for the N1 target and a negative “not detected” for the RNaseP control.
3) The Internal Process Control should yield a positive "detected" result for RNaseP. Detection of RNaseP is required to report a negative SARS-CoV-2 result.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and (optionally) RNAseZAP(TM) product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
### 2) Examination and Interpretation of Patient Specimen Results:
Assessment of clinical patient specimen test results should be performed after the positive, negative, and internal controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted. Patient specimen results will be interpreted according to Table 5 below.
#### Table 5: Interpretation of Patient Specimen Results
| ABI QuantStudio(TM) 7 Pro | | |
| :---: | :---: | :---: |
| **Result** | **Ct Value: N1** | **Ct Value: RP** |
| Positive | \<38.0 | Any Value |
| Negative | ≥38.0 | \<35.0 |
| Invalid | ≥38.0 | ≥35.0 |
| **Bio-Rad CFX96 Touch(TM) ABI QuantStudio(TM) 6 Flex** | | |
| **Result** | **Ct Value: N1** | **Ct Value: RP** |
| Positive | \<40.0 | Any Value |
| Negative | ≥40.0 | \<35.0 |
| \*Invalid | ≥40.0 | ≥35.0 |
||
\*Invalid test results will be repeated by rerunning the primary sample if available, otherwise by rerunning the inactivated sample. Results from retested samples will follow the same interpretation as listed in Table 5.
If the final interpretation of the test result is invalid, then "Invalid/Inconclusive" should be reported and retesting of the individual is recommended.
## I. PRODUCT MANUFACTURING
### 1) Overview of Manufacturing and Distribution:
The **FloodLAMP EasyPCR(TM) COVID-19 Test** utilizes standard chemicals available from multiple vendors, with the exception of the New England Biolabs LunaⓇ Universal Probe One-Step RT-qPCR Kit.
The **FloodLAMP EasyPCR(TM) COVID-19 Test** utilizes the same primer and probes as the EUA authorized SalivaDirect(TM) test, which derive from the CDC primer set. These are available in very large quantities with immediate distribution from multiple vendors including Eurofins Genomics, Integrated DNA Technologies, and LGC Biosearch.
New England Biolabs has expressed strong support for the **FloodLAMP EasyPCR(TM) COVID-19 Test** and FloodLAMP's other open source protocol EUA submissions that incorporate their products. New England Biolabs has very large quantities of the LunaⓇ Universal Probe One-Step RT-qPCR Kit prepared and ready for immediate distribution, typically with 24 hour shipping. Their manufacturing capacity is among the largest in the United States and can surge to meet increased demand.
**\*Under the Emergency Use Authorization (EUA) any of the 21 CFR Part 820 Quality System Regulation (QSR) requirements can be waived for the duration of the EUA but FDA recommends that developers follow comparable practices as much as possible if such requirements are waived. Among other things, FDA may consider previous compliance history when determining whether or not to waive certain QSR requirements for a specific product. Please note adverse events, as per 21 CFR Part 803, have to be reported for authorized devices (see Section P).**
### 2) Components Included with the Test
None. Designated CLIA labs may order components directly from vendors.
### 3) Components Required But Not Included with Test:
The **FloodLAMP EasyPCR(TM) COVID-19 Test** is to be used with the following reagents or equivalents listed in Table 6.
#### Table 6: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | ----- | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease-freeWater | | Ultrapure Water, DNAse RNAse free | Thermo Fisher | 10977015 |
| NaCl | 5M | Sodium Chloride | Thermo Fisher | 24740011 |
| PCR MasterMix \* | - | 2X PCR Master Mix (in LunaⓇ Universal Probe One-Step RT-qPCR Kit) | New England Biolabs | E3006 |
| PCR RT \* | - | Reverse Transcriptase (in LunaⓇ Universal Probe One-Step RT-qPCR Kit) | New England Biolabs | E3006 |
||
\* Item may not be substituted for equivalents. Only the specified vendor and catalog number may be utilized.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
The 100X Inactivation Solution is prepared by mixing the components in Table 7. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved.
#### Table 7: 100X Inactivation Solution
| Component | Source Concentration | Volume | 100X Concentration |
| :---- | :---: | :---: | :---: |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
For swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 8. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 8: 1X Inactivation Saline Solution
| Component | Volume |
| :---- | :---: |
| 0.9% Saline (154 mM NaCl) | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
The **FloodLAMP EasyPCR(TM) COVID-19 Test** uses the validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a duplex assay, detecting the 2 targets in a single well. This configuration is described in the SalivaDirect(TM) EUA Authorized test ([www.fda.gov/media/141192/download](http://www.fda.gov/media/141192/download)).
The complete set of 6 primers and probes may be purchased from the vendor Eurofins Genomics using the catalog number 12YS-010YST. This product contains primers and probes suspended at 100µM and is enough for 12,500 reactions. The contents can be mixed along with nuclease-free water to create the primer stocks used in the **FloodLAMP EasyPCR(TM) COVID-19 Test**. See Table 9 below for details. A large volume of primer-probe stock can be prepared in advance and stored at 4oC for one month or \-20oC for up to 1 year. Vendors for the Primer and Probe sets are below in Table 10.
#### Table 9: 5X PCR Primer Stock Preparation from Eurofins Genomics Product
| Component (final concentration) | Volume (1 reaction) | Volume (3,125 reactions) |
| ----- | :---: | :---: |
| 2019-nCov\_N1-F (10 µM) | 0.4 µl | 1,250 µl |
| 2019-nCov\_N1-R (10 µM) | 0.4 µl | 1,250 µl |
| 2019-nCov\_N1-P (5 µM) | 0.2 µl | 625 µl |
| RP-F (3.75 µM) | 0.15 µl | 469 µl |
| RP-R (3.75 µM) | 0.15 µl | 469 µl |
| RP-P (5 µM) | 0.2 µl | 625 µl |
| Nuclease-free water | 2.5 µl | 7,813 µl |
| **TOTAL VOLUME** | **4 µl** | **12,500 µl** |
||
#### Table 10: Primer and Probe Set Products
| Vendor | Item | Catalog number | Quantity | #Reactions |
|---------|------|----------------|-----------|------------|
| Eurofins Genomics | SalivaDirect™ complete set of 6 primers and probes | 12YS-010YST | 50-100 nmol | 12,500 |
| Integrated DNA Technologies | nCoV_N1 Forward Primer Aliquot | 10006821 | 50 nmol | 6,2500 |
| Integrated DNA Technologies | nCoV_N1 Forward Primer Aliquot | 10006830 | 100 nmol | 12,500 |
| Integrated DNA Technologies | nCoV_N1 Reverse Primer Aliquot | 10006822 | 50 nmol | 6,250 |
| Integrated DNA Technologies | nCoV_N1 Reverse Primer Aliquot | 10006831 | 100 nmol | 12,500 |
| Integrated DNA Technologies | NCoV_N1 Probe Aliquot | 10006831 | 25 nmol | 6,250 |
| Integrated DNA Technologies | NCoV_N1 Probe Aliquot | 10006832 | 50 nmol | 12,500 |
| Integrated DNA Technologies | RNaseP Forward Primer Aliquot | 10006827 | 50 nmol | 16,600 |
| Integrated DNA Technologies | RNaseP Forward Primer Aliquot | 10006836 | 100 nmol | 33,300 |
| Integrated DNA Technologies | RNaseP Reverse Primer Aliquot | 10006828 | 50 nmol | 16,600 |
| Integrated DNA Technologies | RNaseP Reverse Primer Aliquot | 10006837 | 100 nmol | 33,300 |
| Integrated DNA Technologies | RNase P Probe | Custom order (Cy5) | 25 nmol | 6,250 |
| Integrated DNA Technologies | RNase P Probe | Custom order (Cy5) | 50 nmol | 12,500 |
| Integrated DNA Technologies | RNase P Probe | 10007061 (ATTO647) | 25 nmol | 6,250 |
| Integrated DNA Technologies | RNase P Probe | 10007062 (ATTO647) | 50 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Forward Primer | nCoV-N1-F-100 | 100 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Forward Primer | nCoV-N1-F-1000 | 1000 nmol | 125,000 |
| LGC Biosearch Technologies | nCoV_N1 Reverse Primer | nCoV-N1-R-100 | 100 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Reverse Primer | nCoV-N1-R-1000 | 1000 nmol | 125,000 |
| LGC Biosearch Technologies | NCoV_N1 Probe | nCoV-N1-P-25 | 25 nmol | 6,250 |
| LGC Biosearch Technologies | NCoV_N1 Probe | nCoV-N1-P-250 | 250 nmol | 62,500 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-20 | 20 nmol | 6,660 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-100 | 100 nmol | 33,300 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-1000 | 1000 nmol | 333,300 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-20 | 20 nmol | 6,660 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-100 | 100 nmol | 33,300 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-1000 | 1000 nmol | 333,300 |
| LGC Biosearch Technologies | RNase P Probe | RNP-PQ670-25 | 25 nmol | 6,250 |
| LGC Biosearch Technologies | RNase P Probe | RNP-PQ670-250 | 50 nmol | 12,500 |
||
The final amplification reaction components are listed in Table 11. PCR plates or strip tubes used for the amplification reactions should be maintained on ice or a cold block.
#### Table 11: PCR Amplification Reaction
| Component | Volume (1 reaction) | Volume (100 reactions) |
| :---- | :---: | :---: |
| 5X PCR Primer Stock | 4 µL | 400 µL |
| New England Biolabs PCR MM | 10 µL | 1000 µL |
| New England Biolabs PCR RT | 1 µL | 100 µL |
| Nuclease-Free Water | 3 µL | 300 µL |
| **SUBTOTAL VOLUME** | **18 µL** | **2250 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **20 µL** | - |
||
### 4) Software Validation
The **FloodLAMP EasyPCR(TM) COVID-19 Test** has been validated on the RT-PCR instruments listed in Table 2 using the baseline threshold settings unless otherwise noted in the Instructions for Use. The test does not require any additional software.
### 5) Testing Capabilities
The **FloodLAMP EasyPCR(TM) COVID-19 Test** has been optimized for a robust, streamlined workflow and for rapid turnaround time on results. The total time to perform the test is dependent upon the following factors: number of lab technicians, batch size of samples, and in advance preparation of reaction mixes. The minimum turnaround time is approximately 1 hour and 45 minutes, of which approximately 1 hour and 20 minutes is the RT-PCR instrument run time. Automation can greatly increase overall throughput.
### 6) Reagent Stability:
A stability test plan for the components of the **FloodLAMP EasyPCR(TM) COVID-19 Test** will be developed during an interactive review. Briefly, the proposed study includes assessing all prepared solutions including: 100X Inactivation Solution, 1X Inactivation Saline Solution, 5X PCR Primer Stock, and the full PCR Amplification Mix. Prepared solutions will be assessed both for long term storage stability (typically 1-3 months at \-20oC) and short term storage stability prior to usage (typically hours to several days at room temperature, 4oC or \-20oC).
The proposed study uses a contrived positive sample consisting of gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative specimens at approximately 50,000 copies/mL (4X LoD). The contrived positive stability study samples will be prepared, aliquoted and stored at \-80oC to permit repeated testing of the various solutions at the appropriate step of the test protocol.
For test components supplied by vendors, such as New England Biolab’s LunaⓇ Universal Probe One-Step RT-qPCR Kit, the manufacturer's recommended storage conditions and duration will be followed.
### 7) Sample Stability:
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
Samples can be stored at room temperature for 56 hours after collection prior to inactivation. For longer term storage, samples can be stored at ≤-70oC.
## J. PERFORMANCE EVALUATION
### 1) Limit of Detection (LoD) - Analytical Sensitivity:
The Limit of Detection (LoD) for the **FloodLAMP EasyPCR(TM) COVID-19 Test** was established using gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The gamma-irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 6,300, 3,100 and 1,600 copies/mLwere selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 12. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 3,100 copies/mL.
#### Table 12: Confirmatory LoD Data Results
| Instrument | LoD | Positive Replicates | Mean Ct Value (SD) |
| ----- | :---: | :---: | :---: |
| ABI QuantStudio(TM) 7 Pro | 3,100 copies/mL | 95% (20/21) | 36.5 (.8) |
| ABI QuantStudio(TM) 6 Flex | 3,100 copies/mL | 100% (21/21) | 36.9 (1.1) |
| Bio-Rad CFX96 Touch(TM) | 3,100 copies/mL | 95% (20/21) | 37.2 (.9) |
||
### 2) Inclusivity (analytical sensitivity):
**FloodLAMP EasyPCR(TM) COVID-19 Test** includes a modified RT-qPCR assay by duplexing the previously authorized CDC N1 and human RNase P primer-probe sets. Inclusivity was tested in the original US CDC EUA with all publicly available SARS-CoV-2 genomes as of 1 February 2020. The initial analysis showed 100% homology between the N1 primer-probe set and available genomes, except for one low frequency mismatch with the N1 forward primer. However, this was not expected to affect performance of the primer-probe set due to annealing temperatures of 55°C which tolerate 1-2 mismatches. Indeed, performance of the N1 primer-probe set was shown to be high in the previous comparison of primer-probes sets ([https://www.nature.com/articles/s41564-020-0761-6](https://www.nature.com/articles/s41564-020-0761-6)). GISAID continuously evaluates mismatches between newly available SARS-CoV-2 genomes and primer-probe sets and confirms a low frequency of nucleotide mismatches (\<5%) with the N1 primer-probe set.
### 3) Cross-reactivity (Analytical Specificity):
The primer and probe sets used in the duplex assay were developed by the US CDC and have been EUA certified. The CDC reported no cross-reactivity with other human coronaviruses (229E, OC43, NL63, and HKU1), MERS-coronavirus, SARS-coronavirus, and 14 additional human respiratory viruses (see [https://www.fda.gov/media/134922/download](https://www.fda.gov/media/134922/download)).
#### Endogenous Interference Substances Studies:
Exogenous and endogenous substances were tested for potential interference with the **FloodLAMP EasyPCR(TM) COVID-19 Test*.*** 10 µL of each stock of interfering substance was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. The gamma-irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived Positive Control Spiked comprised 20 µL of 8e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 160,000 copies/mL in the sample input into the amplification reaction.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 13 and Supporting Data.
#### Table 13: Interfering Substances Results
| Interfering Substance | Active Ingredient | Concentration | % Agreement with Expected Results | |
| :---: | :---: | :---: | :---: | :---: |
| | | | **Positive Control Spiked** | **Negative Control Unspiked** |
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
### 4) Clinical Evaluation
The clinical evaluation of the **FloodLAMP EasyPCR(TM) COVID-19 Test** utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The **FloodLAMP EasyPCR(TM) COVID-19 Tes**t showed a positive agreement of 97.5% and a negative agreement of 100%. The single false negative result was a specimen with a high Ct value as previously measured by the comparator test, indicating very low viral load. A summary of the clinical performance is below in Table 14.
Anterior nares swab specimens were collected from patients in phosphate buffered saline by the Stanford COVID-19 clinical testing program. Specimens were initially tested by the Stanford clinical laboratory using the Hologic Panther Fusion and Aptima SARS-CoV-2 Assays, which serves as the high sensitivity comparator test.
For the **FloodLAMP EasyPCR(TM) COVID-19 Test**, materials and the Instructions For Use were provided to the Stanford clinical laboratory. The materials provided consisted of the validated reagents listed in Table 6, the Eurofins Genomics primers and probes, and an aliquot of the positive control. The Bio-Rad CFX96 instrument was used to perform the RT-PCR. After thawing the frozen specimens, 1 mL of each specimen was transferred to 5mL tubes for the inactivation step. The positive and negative clinical specimens were assigned a new ID in a random order, then transferred to new tubes that were barcoded and labeled with the new ID. Line Item data are provided in the Supporting Data.
#### Table 14: Clinical Evaluation Results
| FloodLAMP EasyPCR(TM) COVID-19 Test Results | Comparator \- High Sensitivity EUA Authorized Test | | |
| :---: | :---: | :---: | :---: |
| | **Positive** | **Negative** | **Total** |
| Positive | 39 | 0 | 39 |
| Negative | 1 | 40 | 41 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 97.5% (39/40) 95% CI: 86.8% to 99.9% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## K. UNMET NEED ADDRESSED BY THE PRODUCT
This section will be completed by FDA.
## L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the detection of the SARS-CoV-2 have been approved/cleared by FDA.
## M. BENEFITS AND RISKS:
This section will be completed by FDA.
## N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
Fact Sheets for Patients and Healthcare Providers attached.
## O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
Instructions for Use attached.
## P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
QuantStudio is a trademark of Thermo Fisher Scientific (NYSE: TMO)
Bio-Rad and Bio-Rad CFX96 Touch is a trademark of Bio-Rad Laboratories, Inc. (NYSE: BIO)
# 16,140 2021-05-18_EUA Submission - FloodLAMP QuickColor COVID-19 Test v1.1.md
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title: EUA Submission - FloodLAMP QuickColor COVID-19 Test v1.1
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summary_short: The EUA Submission for the FloodLAMP QuickColor™ COVID-19 Test v1.1 describes an extraction-free RT-LAMP, colorimetric assay for qualitative SARS-CoV-2 RNA detection from upper respiratory swab specimens in both symptomatic individuals and routine serial screening programs. It details intended use, primer targets (ORF1ab, N, E), workflow and controls, manufacturing inputs, and analytical/clinical performance data to support an FDA Emergency Use Authorization request.
CONTENT
***INTERNAL TITLE:*** EUA Submission - FloodLAMP QuickColor(TM) COVID-19 Test
## A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the **FloodLAMP QuickColor(TM) COVID-19 Test** for the *in vitro* qualitative detection of RNA from the SARS-CoV-2 in in upper respiratory specimens including oropharyngeal and nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week, such as those implemented by schools, workplaces and community groups**. Additional testing and confirmation procedures should be performed in consultation with public health and/or other authorities to whom reporting is required. Test results should be reported in accordance with local, state, and federal regulations.
## B. MEASURAND
Specific nucleic acid sequences from the genome of the SARS-CoV-2, targeted by **primers from the ORF1ab, N and E regions** of the virus. Primer names and sequences are listed in Table 1.
#### Table 1: Primer names and sequences
| Primer Name | Sequence (5’-3’) |
| :---- | :---- |
| **ORF1ab gene (AS1e)** | |
| Orf1ab\_FIP | TCAGCACACAAAGCCAAAAATTTATTTTTCTGTGCAAAGGAAATTAAGGAG |
| Orf1ab\_BIP | TATTGGTGGAGCTAAACTTAAAGCCTTTTCTGTACAATCCCTTTGAGTG |
| Orf1ab\_F3 | CGGTGGACAAATTGTCAC |
| Orf1ab\_B3 | CTTCTCTGGATTTAACACACTT |
| Orf1ab\_LF | TTACAAGCTTAAAGAATGTCTGAACACT |
| Orf1ab\_LB | TTGAATTTAGGTGAAACATTTGTCACG |
| **N Gene (N2)** | |
| N2\_FIP | TTCCGAAGAACGCTGAAGCGGAACTGATTACAAACATTGGCC |
| N2\_BIP | CGCATTGGCATGGAAGTCACAATTTGATGGCACCTGTGTA |
| N2\_F3 | ACCAGGAACTAATCAGACAAG |
| N2\_B3 | GACTTGATCTTTGAAATTTGGATCT |
| N2\_LF | GGGGGCAAATTGTGCAATTTG |
| N2\_LB | CTTCGGGAACGTGGTTGACC |
| **E Gene (E1)** | |
| E1\_FIP | ACCACGAAAGCAAGAAAAAGAAGTTCGTTTCGGAAGAGACAG |
| E1\_BIP | TTGCTAGTTACACTAGCCATCCTTAGGTTTTACAAGACTCACGT |
| E1\_F3 | TGAGTACGAACTTATGTACTCAT |
| E1\_B3 | TTCAGATTTTTAACACGAGAGT |
| E1\_LF | CGCTATTAACTATTAACG |
| E1\_LB | GCGCTTCGATTGTGTGCGT |
||
## C. APPLICANT
FloodLAMP Biotechnologies, a DE Public Benefit Corporation
| Mailing Address: 4860 Alpine Rd. Portola Valley, CA 94028 | Laboratory Address: 930 Brittan Ave San Carlos, CA 94070 | Randall J. True, CSO Phone: (415) 269-2974 Email: randy@floodlamp.bio |
| :---- | :---- | :---- |
## D. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name \- **FloodLAMP QuickColor(TM) COVID-19 Test**
Established Name \- **FloodLAMP QuickColor(TM) COVID-19 Test**
## E. REGULATORY INFORMATION
***Approval/Clearance Status:***
The **FloodLAMP QuickColor(TM) COVID-19 Test** is not cleared, CLIA waived, approved, or subject to an approved investigational device exemption.
***Product Code:***
QJR
## F. PROPOSED INTENDED USE
### 1) Intended Use:
**FloodLAMP QuickColor(TM) COVID-19 Test** is a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week**. Testing is limited to **laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.**
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis
for patient management decisions. Negative results must be combined with clinical observations,
patient history, and epidemiological information.
The **FloodLAMP QuickColor(TM) COVID-19 Test** is intended for use by **qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures**. The **FloodLAMP QuickColor(TM) COVID-19 Test** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
### 2) Special Conditions for Use Statements:
For Emergency Use Authorization (EUA) only
For prescription use only
For *in vitro* diagnostic use only
### 3) Special Instrument Requirements:
The **FloodLAMP QuickColor(TM) COVID-19 Test** does not have special instrument requirements.
## G. DEVICE DESCRIPTION AND TEST PRINCIPLE
### 1) Product Overview/Test Principle:
The **FloodLAMP QuickColor(TM) COVID-19 Test** is a RNA extraction-free reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) molecular assay that indicates the presence of the SARS-CoV-2 viral RNA with a simple visual color change. It can widely and rapidly scale because 1) no special instrumentation of any kind is required, neither nucleic acid extraction equipment nor a RT-PCR instrument, 2) it utilizes reagents and supplies readily available in large quantities, and 3) is a straightforward protocol with minimal steps that can be executed quickly and reliably. It also utilizes the same streamlined sample preparation as the **FloodLAMP EasyPCR(TM) COVID-19 Test**. Both are supply chain robust, "open source" protocol tests, meaning designated laboratories may obtain the test components directly from vendors. Together, the two tests can be used in an integrated program for screening and rapid confirmation in large populations by a broad range of laboratories.
The **FloodLAMP QuickColor(TM) COVID-19 Test** uses a set of specific primers that target ORF1ab, N and E genes for the detection of SARS-CoV-2 RNA. It uses Loop Mediated Isothermal Amplification (LAMP), a nucleic acid amplification technique wherein DNA amplification is carried out at a constant temperature of approximately 65°C. Samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step. The resulting inactivated sample is directly used as input in the LAMP reaction. The amplification reaction mix includes a reverse transcriptase (RT) polymerase to create complementary cDNA from RNA. The cDNA is subsequently amplified by a high strand displacement DNA polymerase. The amplified DNA products lower the pH of the reaction. A phenol red pH indicating dye is included in the amplification reaction mix, thus causing the reaction solution to visibly change from an initial bright pink to a bright yellow when sufficient amplification occurs. Reactions that change color to yellow indicate that SARS-CoV-2 RNA is present.
### 2) Description of Test Steps:
Specimens including **nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs** are collected in **sterile collection tubes.** Swabs are transported and stored dry prior to processing. At the laboratory, an inactivation solution at 1X containing TCEP (2.5 mM), EDTA (1 mM), and NaOH (11 mM) in 0.9% saline (154 mM) is added to the container with the swab, at the volume of 1 mL. Alternatively, for swabs that are collected or eluted in a saline solution or equivalent, the inactivation solution at 100X concentration should be added at 1/100th the sample solution volume.
The container with the specimen and inactivation solution is mixed by vortexing for 30 seconds. Subsequently, the container is heated for 8 minutes in a 95°C water bath or dry heat block. The now inactivated specimen container is allowed to cool at room temperature for 10 minutes and then stored on ice or at 4°C until amplification.
An amplification reaction mix (23 µl) is prepared per manufacturer's specifications, containing the Colorimetric LAMP master mix (NEB M1800, 12.5 µl) and a primer-guanidine solution (10.5 µl) comprising 10X primers mix (2.5 µl of 10X w FIP/BIP at 16 µM, F3/B3 at 2 µM, and LF/BF at 4 µM), guanidine hydrochloride (2.5 µl of 400 mM), and nuclease-free water (5.5 µl). The primer-guanidine solution may be prepared ahead of time and stored at \-20°C for up to 1 month.
2 µl of the inactivated sample is added to 23µl of the amplification reaction mix. The reaction is incubated at 65°C for 25 minutes in a thermal cycler, dry heat block, or water bath. After removal from the heat, the reaction solution is allowed to cool at room temperature for 1 minute and then the test result is determined visually based on the color of the reaction solution.
### 3) Control Materials to be Used with test:
**One positive and one negative control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes on each heater:
1) A “no template” (negative) control (NTC) is needed to **assure the absence of cross contamination from positive samples, positive controls, or amplicons** and is used **to determine if sample results are valid.** **It consists of 100X Inactivation Solution diluted to 1X in 0.9% saline.** This NTC is the same solution added to dry swabs (see Section I below for the components)**.**
2) A positive template control is needed to **assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water.** Stock and working aliquots of the positive control are produced from the sources listed in Table 2 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at \-80°C, or at most 1 month at \-20°C.
#### Table 2: Components for Positive Template Control
| Material | Supplier | Catalog \# | Volume |
| ----- | :---: | :---: | :---: |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µL |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µL |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895 µL |
||
## H. INTERPRETATION OF RESULTS
### 1) FloodLAMP QuickColor(TM) COVID-19 Test Controls
All test controls should be examined prior to interpretation of specimen results. If the controls are not valid, the specimen results cannot be interpreted. An example of the expected appearance of the negative and positive controls after amplification is shown in Figure 1.
_Photo showing negative control (pink, left) and positive control (yellow, right) after amplification._
#### Figure 1. Negative control (left) and positive control (right) after amplification.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and optionally RNAseZAP product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
### 2) Examination and Interpretation of Patient Specimen Results:
Assessment of clinical patient specimen test results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
Test results should be read at least 1 minute and no more than 8 hours after plates or tubes have been removed from heat. Test results may be determined directly from visual inspection of the color of the reaction tubes:
* yellow \- result is positive
* bright pink or red \- result is negative
* any other color \- result is inconclusive.
Examples are shown below in Figure 2. Edge cases for positive and negative results are shown below in Figure 3. Any color variance stronger than the edge cases should be interpreted as inconclusive. In order to reduce the chance of both false negative and false positive results, this window for color variance is intentionally set to be small.
If the initial test is inconclusive, then one of the following should be performed:
1) repeat the Colorimetric LAMP Amplification Reaction on the inactivated sample. If the repeat test has a positive result then the final interpretation of the test is positive. If the repeat test has a negative or another inconclusive result, then the final interpretation is inconclusive.
2) follow-up test the inactivated sample with the FloodLAMP EasyPCR(TM) COVID-19 Test or another high sensitivity EUA authorized test that comprises the same inactivation protocol. The final interpretation is the result of the follow-up test.
For serial screening of individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, the initial inconclusive test result may be considered the final interpretation. If the final interpretation of the test result is inconclusive, then "Inconclusive" should be reported and retesting of the individual is recommended.
_Photos showing example test results (Figure 2: two negative pink and two positive yellow tubes) and edge case results (Figure 3: edge-case negative pink and edge-case positive yellow tubes)._
## I. PRODUCT MANUFACTURING
### 1) Overview of Manufacturing and Distribution:
The **FloodLAMP QuickColor(TM) COVID-19 Test** utilizes standard chemicals available in very large quantities from multiple vendors, with the exception of the LAMP Primers and New England Biolabs Colorimetric LAMP Master Mix.
FloodLAMP has partnered with LGC Biosearch for the LAMP Primers. LGC Biosearch has very large scale oligo production capacity and mature distribution capabilities. The first production scale lot of the LAMP Primers has been completed, with 1.2 million reactions ready for immediate distribution. FloodLAMP has purchased 600K reactions of the LAMP Primers. LGC Biosearch is supplying FloodLAMP for the **FloodLAMP QuickColor(TM) COVID-19 Test** and is also offering the LAMP Primers as a catalog product.
New England Biolabs has expressed strong support for the **FloodLAMP QuickColor(TM) COVID-19 Test** and FloodLAMP's other open source protocol EUA submissions that incorporate their products. New England Biolabs has very large quantities of the Colorimetric LAMP Master Mix product prepared and ready for immediate distribution, typically with 24 hour shipping within the U.S. Their manufacturing capacity is among the largest in the United States and can surge to meet increased demand.
**\*Under the Emergency Use Authorization (EUA) any of the 21 CFR Part 820 Quality System Regulation (QSR) requirements can be waived for the duration of the EUA but FDA recommends that developers follow comparable practices as much as possible if such requirements are waived. Among other things, FDA may consider previous compliance history when determining whether or not to waive certain QSR requirements for a specific product. Please note adverse events, as per 21 CFR Part 803, have to be reported for authorized devices (see Section P).**
### 2) Components Included with the Test
None. Designated CLIA labs may order components directly from vendors.
### 3) Components Required But Not Included with Test:
The **FloodLAMP QuickColor(TM) COVID-19 Test** is to be used with the reagents or equivalents listed in Table 3. No specialized instruments are needed. Only ordinary laboratory equipment such as pipettes, centrifuges, and heaters are needed.
#### Table 3: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog No. |
| :---- | ----- | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease- free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5 M | Sodium Chloride | Thermo Fisher | 24740011 |
| Guanidine | 6 M | Guanidine Hydrochloride | Sigma-Aldrich | SRE0066 |
| ColorimetricLAMP MM\* | - | Colorimetric LAMP Master Mix | New England Biolabs | M1804 |
||
\* Item may not be substituted for equivalents. Only the specified vendor and catalog number may be utilized.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
A 100X Inactivation Solution is prepared by mixing the components in Table 4. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved. Aliquots of 100X Inactivation Solution should be stored in the dark at \-20°C for up to 3 months. Upon thaw, working aliquots of 100X Inactivation Solution should be stored in the dark at room temperature for up to 1 month.
#### Table 4: 100X Inactivation Solution
| Component | Source Concentration | Volume for 100X | 100X Concentration |
| :---- | :---: | :---: | :---: |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
For swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 5. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 5: 1X Inactivation Saline Solution
| Component | Volume |
| :---- | :---: |
| 0.9% Saline (154 mM NaCl) in MilliQ Water | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
The **FloodLAMP QuickColor(TM) COVID-19 Test** uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. Primer names and sequences are shown above in Table 1. All 18 primers are mixed together and input into a single amplification reaction.
Primers may be purchased from the vendor LGC Biosearch Technologies as 3 pre-blended sets, or the primers may be purchased as 18 individual custom oligos. Table 6 below lists the primer products to be ordered.
The LGC Biosearch primer products are provided already blended for each target (6 primers per tube) and dried such that upon resuspension with 1 mL of nuclease-free water, the primers for each target are at 30X concentration. One resuspended tube for each of the 3 targets (i.e. primer blends) are mixed together to yield a 3 mL total volume that contains all individual primers at 10X concentration. This 3 mL of 10X LAMP Primer Mix provides for 1,200 reactions at 2.5 µL per reaction.
Alternatively to the pre-blended LGC Biosearch products, primers may be purchased as individual custom oligos. Custom oligos may be blended to form 30X Primer Set Mixes as intermediates or all mixed together for the 10X LAMP Primer Mix. The FIP and BIP primers for each target require purification by HPLC or an equivalent process. Appropriate validation of primer mixes from custom oligos is required. Primers may be stored at 4°C for up to one month, or at \-20°C for up to 1 year.
#### Table 6: 10X LAMP Primer Mix Components
| Vendor | Item | Catalog number | Quantity | #Reactions |
|---------|------|----------------|-----------|------------|
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LB | Custom Order | 250 nmol | 25,000 |
||
The primers are mixed with guanidine hydrochloride to form an intermediate Primer-Guanidine Solution prior to combining with the sample and Colorimetric LAMP MM for the full amplification reaction. The components and volumes for the Primer-Guanidine Solution are listed in Table 7 and may be proportionally scaled for batch sizes of different numbers of reactions. The Primer-Guanidine Solution may be prepared in advance and should be stored at \-20°C for up to 1 month.
#### Table 7: Primer-Guanidine Solution
| Component | Volume (1 reaction) | Volume (100 reactions) |
| :---- | :---: | :---: |
| 10X LAMP Primer Mix | 2.5 µL | 250 µL |
| Guanidine (400 mM) | 2.5 µL | 250 µL |
| Nuclease-free Water | 5.5 µL | 550 µL |
| **TOTAL VOLUME** | **10.5 µL** | **1050 µL** |
||
The final Colorimetric LAMP Amplification Reaction components are listed in Table 8. PCR plates or strip tubes used for the amplification reactions should be maintained on ice or a cold block until less than 5 minutes before incubation on the heater. Reaction plates/strip tubes comprising the Colorimetric LAMP Amplification Reaction Solution may be prepared in advance, capped/sealed, and stored at \-20°C for up to 1 day prior to addition of the sample. A heated plate sealer is recommended. Alternatively, a manually applied foil or optical seal may be used.
#### Table 8: Colorimetric LAMP Amplification Reaction
| Component | Volume (1 reaction) | Volume (100 reactions) |
| :---- | :---: | :---: |
| Primer-Guanidine Solution | 10.5 µL | 1050 µL |
| Colorimetric LAMP MM | 12.5 µL | 1250 µL |
| **SUBTOTAL VOLUME** | **23 µL** | **2300 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **25 µL** | - |
||
### 4) Software Validation
No software is required for labs to run the **FloodLAMP QuickColor(TM) COVID-19 Test*.***
### 5) Testing Capabilities
The **FloodLAMP QuickColor(TM) COVID-19 Test** has been optimized for a robust, streamlined workflow and rapid turnaround time on results. The total time to perform the test is dependent upon the following factors: number of lab technicians, batch size of samples, and advance preparation of reaction mixes. **The minimum turnaround time is approximately 45 minutes.**
Since the **FloodLAMP QuickColor(TM) COVID-19 Test** does not require specialized instruments, it can be scaled up without the capital investment required for PCR machines or automated extraction. The number of tests capable of being performed per day by a laboratory is not constrained by PCR machines or extraction instruments. One technician can manually process approximately one plate (94 samples) per hour. This includes intake (debagging and barcode scanning), inactivation, and LAMP amplification. Automation can greatly increase throughput.
### 6) Reagent Stability
A stability test plan for the components of the **FloodLAMP QuickColor(TM) COVID-19 Test** will be developed during an interactive review. Briefly, the proposed study includes assessing all prepared solutions including: 100X Inactivation Solution, 1X Inactivation Saline Solution, 30X Primer Stock, 10X Primer Mix, Primer-Guanidine Solution, and the full Colorimetric LAMP Amplification Reaction Mix. Prepared solutions will be assessed both for long term storage stability (typically 1-3 months at \-20oC) and short term storage stability prior to usage (typically hours to several days at room temperature, 4oC or \-20oC).
The proposed study uses a contrived positive sample consisting of inactivated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative specimens at approximately 50,000 copies/mL (4X LoD). The contrived positive stability study samples will be prepared, aliquoted and stored at \-80oC to permit repeated testing of the various solutions at the appropriate step of the test protocol.
For test components supplied by vendors, such as the Colorimetric LAMP Master Mix, the manufacturer's recommended storage conditions and duration will be followed.
### 7) Sample Stability
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
Samples can be stored at room temperature for 56 hours after collection prior to inactivation. For longer term storage, samples can be stored at ≤-70oC.
## J. PERFORMANCE EVALUATION
### 1) Limit of Detection (LoD) - Analytical Sensitivity:
The Limit of Detection (LoD) for the **FloodLAMP QuickColor(TM) COVID-19 Test** was established using gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The negative specimens were confirmed by PCR using the CDC primers. The gamma-irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 12,500 and 6,250 were selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 9. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 12,500 copies/mL.
#### Table 9: LoD Confirmatory Data Results
| Concentration of Contrived Positive Sample | Replicates Detected |
| :---: | :---: |
| 12,500 copies/mL | 95% (20/21) |
| 6,250 copies/mL | 52% (11/21) |
||
### 2) Inclusivity (analytical sensitivity):
An inclusivity study was conducted for the ORF1ab, N2, and E1 primer sets against all complete, high coverage SARS-CoV-2 sequences deposited at GISAID as of February 27, 2021. Table 10 summarizes the results of this in silico inclusivity analysis. A total of 498,224 sequences were considered. There are 10 sequence isolates that have 1mm to both As1e and E1 and had N2 excluded due to greater than 15 N's, with the other 498,214 sequence isolates all have at least 1 target region that is a complete match.
Each primer set matched at 100% similarity against the SARS-CoV-2 RefSeq reference genome (Wuhan-Hu-1; NC\_045512.1). All three primer sets differed by one or fewer mutations for 99.7% of GISAID sequences, indicating nominal primer hybridization for all SARS-CoV-2 variants under consideration.
#### Table 10: *In Silico* Inclusivity Analysis for LAMP Primers
| Primer | AS1e (ORF1ab gene) | | N2 (N gene) | | E1 (E gene) | |
| :---- | ----- | ----- | ----- | ----- | ----- | ----- |
| **Total Primer Length** | 195 | | 169 | | 168 | |
| **Total Number of Strains Evaluated** | 498,224 | | 498,224 | | 498,224 | |
| **100% Match** | 474,717 | 95.3% | 479,548 | 96.3% | 462,538 | 92.8% |
| **1 Mismatch** | 19,301 | 3.9% | 15,698 | 3.2% | 30,626 | 6.1% |
| **2 Mismatches** | 338 | 0.1% | 161 | 0.0% | 1,455 | 0.3% |
| **3 Mismatches** | 9 | 0.0% | 5 | 0.0% | 103 | 0.0% |
| **\> 3 Mismatches** | 0 | 0.0% | 0 | 0.0% | 1 | 0.0% |
| **Total Strains Removed** | 3,859 | 0.8% | 2,812 | 0.6% | 3,501 | 0.7% |
||
#### Evaluation of Impact of Viral Mutations
The As1e, E1 and N2 primer regions of all SARS-CoV-2 genomes present in GISAID as of 2/26/2021 were evaluated to assess the potential impact of genomic variants on LAMP primer binding. This analysis was performed with the Primer Monitoring Tool from New England Biolabs ([primer-monitor.neb.com](https://primer-monitor.neb.com/)), which continually monitors registered primer sets for overlapping variants in sequences from GISAID. Results are summarized by region and locus below in Table 11, including the 30 countries with most sequences in GISAID. Sequences were aligned to the SARS-CoV-2 reference sequence (NC\_045512.2) using minimap2 (minimap2 \-t 16 \-x asm5 \-a). Variant sites (excluding Ns) were identified using samtools mpileup and summarized by region and genome position. Genomic positions having \>= 40 global variant observations are shown (column labels). When present, box labels indicate the fraction of variants observed at a given locus.
The aggregate of current published mutations is not expected to reduce performance of the **FloodLAMP QuickColor(TM) COVID-19 Test** by more than 5% from that established by the performance evaluation in this EUA submission. Further, the use of 3 primer sets targeting different regions in the SARS-CoV-2 genome should make the test robust to new genetic variants.
#### Table 11: Variant Analysis of LAMP Primers
_Heatmap charts showing variant frequency at LAMP primer binding sites across 30 countries for AS1e, N2, and E1 primer sets, based on GISAID sequences aligned to the SARS-CoV-2 reference genome._
### 3) Cross-reactivity (Analytical Specificity):
*In silico* cross-reactivity analysis was performed by aligning the primer sequences of the **FloodLAMP QuickColor(TM) COVID-19 Test** against sequences of other coronaviruses and common respiratory flora using the BLASTn alignment tool from NCBI. Results of this analysis are presented in Tables 12A, 12B, and 12C.
The % identity range (\# identical bases/ \# primer bases) is shown for each primer and organism. Darker font indicates % identity greater than 80%. Organisms with \>= 50% identity primer hits are shown. This analysis is not intended to predict amplification. Near perfect homology across B3, F3, FIP and BIP is necessary to support successful amplification. With the exception of SARS-CoV, simultaneous homologies do not occur between any of the primers and microorganisms screened. With respect to clinical relevance of the in silico cross-reactivity analysis, there are no known circulating strains of SARS-CoV circulating in humans, thus the overall probability for the test to produce a cross-reactive signal is negligible.
#### Table 12A: *In Silico* Cross-Reactivity Analysis for AS1e Primers
| Organism Group | Organism Name | Organism ID | As1_B3 (22 bp) | As1e_BIP (49 bp) | As1_F3 (18 bp) | As1e_FIP (51 bp) | As1_LB (27 bp) | As1_LF (28 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 47%-55% | 100% | 43%-53% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| | SARS coronavirus | NC_004718 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 72%-89% | 29% | 52%-67% | |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 77% | | 89% | 37%-51% | 52%-89% | |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 59%-73% | 33%-35% | 89% | 33%-45% | 52% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-73% | 31% | 72%-83% | 29%-59% | 52% | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | 83% | | | |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 59%-82% | 39% | | 29%-41% | 67% | 61% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-82% | | 72% | 39%-87% | 59% | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 59%-82% | 31% | 72% | 31% | 52%-67% | |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | 72%-78% | | 70% | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | 72% | 29%-35% | 78% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.15 | NW_017264789.1 | 59% | | | 78% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.11 | NW_017264785.1 | 77% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 77% | | | 35% | 63% | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59% | 43%-49% | 72% | 29%-57% | 63%-74% | 68% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | 49% | 72% | 31%-41% | 56%-74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | 31%-43% | 74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 73% | | 72% | 29%-39% | 52% | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 59%-68% | 31%-37% | 72% | 29%-35% | 56%-67% | 57%-71% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | 37%-41% | 72% | 29%-41% | 52%-63% | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.14 | NW_017264788.1 | | | | 35% | | 71% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | | | | 29%-47% | 70% | 68% |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59%-68% | 35% | | 29%-43% | | 68% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 68% | 37% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 33%-49% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | 43% | | 38% | | 68% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 64% | | | | | 57% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | | | | 33%-35% | 59% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 59% | | | | | 50% |
| | Bordetella pertussis 18323 | NC_018518.1 | | | | | | 57% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | | 52% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | 39%-47% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.54 | NW_017264828.1 | | 47% | | | | |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | | 31% | | 31%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | | | | 33%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.19 | NW_017264793.1 | | | | 38% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | | | | 35% | | |
| | Respiratory syncytial virus | NC_001803.1 | | | | 33% | | |
||
#### Table 12B: *In Silico* Cross-Reactivity Analysis for N2 Primers
| Organism Group | Organism Name | Organism ID | N2_B3 (25 bp) | N2_BIP (40 bp) | N2_F3 (21 bp) | N2_FIP (42 bp) | N2_LB (20 bp) | N2_LF (21 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 53% | 100% | 48%-55% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 64% | 53% | 90% | 55% | 85% | 90% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 60%-80% | | 95% | | 75% | 62%-71% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | 40% | 75%-90% | |
| | Bordetella pertussis 18323 | NC_018518.1 | | 35% | | | 65%-80% | 81% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | 56%-72% | 43% | | | | 62%-81% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | 56%-76% | | 62%-71% | 45% | | 62%-81% |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 56%-80% | 35%-68% | 62% | | | 62%-81% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 60%-80% | 35%-45% | 71% | | | 62%-71% |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 60%-72% | 35%-45% | 71%-76% | | | 62%-76% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 56%-76% | | 76% | 36% | 65% | |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 60%-76% | 43% | | 36%-55% | | 62%-76% |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | 60% | | | | 65%-75% | 76% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 68%-64% | | | | | 76% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | 35% | | | 75% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 56%-72% | 48% | 62% | 40% | | 67%-71% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 56%-72% | | 71% | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.17 | NW_017264791.1 | 56%-72% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | 60%-72% | | 71% | | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 56%-68% | 35% | | | | 62%-71% |
| | Human parainfluenza virus 1 | NC_003461.1 | | | 71% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 60%-68% | | | | | 62%-71% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 60%-68% | 50% | | 43% | | 62%-67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 68% | | | | | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 60%-68% | | 62% | | | 62% |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 56% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 56%-60% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 64% | 35% | | | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 60%-64% | 43%-50% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 60% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.51 | NW_017264825.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.67 | NW_017264841.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 56% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.21 | NW_017264795.1 | 52% | | | | | |
||
#### Table 12C: *In Silico* Cross-Reactivity Analysis for E1 Primers
| Organism Group | Organism Name | Organism ID | E1_B3 (22 bp) | E1_BIP (44 bp) | E1_F3 (23 bp) | E1_FIP (42 bp) | E1_LB (19 bp) | E1_LF (18 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 45%-57% | 100% | 45%-62% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 95% | 55% | 100% | 43%-62% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | | | | 40%-50% | | 72%-89% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | | | | 84% | 72% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | | | 36%-40% | | 78%-83% |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-82% | | 43% | | | 72% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | | | | 43%-50% | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | | | | | | 78% |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | | 45% | | 43%-48% | | 72%-78% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 77% | | | 36%-43% | | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59%-73% | | | 38%-48% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-73% | | 65% | 43% | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 73% | 41% | | 48% | | 72% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 59% | | | 43%-48% | | 72% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | | 36%-50% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | | 65% | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | 59%-68% | | | | | 72% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | | | 40% | 68% | 72% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 70% | | 40%-50% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | | | 70% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 59%-64% | | | 40% | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59% | | | 40%-43% | | |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 0%-59% | 0% | 0% | 0%-36% | 0% | 0% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | 59% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.20 | NW_017264794.1 | 59% | | | | | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | 34% | 57% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.30 | NW_017264804.1 | | | | 50% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.69 | NW_017264843.1 | | | | 50% | | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | | 43% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | | | | 40% | | |
||
Wet testing was performed to demonstrate that the **FloodLAMP QuickColor(TM) COVID-19 Test** does not react with related pathogens, high prevalence disease agents and normal or pathogenic flora that are reasonably likely to be encountered in a clinical specimen. SARS-CoV, RSV, Flu, Human Metapneumovirus. and Streptococcus Salivarius were tested for potential cross-reactivity, as shown in Table 12 and Supporting Data. 5 µL of each stock of cross-reactivity organism was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and cross-reactivity organisms were spiked onto the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived positive had 38 µL of 1e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 38,000 copies/mL in the sample input into the amplification reaction.
All wet testing showed no cross-reactivity with the viral pathogens and common respiratory flora, as shown in Table 13.
#### Table 13: Wet Testing Cross-Reactivity Results
| Organism | Description | BEI Number | Detected Replicates |
| ----- | ----- | :---: | :---: |
| SARS-CoV | UV-inactivated virus | NR-3882 | 0/3 |
| Human Metapneumovirus | Genomic RNA | NR-49122 | 0/3 |
| RSV | Genomic RNA | NR-43976 | 0/3 |
| Influenza B | Genomic RNA | NR-45848 | 0/3 |
| Streptococcus salivarius | Bacterial cell culture | HM-121 | 0/3 |
||
#### Endogenous Interference Substances Studies:
Exogenous and endogenous substances were tested for potential interference with the **FloodLAMP QuickColor(TM) COVID-19 Test.** 10 µL of each stock of interfering substance was spiked on dried AN swab specimens. A contrived positive control was produced by spiking gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) onto dried AN swab specimens. Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol. The contrived Positive Control Spiked comprised 20 µL of 8e6 copies/mL irradiated virus stock spiked in, producing after elution of the swab in 1 mL of Inactivation Saline Solution at most a concentration of 160,000 copies/mL in the sample input into the amplification reaction.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 14 and Supporting Data.
#### Table 14: Interfering Substances Results
| Interfering Substance | Active Ingredient | Concentration | % Agreement with Expected Results | |
| :---: | :---: | :---: | :---: | :---: |
| | | | **Positive Control Spiked** | **Negative Control Unspiked** |
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
### 4) Clinical Evaluation
The clinical evaluation of the **FloodLAMP QuickColor(TM) COVID-19 Test** utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The **FloodLAMP QuickColor(TM) COVID-19 Test** showed a positive agreement of 90% and a negative agreement of 100%. The 4 false negative results were specimens with high Ct values as previously measured by the comparator test, indicating low viral load. A summary of the clinical performance is below in Table 15.
Anterior nares swab specimens were collected from patients in phosphate buffered saline by the Stanford COVID-19 clinical testing program. Specimens were initially tested by the Stanford clinical laboratory using the Hologic Panther Fusion and Aptima SARS-CoV-2 Assays, which serves as the high sensitivity comparator test.
For the **FloodLAMP QuickColor(TM) COVID-19 Test**, materials and the Instructions For Use were provided to the Stanford clinical laboratory. The materials provided consisted of the validated reagents listed in Table 3, the LGC primers and probes, and an aliquot of the positive control. After thawing the frozen specimens, 1 mL of each specimen was transferred to 5mL tubes for the inactivation step. The positive and negative clinical specimens were assigned a new ID in a random order, then transferred to new tubes that were barcoded and labeled with the new ID. The Bio-Rad C1000 Touch(TM) thermal cycler was used for the heating device to perform the isothermal amplification. Two different technicians independently interpreted the results visually per the Instructions For Use, with identical results. Line Item data are provided in the Supporting Data.
Of the 40 positive specimens, 7 specimens had initial inconclusive results due to color variation beyond the edge case examples. Per Section H2 above, the inactivated samples were follow-up tested with the FloodLAMP EasyPCR(TM) COVID-19 Test, for which all 7 inconclusive results were positive.
#### Table 15: Clinical Evaluation Results
| FloodLAMP QuickColor(TM) COVID-19 Test Results | Comparator \- High Sensitivity EUA Authorized Test | | |
| :---: | :---: | :---: | :---: |
| | **Positive** | **Negative** | **Total** |
| Positive | 36 | 0 | 36 |
| Negative | 4 | 40 | 44 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 90.0% (36/40) 95% CI: 76.3% to 97.2% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## K. UNMET NEED ADDRESSED BY THE PRODUCT
This section will be completed by FDA.
## L. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for the detection of the SARS-CoV-2 have been approved/cleared by FDA.
## M. BENEFITS AND RISKS:
This section will be completed by FDA.
## N. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
Fact Sheets for Patients and Healthcare Providers attached.
## O. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
Instructions for Use attached.
## P. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
# 14,252 2021-05-18_Instructions for Use - FloodLAMP EasyPCR COVID-19 Test v1.1.md
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file_name: 2021-05-18_Instructions for Use - FloodLAMP EasyPCR COVID-19 Test v1.1.md
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title: Instructions for Use - FloodLAMP EasyPCR COVID-19 Test v1.1
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summary_short: The Instructions for Use for the FloodLAMP EasyPCR COVID-19 Test v1.1 provides CLIA high-complexity labs with the complete protocol for an extraction-free, duplex RT-qPCR assay (CDC N1 + RNaseP) used in routine screening programs with at least weekly testing. It details required reagents and equipment, inactivation and amplification workflows, instrument template setup, data export/compilation, and Ct-based interpretation with control acceptance criteria. It also summarizes stated analytical and clinical performance, including a 3,100 copies/mL LoD and 97.5% positive agreement with 100% negative agreement in an 80-specimen evaluation.
CONTENT
***INTERNAL TITLE:*** FloodLAMP EasyPCR(TM) COVID-19 Test
Instructions for Use v1.1
IVD
COVID-19 Emergency Use Authorization Only
For *in vitro* diagnostic (IVD) Use
www.floodlamp.bio
FloodLAMP Biotechnologies, PBC | 930 Brittan Ave. San Carlos, CA 94070 USA
## Table of Contents
| | |
|---------|------|
| Intended Use | 3 |
| Principles of Procedure | 3 |
| Materials Provided and Storage | 4 |
| Materials Required but Not Provided | 4 |
| • Standard Lab Equipment and Consumables | 5 |
| Warnings and Precautions | 6 |
| • General Precautions | 6 |
| • Contamination Precautions | 7 |
| Limitations | 7 |
| Conditions of Authorization for the Laboratory | 8 |
| Specimen Collection and Storage | 9 |
| Running Tests | 10 |
| • Reagent Preparation | 10 |
| • Controls Preparation | 11 |
| • PCR Primer Stock Preparation | 12 |
| • Sample Preparation | 14 |
| • Sample Inactivation | 14 |
| • Preparing to Run Assay for the First Time | 14 |
| • Create the Plate Layout Map | 16 |
| • PCR Amplification Reaction Preparation | 19 |
| • Sample Addition | 19 |
| • Run the Assay | 20 |
| • Analyzing Data | 22 |
| • Results Interpretation | 23 |
| • Test Controls | 23 |
| • Patient Specimen Results Interpretation | 23 |
| Performance Evaluation | 24 |
| • Analytical Sensitivity: Limit of Detection (LoD) | 24 |
| • Analytical Sensitivity: Inclusivity/Cross-Reactivity (in silico) | 24 |
| • Analytical Specificity: Cross-Reactivity | 25 |
| • Analytical Specificity: Interfering Substances | 25 |
| Clinical Evaluation | 26 |
| Support | 26 |
||
FloodLAMP EasyPCR(TM) COVID-19 Test
For COVID-19 Emergency Use Authorization Only
Instructions for Use
## Intended Use
FloodLAMP EasyPCR(TM) COVID-19 Test is a real-time reverse transcriptase polymerase chain reaction (RT-qPCR) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week, such as those implemented by schools, workplaces and community groups. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The FloodLAMP EasyPCR(TM) COVID-19 Test is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures. The FloodLAMP EasyPCR(TM) COVID-19 Test is only for use under the Food and Drug Administration’s Emergency Use Authorization.
## Principles of Procedure
The FloodLAMP EasyPCR(TM) COVID-19 Test is a RNA extraction-free, duplexed RT-qPCR assay which indicates whether SARS-CoV-2 RNA is present. It can widely and rapidly be scaled because 1) it does not require nucleic acid extraction equipment, 2) it utilizes reagents and supplies readily available in large quantities, and 3) it is a straightforward protocol with minimal steps that can be executed quickly and reliably. It also utilizes the same streamlined sample preparation as the FloodLAMP QuickColor(TM) COVID-19 Test. Both are supply chain robust, "open source" protocol tests, meaning designated laboratories may obtain the test components directly from vendors. Further, the FloodLAMP QuickColor(TM) COVID-19 Test is isothermal, does not require any instrumentation and has a visual readout. Together, the two tests can be used in an integrated program for screening and rapid confirmation in large populations by a broad range of laboratories.
In the FloodLAMP EasyPCR(TM) COVID-19 Test, samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step, and the resulting inactivated sample is directly used as input in the duplexed RT-qPCR test. The test does not use new primers and probes for RT-qPCR testing, but rather uses previously validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC, which are readily available from multiple commercial suppliers. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a duplex assay, reducing the number of tests to 1 assay with 2 sets.
## Materials Provided and Storage
The FloodLAMP EasyPCR(TM) COVID-19 Test utilizes standard chemicals available from multiple vendors, with the exception of the PCR Kit. Designated CLIA labs may order components directly from vendors.
## Materials Required but Not Provided
The FloodLAMP EasyPCR(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1. The FloodLAMP EasyPCR(TM) COVID-19 Test is to be used with RT-PCR Instruments such as Applied Biosystems Quantstudio(TM) Systems and Bio-Rad CFX(TM) Systems.
#### Table 1: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| ----- | :---: | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease-free Water | - | Ultrapure Water, nuclease free | Thermo Fisher | 10977015 |
| NaCl | 5 M | Sodium Chloride | Thermo Fisher | 24740011 |
| PCR Kit\* | - | LunaⓇ Universal Probe One-Step RT-qPCR Kit | New England Biolabs | E3006 |
||
\* Item may not be substituted for equivalent.
The FloodLAMP EasyPCR(TM) COVID-19 Test uses the validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a duplex assay, detecting the 2 targets in a single well. This configuration is described in the SalivaDirect(TM) EUA Authorized test ([www.fda.gov/media/141192/download](http://www.fda.gov/media/141192/download)).
The complete set of 6 primers and probes may be purchased from the vendor Eurofins Genomics using the catalog number 12YS-010YST. This product contains primers and probes suspended at 100µM and is enough for 12,500 reactions. The contents can be mixed along with nuclease-free water to create the primer stocks used in the FloodLAMP EasyPCR(TM) COVID-19 Test. See Table 6 below for details. A larger volume of primer-probe stock can be prepared in advance and stored at \-20oC for up to 1 year.
#### Table 2: Primers and probes
| Target | Primer/Probe | Sequence |
| ----- | ----- | ----- |
| CDC-N1 | 2019-nCoV\_N1-F | GACCCCAAAATCAGCGAAAT |
| CDC-N1 | 2019-nCoV\_N1-R | TCTGGTTACTGCCAGTTGAATCTG |
| CDC-N1 | 2019-nCoV\_N1-P | **FAM**\-ACCCCGCATTACGTTTGGTGGACC-**IBFQ** |
| Human RNAseP | RP-F | AGATTTGGACCTGCGAGCG |
| Human RNAseP | RP-R | GAGCGGCTGTCTCCACAAGT |
| Human RNAseP | RP-P | **Cy5**\-TTCTGACCTGAAGGCTCTGCGCG-**IBRQ** |
||
### Standard Lab Equipment and Consumables
* 70% ethanol
* 10% bleach, prepared daily
* 96-well PCR reaction plates (Applied Biosystems \# 4346906, 4366932, 4346907, Eppendorf \# 951020303 or equivalent)
* Optical strip caps (Applied Biosystems \# 4323032 or equivalent)
* Optical plate seal (Applied Biosystems \# 4311971 or equivalent)
* PCR strip tubes and caps (USA Scientific catalog \# 1402-2500 or equivalent)
* 5 mL transport tubes or equivalent (sterile)
* 1.5 mL microcentrifuge tubes or equivalent (nuclease-free)
* Aerosol resistant micropipette tips (nuclease-free)
* Micropipettes (calibrated)
* Bottle top dispenser for 1 mL volume (optional, calibrated)
* 96-well cold block
* Cold blocks for 5 mL and 1.5 mL \- 2.0 mL tubes, or ice
* Vortex mixer
* 96-well plate centrifuge or equivalent
* Mini centrifuge for 1.5 mL tubes or equivalent
* Thermal cycler, water bath, dry heat bath or equivalent (calibrated)
* Class II Biological Safety Cabinet (BSC)
* PCR Instrument (choose one)
* QuantStudio(TM) 6 Flex
* QuantStudio(TM) 7 Pro
* Bio-Rad CFX96 Touch(TM)
## Warnings and Precautions
Materials or chemicals required for the use of the FloodLAMP EasyPCR(TM) COVID-19 Test should be closely examined by the user. The user should carefully read all warnings, instructions or Safety Data Sheets provided by the supplier and follow the general safety precautions when handling biohazards, chemicals and other materials.
### General Precautions
* The FloodLAMP EasyPCR(TM) COVID-19 Test is for *in vitro* diagnostic use (IVD) only. Rx Only.
* For use under COVID-19 Emergency Use Authorization Only.
* Standard precautions and procedures should be taken when handling and disposing of human samples.
* This test has not been FDA cleared or approved; the test has been authorized by FDA under an Emergency Use Authorization (EUA) for use by laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA) of 1988, 42 U.S.C. §263a, to perform high complexity tests.
* This test has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens.
* This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of *in vitro* diagnostic tests for detection and/or diagnosis of COVID19 under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
* Standard precautions and procedures should be taken when handling and extracting human samples.
* Standard precautions and procedures should be taken when using laboratory equipment.
* Standard precautions and procedures should be taken when disposing of waste.
* Dispose of reagents according to local regulations.
* Do not use reagents after their recommended stability time frame.
* Ensure reagents are stored at the recommended temperatures as described below and in the vendor product information and manuals.
### Contamination Precautions
* Avoid contamination by following good laboratory practices, wearing proper personal protective equipment, segregating workflow, and decontaminating workspace appropriately.
* Ensure that surfaces and equipment used for all test steps have been properly cleaned with 10% bleach and 70% ethanol.
* Ensure all consumables are DNase and RNase free except for sample collection tubes which may be sterile.
* Use only calibrated pipettes and filter tips that are sterile and PCR clean.
* After completion of the test, dispose of the amplification reaction plates or tubes. Do not open tubes or remove the seals on plates after heating amplification reactions.
## Limitations
* The use of this assay as an *in vitro* diagnostic under the FDA COVID-19 Emergency Use Authorization (EUA) is limited to laboratories that are certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, to perform high complexity tests by Rx only.
* Use of this assay is limited to personnel who are trained in the procedure. Failure to follow these instructions may lead to erroneous results.
* The performance of the FloodLAMP EasyPCR(TM) COVID-19 Test was established using Nasopharyngeal Swab specimen type collected in saline. Nasal swabs, oropharyngeal swabs, mid-turbinate nasal swabs specimens are also considered acceptable specimen types for use with the test but performance has not been established.
* Samples must be collected according to recommended protocols and transported and stored as described herein.
* Samples should not be collected in UTM or VTM or Liquid Amies transport media.
* The effect of vaccines, antiviral therapeutics, antibiotics, chemotherapeutic or immunosuppressant drugs have not been evaluated.
* Detection of SARS-CoV-2 RNA may be affected by sample collection methods, patient factors (e.g., presence of symptoms), and/or stage of infection.
* False-positive results may arise from various reasons, including, but not limited to the following:
* Contamination during specimen collection, handling, or preparation
* Contamination during assay preparation
* Incorrect sample labeling
* False-negative results may arise from various reasons, including, but not limited to the following:
* Improper sample collection or storage
* Degradation of SARS-CoV-2 RNA
* Presence of inhibitory substances
* Use of extraction reagents or instrumentation not approved with this assay
* Incorrect sampling window
* Failure to follow instructions for use
* Mutations in SARS-CoV-2 target sequences
* Nucleic acid may persist even after the virus is no longer viable.
* This test cannot rule out diseases caused by other bacterial or viral pathogens.
* Performance has not yet been established in asymptomatic individuals and will be established during a post-authorization study.
* Use of the test in a general, asymptomatic population for serial screening is intended to be used as part of an infection control plan, that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. Negative results should not be treated as definitive and do not preclude current or future infection obtained through community transmission or other exposures. Negative results must be considered in the context of an individual’s recent exposures, history, and presence of clinical signs and symptoms consistent with COVID-19.
* This test should not be used within 30 minutes of administering nasal or throat sprays.
* Positive results must be reported to appropriate public health authorities, following state and national guidelines.
* The clinical performance of the test has not been established in all circulating variants, and test performance may vary depending on the prevalence of variants circulating at the time of patient testing.
* Negative test results do not exclude possibility of exposure to or infection with SARS-CoV-2 virus. Patient handling will be directed by healthcare professionals.
## Conditions of Authorization for the Laboratory
The FloodLAMP EasyPCR(TM) COVID-19 Test Letter of Authorization, along with the authorized Fact Sheet for Healthcare Providers, the authorized Fact Sheet for Patients, and authorized labeling are available on the FDA website: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas)
However, to assist clinical laboratories running the FloodLAMP EasyPCR(TM) COVID-19 Test, the relevant Conditions of Authorization are listed below:
* Authorized laboratories1 using the FloodLAMP EasyPCR(TM) COVID-19 Test will include all authorized Fact Sheets with test result reports. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
* Authorized laboratories1 using the FloodLAMP EasyPCR(TM) COVID-19 Test will use the FloodLAMP EasyPCR(TM) COVID-19 Test as outlined in the FloodLAMP EasyPCR(TM) COVID-19 Test Instructions for Use. Deviations from the authorized procedures, including the authorized clinical specimen types, authorized control materials, authorized other ancillary reagents and authorized materials required to perform the test are not permitted.
* Authorized laboratories must notify the relevant public health authorities of their intent to run the test prior to initiating testing.
* Authorized laboratories using the FloodLAMP EasyPCR(TM) COVID-19 Test will have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
* Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
* All laboratory personnel using the test must be appropriately trained in molecular assay techniques and use appropriate laboratory and personal protective equipment when handling these test components, and use the test in accordance with the authorized labeling.
* FloodLAMP Biotechnologies, PBC authorized distributors, and authorized laboratories using the FloodLAMP EasyPCR(TM) COVID-19 Test will ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
1 For ease of reference, this will refer to, “Clinical Laboratory Improvement Amendments of
1988 (CLIA), 42 U.S.C. §263a certified laboratories with FDA Emergency Use Authorization
FDA for performing SARS-CoV-2 testing
## Specimen Collection and Storage
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19:
[https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html](https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html)
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
* Samples can be stored at room temperature for 56 hours after collection prior to inactivation.
* For longer term storage, samples can be stored at ≤-70o C.
Note: Specimens must be packaged, shipped, and transported according to the current edition of the International Air Transport Association Dangerous Goods Regulation. Follow shipping regulations for UN 3373 Biological Substance, Category B when sending potential 2019-nCoV specimens.
## Running Tests
### Reagent Preparation
The FloodLAMP EasyPCR(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1.
#### Table 1: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| ----- | :---: | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease- free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5M | Sodium Chloride | Thermo Fisher | 24740011 |
| PCR Kit\* | - | LunaⓇ Universal Probe One-Step RT-qPCR Kit | New England Biolabs | E3006 |
||
\* Item may not be substituted for equivalent.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
The 100X Inactivation Solution is prepared by mixing the components in Table 3 and vortexing for 30 seconds. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved. Aliquots of 100X Inactivation Solution should be stored in the dark at \-20° C for up to 3 months. Upon thaw, working aliquots of 100X Inactivation Solution should be stored in the dark at room temperature for up to 1 month.
#### Table 3: 100X Inactivation Solution
| Component | Source Concentration | Volume | 100X Concentration |
| ----- | :---: | :---: | :---: |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
For swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 4. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 4: 1X Inactivation Saline Solution
| Component | Volume |
| ----- | :---: |
| 0.9% Saline (154 mM NaCl) in MilliQ Water | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
### Controls Preparation
One **Positive Template Control and one Negative (No Template) Control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes. An **Internal Process Control** is included in every PCR reaction.
1) A **“No Template” (Negative) Control (NTC)** is needed to assure the absence of cross-contamination from positive samples, positive controls, or amplicons and is used to determine if sample results are valid. It consists of nuclease-free water.
2) A **Positive Template Control** is needed to assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water. Stock and working aliquots of the positive control are produced from the sources listed in Table 5 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at \-80°C, or at most 1 month at \-20°C.
3) An **Internal Process Control** is needed to assure sufficient specimen quantity and quality. It consists of a primer/probe set targeting the human RNaseP gene that is included in a single PCR amplification reaction. The RNAseP Internal Process Control uses a fluorescent reporter in a separate channel from the SARS-CoV-2 channel (i.e. in duplex).
#### Table 5: Components for Positive Template Control
| Material | Vendor | Catalog \# | Volume |
| ----- | :---: | :---: | :---: |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µL |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µL |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895µL |
||
### PCR Primer Stock Preparation
The FloodLAMP EasyPCR(TM) COVID-19 Test uses the validated primer and probe sets (2019-nCoV\_N1 and RP) developed by the US CDC. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a duplex assay, detecting the 2 targets in a single well. This configuration is described in the SalivaDirect(TM) EUA Authorized test ([www.fda.gov/media/141192/download](http://www.fda.gov/media/141192/download)).
The complete set of 6 primers and probes may be purchased from the vendor Eurofins Genomics using the catalog number 12YS-010YST. This product contains primers and probes suspended at 100µM and is enough for 12,500 reactions. The contents can be mixed along with nuclease-free water to create the primer stocks used in the FloodLAMP EasyPCR(TM) COVID-19 Test. See Table 6 below for details. A large volume of primer-probe stock can be prepared in advance and stored at 4°C for one month or \-20°C for up to 1 year. Vendors for the Primer and Probe sets are below in Table 7.
#### Table 6: 5X PCR Primer Stock Preparation from Eurofins Genomics Product
| Component | 5X PCR Primer Stock Concentration | Volume (1 reaction) | Volume (3,125 reactions) |
| ----- | :---: | :---: | :---: |
| 2019-nCov\_N1-F | 2 µM | 0.4 µl | 1,250 µl |
| 2019-nCov\_N1-R | 2 µM | 0.4 µl | 1,250 µl |
| 2019-nCov\_N1-P | 1 µM | 0.2 µl | 625 µl |
| RP-F | 0.75 µM | 0.15 µl | 469 µl |
| RP-R | 0.75 µM | 0.15 µl | 469 µl |
| RP-P | 1 µM | 0.2 µl | 625 µl |
| Nuclease-free water | - | 2.5 µl | 7,813 µl |
| **Total Volume** | - | **4 µl** | **12,500 µl** |
||
#### Table 7: PCR Primer Stock Components
| Vendor | Item | Catalog number | Quantity | #Reactions |
|---------|------|----------------|-----------|------------|
| Eurofins Genomics | SalivaDirect™ complete set of 6 primers and probes | 12YS-010YST | 50-100 nmol | 12,500 |
| Integrated DNA Technologies | nCoV_N1 Forward Primer Aliquot | 10006821 | 50 nmol | 6,2500 |
| Integrated DNA Technologies | nCoV_N1 Forward Primer Aliquot | 10006830 | 100 nmol | 12,500 |
| Integrated DNA Technologies | nCoV_N1 Reverse Primer Aliquot | 10006822 | 50 nmol | 6,250 |
| Integrated DNA Technologies | nCoV_N1 Reverse Primer Aliquot | 10006831 | 100 nmol | 12,500 |
| Integrated DNA Technologies | NCoV_N1 Probe Aliquot | 10006831 | 25 nmol | 6,250 |
| Integrated DNA Technologies | NCoV_N1 Probe Aliquot | 10006832 | 50 nmol | 12,500 |
| Integrated DNA Technologies | RNaseP Forward Primer Aliquot | 10006827 | 50 nmol | 16,600 |
| Integrated DNA Technologies | RNaseP Forward Primer Aliquot | 10006836 | 100 nmol | 33,300 |
| Integrated DNA Technologies | RNaseP Reverse Primer Aliquot | 10006828 | 50 nmol | 16,600 |
| Integrated DNA Technologies | RNaseP Reverse Primer Aliquot | 10006837 | 100 nmol | 33,300 |
| Integrated DNA Technologies | RNase P Probe | Custom order (Cy5) | 25 nmol | 6,250 |
| Integrated DNA Technologies | RNase P Probe | Custom order (Cy5) | 50 nmol | 12,500 |
| Integrated DNA Technologies | RNase P Probe | 10007061 (ATTO647) | 25 nmol | 6,250 |
| Integrated DNA Technologies | RNase P Probe | 10007062 (ATTO647) | 50 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Forward Primer | nCoV-N1-F-100 | 100 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Forward Primer | nCoV-N1-F-1000 | 1000 nmol | 125,000 |
| LGC Biosearch Technologies | nCoV_N1 Reverse Primer | nCoV-N1-R-100 | 100 nmol | 12,500 |
| LGC Biosearch Technologies | nCoV_N1 Reverse Primer | nCoV-N1-R-1000 | 1000 nmol | 125,000 |
| LGC Biosearch Technologies | NCoV_N1 Probe | nCoV-N1-P-25 | 25 nmol | 6,250 |
| LGC Biosearch Technologies | NCoV_N1 Probe | nCoV-N1-P-250 | 250 nmol | 62,500 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-20 | 20 nmol | 6,660 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-100 | 100 nmol | 33,300 |
| LGC Biosearch Technologies | RNaseP Forward Primer | RNP-F-1000 | 1000 nmol | 333,300 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-20 | 20 nmol | 6,660 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-100 | 100 nmol | 33,300 |
| LGC Biosearch Technologies | RNaseP Reverse Primer | RNP-R-1000 | 1000 nmol | 333,300 |
| LGC Biosearch Technologies | RNase P Probe | RNP-PQ670-25 | 25 nmol | 6,250 |
| LGC Biosearch Technologies | RNase P Probe | RNP-PQ670-250 | 50 nmol | 12,500 |
||
### Sample Preparation
\* For wet swab specimens (swabs in saline or unprocessed swab elution):
1) If samples are frozen, thaw unless no ice crystals are present and then keep on ice, cold block or at 4°C.
2) Pulse vortex each sample and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
3) Wipe the outside of the sample tube with 70% ethanol.
For dry swab specimens:
1) Wipe the outside of the sample tube with 70% ethanol.
### Sample Inactivation
1) Place the inactivation heater (a thermal cycler, water bath, dry heat bath or equivalent) in the BSC, turn on, and set the temperature to hold at 100°C.
2) \* For wet swab specimens: transfer 1 mL or available volume of each sample to an appropriately labeled 1.5 mL or 5mL tube and securely cap.
3) \* For wet swab specimens: add 10µL per 1 mL sample volume of 100X Inactivation Solution to each sample tube.
4) For dry swab specimens (DO NOT DO FOR WET SWAB SPECIMENS): add 1 mL of 1X Inactivation Solution to each sample tube.
5) Vortex for 30 seconds.
6) Place sample tubes into the inactivation heater for 8 minutes.
7) Remove sample tubes from the inactivation heater and let cool at room temperature for 10 minutes.
8) Place sample tubes on ice, in the refrigerator, or on a cold block at 4°C until ready to perform amplification reaction.
Note: Testing of inactivated specimens must be conducted the same day inactivation is performed. For long term storage, keep the original specimen at ≤-70°C.
### Preparing to Run Assay for the First Time
*Note: Any instrument running the FloodLAMP EasyPCR(TM) COVID-19 Test must be calibrated for the following dyes: FAM and Cy5.*
#### Download the Template Run File
The Template Run File contains all the parameters preconfigured to run the FloodLAMP EasyPCR(TM) COVID-19 Test. These parameters can be seen in more detail under “Create the Run File ...” headings below.
To download the Template Run File:
1) Go to www.floodlamp.bio/euas
2) Download the Template Run file(s) for the instrument type and assay to be run.
#### Table 7: RT-PCR Instrument Template Run Files
| Instrument | Setup Template Filename |
| ----- | ----- |
| ABI QuantStudio(TM) 7 Pro | FloodLAMP\_QS7Pro\_PCR\_template\_run.edt |
| ABI QuantStudio(TM) 6 Flex | FloodLAMP\_QS6Flx\_PCR\_template\_run.edt |
| Bio-Rad CFX96 Touch(TM) | FloodLAMP\_BRCFX\_PCR\_protocol.prcl |
| Bio-Rad CFX96 Touch(TM) | FloodLAMP\_BRCFX\_PCR\_template\_run.pltd |
||
*Note: Template Run Files only need to be downloaded once upon first use.*
#### Alternatively Create the Template Run File on QuantStudio(TM) 6 Flex or 7 Pro
1) Open the Design and Analysis Software.
2) Select the “SET UP PLATE” option.
3) From the sidebar on the screen, select the following properties to filter:
1) Instrument – choose the appropriate instrument
2) Block – choose the appropriate block
3) RunMode – Standard
4) Analysis options are left blank
4) From the plate sections present on the screen, select the correct System Template and the system will automatically navigate to the "Run Method" tab.
1) "Presence/Absence" for QuantStudio(TM) 7 Pro
2) “Presence-Absence Standard Pre PCR Post” for QuantStudio(TM) 6 Flex
5) Change Run Parameters as shown below:
- **Run Method:**
- 20μL Rxn Vol.
- 105° C Heated Cover Temp
- Ramp Rate: 1.6° C/s
#### Table 8 : Thermal cycling and plate read steps for QuantStudio(TM) Systems for PCR
| Stage | Temperature | Time | Reps |
| :---: | :---: | :---: | :---: |
| 1 | 52° C | 10 min | 1 |
| 2 | 95° C | 2 min | 1 |
| 3 | 95° C | 10 sec | 44 |
| 3 | 55° C \* | 30 sec | 44 |
| 4 | 55° C \*\* | 30 sec | 1 |
||
\* *This step should be the optical read step*
*\*\* This step is only required for QuantStudio(TM) 6 Flex*
- **Plate Setup**
- Targets: FAM (N1) & Cy5 (RP)
- Quencher: None
- Passive Reference: ROX
6) Once done setting up the template, go to “Actions” in the top right corner and hit “Save As”:
1. On Connect: Save to template folder.
2. Offline: Save to preferred location.
#### Create the Template Run File on Bio-Rad CFX96 Touch(TM)
1) Launch the CFX96 Touch(TM) software package.
2) In the Startup Wizard pop-up window select the instrument “CFX96” from the drop down menu.
3) Under “Select Run Type” press the “User-defined” button.
4) Create a new thermocycler protocol by selecting “Create New” from the Run Setup window.
5) Under Tools in the top left toolbar select “Run Time Calculator” and check “96 Wells-All Channels”.
6) Make the following changes to the cycling conditions in the Protocol Editor:
- Sample Volume to 20 µL
- Lid Setting to 105°C
- Change cycles to be as shown below:
#### Table 9 : Thermal cycling and plate read steps for the Bio-Rad CFX96 Touch(TM)
| Stage | Temperature | Time | Reps |
| :---: | :---: | :---: | :---: |
| 1 | 52° C | 10 min | 1 |
| 2 | 95° C | 2 min | 1 |
| 3 | 95° C | 10 sec | 44 |
| 3 | 55° C \* | 30 sec | 44 |
||
*\* This step should be the optical read step*
7. Click “OK” to save the protocol as type Protocol File (\*.prcl) and return to the Protocol tab in Run Setup.
### Create the Plate Layout Map
#### QuantStudio(TM) 6 Flex or 7 Pro Option 1: Sample Name Input
For this option, sample names (i.e. specimen IDs) are directly input into the instrument software prior to starting the run.
1) Open template in Design and Analysis app and go to the “Plate Setup” tab.
2) On the right side of the screen ensure the “Samples” tab is highlighted and press the addition icon to add the number of samples being tested.
3) Click on the “Sample 1” box to rename the sample.
1) Repeat this step for all subsequent samples being entered.
4) Click the well located in the plate map then check the box next to the sample name from the right side bar to associate the name to the well.
1) There is also the option to highlight the well location in the plate map and click on the “Enter sample” box. Enter the sample ID and press tab to continue to the next well in the plate map. This will automatically load the sample name into the sidebar.
5) Once the sample names have been entered, the wells may be highlighted by left clicking the mouse over the starting well and dragging the mouse across all wells associated in run. The targets are then chosen by clicking the check boxes next to each target in the sidebar.
1) FAM & Cy5 targets should be chosen and named “N1” and “RP” respectively.
6) Once done setting up the template, go to “Actions” in the top right corner and hit “Save As,” a pop-up window will appear directing the user to title the file according to information pertaining to the sample run.
1) Connect: Save to the desired folder (only applicable for 7 Pro).
2) Offline: Save to a USB that is inserted into the computer.
7) Use your plate layout to load your samples and controls after preparing the amplification reaction mix.
#### QuantStudio(TM) 6 Flex or 7 Pro Option 2: Lookup Based on Well Position
For this option, a single generic sample name is applied to all wells, and subsequently, outside of the instrument software, the results are linked to the actual sample name via a lookup table to the well position.
1) Open the template in the Design and Analysis app and go to the “Plate Setup” tab.
2) Highlight the entire plate and add 1 sample to all wells, with the same sample name in every well.
3) Once the sample name has been entered, the targets are chosen by clicking the check boxes next to each target in the sidebar.
1) FAM & Cy5 targets should be chosen and named “N1” and “RP” respectively.
4) Go to “Actions” in the top right corner and hit “Save As” and name the Template Run File as desired and the software will automatically save as a .edt file.
1) Connect: Save to desired location (only applicable for QuantStudio 7 Pro).
2) Offline: Save to a USB that is inserted into the computer.
This process only needs to be done once – all subsequent runs can use the same Template Run File.
#### Bio-Rad CFX96 Touch(TM):
1) Launch the CFX96 Touch(TM) software package and open the correct protocol template.
2) Review the details of the protocol. If correct, click “Next” to proceed to the Plate tab.
3) On the Plate tab, click “Create New” and the Plate Editor appears.
4) Use the Plate Editor to create a new plate.
5) To ensure the correct plate size is selected, go to “Settings \> Plate Size” and check that 96-well or 384-well is selected from the drop-down menu.
1) The plate size selected must correspond to the block size of the instrument being used.
6) To set the plate type, select” Settings \> Plate Type” and select “BR Clear” or “BR White” from the drop-down menu.
1) The plate type selected should match the plate type used in the run.
7) To set the scan mode, select the “All Channels” scan mode from the Scan Mode drop-down list in the Plate Editor toolbar.
8) Select the “Select Fluorophores” button on the upper right of the Plate Editor window
1) De-select all default fluorophores and select “FAM” and “Cy5” and click OK.
9) In the Plate Editor window highlight the whole plate and click the checkbox in front of FAM and Cy5.
10) Select the “Experiment Settings” button in order to define the Targets.
1) In the lower left of the Experiment Settings window in the New box type in “N1” and select “Add”.
2) Repeat this step and type in “RP”.
3) Select “OK”.
11) In the Plate Editor window next to FAM in the drop-down menu under Target Name select “N1” and for Cy5 select “RP”.
12) Click OK to save changes and close the “Select Fluorophores” dialog box.
#### Bio-Rad CFX96 Touch(TM) Option 1: Sample Name Input
For this option, sample names (i.e. specimen IDs) are directly input into the instrument software prior to starting the run.
1) Load the appropriate sample type to each well by selecting the well and selecting the appropriate Sample Type (Unknown, NTC, or Positive Control) from the drop-down menu.
2) Multiple wells can be selected at once to load the sample type.
1) Note: The EC can be listed as an Unknown sample.
3) In the “Target Names” section confirm that the necessary fluorophores are assigned to each well.
4) Name each well by typing in the sample name and pressing “Enter” in the Sample Names dropdown list in the right pane.
5) Click OK to save the Plate File (\*.pltd)and return to the Plate tab in Run Setup. When prompted, specify a name for the plate and a save location.
#### Bio-Rad CFX96 Touch(TM) Option 2: Lookup Based on Well Position
For this option, a single generic sample name is applied to all wells, and subsequently, outside of the instrument software, the results are linked to the actual sample name via a lookup table to the well position.
1. Name the file as desired and save as type “Plate File (\*.pltd)”
2. Select “Save”, click “OK” in the Plate Editor window and exit the software.
This process only needs to be done once – all subsequent runs can use the same Template Plate File.
### PCR Amplification Reaction Preparation
1) Place a 96-well PCR plate or PCR strip tubes onto a cold block or ice.
2) Thaw frozen reagents until ice crystals are not present.
3) Pulse vortex thawed reagents for 3 seconds and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
4) Store on ice or in the refrigerator or on a cold block at 4°C until ready to use.
5) Prepare the PCR Amplification Reaction Mix by combining the components listed below in Table 10.
NOTE: Component volumes should be scaled proportionally for the number of reactions.
6) Vortex the PCR Amplification Reaction Solution for 10 seconds and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
7) Add 18 µL of the PCR Amplification Reaction Solution into the wells of the PCR plate or PCR strip tubes.
#### Table 10: PCR Amplification Reaction Mix
| Component | Volume (1 reaction) | Volume (1 reaction x 100) 1 x 96-plate w/ 4% overage |
| ----- | :---: | :---: |
| 5X PCR Primer Stock | 4 µL | 400 µL |
| Nuclease-free Water | 3 µL | 300 µL |
| PCR Master Mix\* | 10 µL | 1000 µL |
| PCR RT\* | 1 µL | 100 µL |
| **SUBTOTAL VOLUME** | **18 µL** | **1800 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **20 µL** | - |
||
\* in LunaⓇ Universal Probe One-Step RT-qPCR Kit
### Sample Addition
NOTE: Ensure that positive and negative controls are included in each batch run (i.e. in each PCR plate or group of strip tubes that are heated together).
1) Add 2 μL of each sample into a separate tube in the amplification reaction PCR plate or strip tubes.
2) Mix by pipetting.
3) If using PCR plate, seal with optical film (optionally using heat sealer). If using PCR strip tubes, cap strips.
4) Pulse vortex and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
5) Continue to section “Run the Assay”.
### Run the Assay
Refer to Specific Instrument User Manuals for full system usage and maintenance details.
#### On QuantStudio(TM) 6 Flex
1) To transfer templates from a USB drive plug a USB drive into the USB port below the touchscreen.
2) If the instrument is in standby, touch the touchscreen to activate it and then press the green power icon.
3) In the Main Menu, press “View Templates”.
4) In the Browse Experiments screen, select the template:
1) Press the Folder icon, then choose “USB”.
2) Press the desired template, then press “Save”.
5) In the Save Experiment As screen, set the name for the file.
1) Press the “New Template Name” field, then enter a name for the copied file.
2) Press the “Save to Folder” field, then select the folder to receive the file
3) Hit “Save”.
6) Press the Home icon to return to the Main Menu.
7) Navigate to the Main Menu screen, then press the red eject icon.
8) When the side door opens, load the appropriate plate or PCR strips. Ensure that the consumable is properly aligned in the holder.
9) In the Main Menu, press “Browse Experiments”.
10) In the Experiments screen, choose the desired experiment and then click the Folder icon to choose where to save the experiment.
11) Then press “Start Run” to start the run immediately.
#### On QuantStudio(TM) 7 Pro
1) Log into user on instrument.
2) USB: Plug in USB with saved template on it.
3) From the options on the instrument’s screen press “Load plate file”.
1) The QuantStudio(TM) 7 is a touchscreen device.
4) From the “Run Queue” screen,
1) USB: press “USB drive” on the left side.
2) Connect: press Cloud icon on the left side.
5) This will bring up any plate files saved.
6) Press the plate file associated with the run to be performed.
7) A new window will appear requesting location of results once the run is complete.
1) Connect: Press the “Cloud Connect” icon, press again to verify location the files will be uploaded to and then press “Done”.
2) USB: Press the “USB drive Connected” if the icon is not already highlighted and press “Done”.
8) Press the double-arrow icon located at the top right sided corner of the screen on the instrument.
1) The instrument drawer will open from the front.
9) Place the plate/strips into the plate holder ensuring proper orientation of the plate.
1) A1 well should be in the position of the top left corner.
2) The plate/strips will appear slightly suspended above the block due to two silicone strips above and below this plate. This is to be expected and the instrument lid will press the plate down once the drawer has closed.
10) Press “Start Run” on the screen of the instrument.
1) A pop-up window will appear asking the user to confirm the plate has been loaded.
2) If the plate has been loaded, press “Start Run” again or press “Open Drawer” to place the plate into the block and then press “Start Run”.
#### On Bio-Rad CFX96 Touch(TM)
1) Open the correct .pcrl file and review the protocol details. If correct click “Next” to proceed to the Plate tab.
2) When prompted, open the correct .pltd file and review the plate details in the Run Information section.
3) Select the checkbox for the appropriate block (CFX96 or CFX384) on which to perform the run.
4) To insert the plate or 8-tube strips into the block, click Open Lid.
5) Insert the plate or 8-tube strips into the block. Ensure the plate or 8-tube strips are properly oriented.
6) Click Close Lid.
7) Click Start Run at the bottom right of the screen.
8) When prompted, save the data file (.pcrd) to the desired location.
### Analyzing Data
#### Exporting Data from QuantStudio(TM) 6 Flex or 7 Pro
##### Using USB
1) Confirm Quant says “File Transferred \- USB”.
2) Take USB from Quant and plug it into computer.
3) Export data off of USB onto computer.
##### Using Cloud Connect with QuantStudio(TM) 7 Pro
1) Go to [Cloud Connect](https://apps.thermofisher.com/apps/spa/#/dashboard%20%20) and log in.
2) Go to files and find the data that was just uploaded by the Quant, it will be in the folder chosen previously chosen while running the Quant.
3) Download .xlsx file.
#### Exporting Data from Bio-Rad CFX96 Touch(TM)
1) After the run has completed, open the data file (.pcrd) by going to Select File \> Open \> Data File in the Home window and locating the desired data file. Adjust the following settings as described below.
2) Select Settings \> Cq Determination mode and select Single Threshold.
3) Select Settings \> Baseline Setting and select Baseline Subtracted.
4) Select Settings \> Analysis Mode and select analysis by fluorophore.
5) Select Settings \> Cycles to Analyze and the Cycles to Analyze dialog box appears. Confirm that all cycles are being analyzed and click “OK”.
6) Cq values of each well are displayed in the Quantification Data tab.
7) Export .xlsx files and select Export \> Export all Data Sheets to Excel (Cq values are available in "Quantification Plate View Results").
#### Compiling Results Option 1: Lookup Based on Well Position
For this option, outside of the instrument software the results are linked to the actual sample name via a lookup table to the well position. An example spreadsheet to perform this lookup and results compilation is available with instructions at [www.floodlamp.bio/euas](http://www.floodlamp.bio/ifus).
#### Compiling Results Option 2: Sample Name Input
For this option, sample names (i.e. specimen IDs) are directly input into the instrument software prior to starting the run. Open the results file and continue to “Analyzing Data” section to score results.
### Results Interpretation
#### Test Controls
All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. Target results for the controls will be interpreted according to Table 5 below.
1) The “No Template” (Negative) Control (NTC) should yield a negative “not detected” result for both the N1 and RNaseP targets.
2) The Positive Template Control should yield a positive “detected” result for the N1 target and a negative “not detected” for the RNaseP control.
3) The Internal Process Control should yield a positive "detected" result for RNaseP. Detection of RNaseP is required to report a negative SARS-CoV-2 result.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and (optionally) RNAseZAP(TM) product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
#### Patient Specimen Results Interpretation
NOTE: Patient specimen results can only be interpreted if the positive and negative controls in the plate or group of strip tubes have the expected results.
Use Table 11 below to assign a result to each sample.
#### Table 11: Interpretation of Assay Results
| ABI QuantStudio(TM) 7 Pro | | |
| :---: | :---: | :---: |
| **Result** | **Ct Value: N1** | **Ct Value RP** |
| Positive | \<38.0 | Any Value |
| Negative | ≥38.0 | \<35.0 |
| \*Invalid | ≥38.0 | ≥35.0 |
| **Bio-Rad CFX96 Touch(TM) ABI QuantStudio(TM) 6 Flex** | | |
| **Result** | **Ct Value: N1** | **Ct Value RP** |
| Positive | \<40.0 | Any Value |
| Negative | ≥40.0 | \<35.0 |
| \*Invalid | ≥40.0 | ≥35.0 |
||
\*Invalid test results should be repeated by rerunning the primary sample if available, otherwise the inactivated sample. Results from retested samples will follow the same interpretation as listed in Table 11.
If the final interpretation of the test result is invalid, then "Invalid/Inconclusive" should be reported and retesting of the individual is recommended.
## Performance Evaluation
### Analytical Sensitivity: Limit of Detection (LoD)
The Limit of Detection (LoD) for the FloodLAMP EasyPCR(TM) COVID-19 Test was established using gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The gamma-irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 6,300, 3,100 and 1,600 copies/mL were selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 12. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 3,100 copies/mL.
#### Table 12: Confirmatory LoD Data Results
| Instrument | LoD | Positive Replicates |
| ----- | :---: | :---: |
| ABI QuantStudio(TM) 7 Pro | 3,100 copies/mL | 95% (20/21) |
| ABI QuantStudio(TM) 6 Flex | 3,100 copies/mL | 100% (21/21) |
| Bio-Rad CFX96 Touch(TM) | 3,100 copies/mL | 95% (20/21) |
||
### Analytical Sensitivity: Inclusivity
FloodLAMP EasyPCR(TM) COVID-19 Test includes a modified RT-qPCR assay by duplexing the previously authorized CDC N1 and human RNase P primer-probe sets. Inclusivity was tested in the original US CDC EUA with all publicly available SARS-CoV-2 genomes as of 1 February 2020. The initial analysis showed 100% homology between the N1 primer-probe set and available genomes, except for one low frequency mismatch with the N1 forward primer. However, this was not expected to affect performance of the primer-probe set due to annealing temperatures of 55°C which tolerate 1-2 mismatches. Indeed, performance of the N1 primer-probe set was shown to be high in the previous comparison of primer-probes sets ([https://www.nature.com/articles/s41564-020-0761-6](https://www.nature.com/articles/s41564-020-0761-6)). GISAID continuously evaluates mismatches between newly available SARS-CoV-2 genomes and primer-probe sets and confirms a low frequency of nucleotide mismatches (\<5%) with the N1 primer-probe set.
### Analytical Specificity: Cross-Reactivity
The primer and probe sets used in FloodLAMP’s duplex assay were developed by the US CDC and have been EUA certified. The CDC reported no cross-reactivity with other human coronaviruses (229E, OC43, NL63, and HKU1), MERS-coronavirus, SARS-coronavirus, and 14 additional human respiratory viruses (see [https://www.fda.gov/media/134922/download](https://www.fda.gov/media/134922/download)).
### Analytical Specificity: Interfering Substances
Exogenous and endogenous substances were tested for potential interference with the FloodLAMP EasyPCR(TM) COVID-19 Test. Gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) was spiked onto dried AN swab specimens to produce contrived Positve Controls. Negative Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 13.
#### Table 13: Interfering Substances Results
| Interfering Substance | Active Ingredient | Concentration | % Agreement with Expected Results | |
| :---: | :---: | :---: | :---: | :---: |
| | | | **Positive Control Spiked** | **Negative Control Unspiked** |
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
## Clinical Evaluation
The clinical evaluation of the FloodLAMP EasyPCR(TM) COVID-19 Test utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The FloodLAMP EasyPCR(TM) COVID-19 Test showed a positive agreement of 97.5% and a negative agreement of 100%. The single false negative result was a specimen with a high Ct value as previously measured by the comparator test, indicating low viral load. A summary of the clinical performance is shown below in Table 14.
#### Table 14: Clinical Evaluation Results
| FloodLAMP EasyPCR(TM) COVID-19 Test Results | Comparator \- High Sensitivity EUA Authorized Test | | |
| :---: | :---: | :---: | :---: |
| | **Positive** | **Negative** | **Total** |
| Positive | 39 | 0 | 39 |
| Negative | 1 | 40 | 41 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 97.5% (39/40) 95% CI: 86.8% to 99.9% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## Support
FloodLAMP Biotechnologies, PBC support center
eua.support@floodlamp.bio
650-394-5233
QuantStudio(TM) is a trademark of Thermo Fisher Scientific (NYSE: TMO)
Bio-Rad(TM) and Bio-Rad CFX96 Touch(TM) are trademarks of Bio-Rad Laboratories, Inc. (NYSE: BIO)
# 17,475 2021-05-18_Instructions for Use - FloodLAMP QuickColor COVID-19 Test v1.1.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-05-18_Instructions for Use - FloodLAMP QuickColor COVID-19 Test v1.1.md
file_date: 2021-05-18
title: Instructions for Use - FloodLAMP QuickColor COVID-19 Test v1.1
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subcategory: fl-fda-submissions
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summary_short: The Instructions for Use for the FloodLAMP QuickColor COVID-19 Test v1.1 provides CLIA high-complexity laboratories with the complete workflow for an extraction-free, colorimetric RT-LAMP assay with visual result interpretation after chemical and heat inactivation. It details required reagents, primer preparation, step-by-step testing procedures, control requirements, and criteria for interpreting positive, negative, and inconclusive results without specialized instrumentation. It also summarizes analytical and clinical performance, including a 12,500 copies/mL LoD and 90% positive agreement with 100% negative agreement in an 80-specimen clinical evaluation.
CONTENT
***INTERNAL TITLE:*** FloodLAMP QuickColor(TM) COVID-19 Test
Instructions for Use v1.1
IVD
COVID-19 Emergency Use Authorization Only
For *in vitro* diagnostic (IVD) Use
www.floodlamp.bio
FloodLAMP Biotechnologies, PBC | 930 Brittan Ave. San Carlos, CA 94070 USA
## Table of Contents
| | |
|---------|------|
| Intended Use | 3 |
| Principles of Procedure | 3 |
| Materials Provided and Storage | 4 |
| Materials Required but Not Provided | 4 |
| • Standard Lab Equipment and Consumables | 6 |
| Warnings and Precautions | 6 |
| • General Precautions | 6 |
| • Contamination Precautions | 7 |
| Limitations | 7 |
| Conditions of Authorization for the Laboratory | 9 |
| Specimen Collection and Storage | 10 |
| Running Tests | 11 |
| • Reagent Preparation | 11 |
| • Controls Preparation | 12 |
| • 10X LAMP Primer Mix Preparation | 13 |
| • Sample Preparation | 15 |
| • Sample Inactivation | 15 |
| • Colorimetric LAMP Amplification Reaction Preparation | 15 |
| • Sample Addition and Heating | 16 |
| • Test Controls | 17 |
| • Patient Specimen Results Interpretation | 18 |
| Performance Evaluation | 19 |
| • Analytical Sensitivity: Limit of Detection (LoD) | 19 |
| • Analytical Sensitivity: Inclusivity (*in silico*) | 19 |
| • Evaluation of Impact of Viral Mutations | 20 |
| • Analytical Specificity: Cross-Reactivity (*in silico*) | 22 |
| • Analytical Specificity: Cross-Reactivity (wet testing) | 26 |
| • Analytical Specificity: Interfering Substances | 26 |
| Clinical Evaluation | 27 |
| Support | 27 |
||
FloodLAMP QuickColor(TM) COVID-19 Test
For COVID-19 Emergency Use Authorization Only
Instructions for Use
## Intended Use
FloodLAMP QuickColor(TM) COVID-19 Test is a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week, such as those implemented by schools, workplaces and community groups. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The FloodLAMP QuickColor(TM) COVID-19 Test is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures. The FloodLAMP QuickColor(TM) COVID-19 Test is only for use under the Food and Drug Administration’s Emergency Use Authorization.
## Principles of Procedure
The FloodLAMP QuickColor(TM) COVID-19 Test is a RNA extraction-free reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) molecular assay that indicates the presence of the SARS-CoV-2 viral RNA with a simple visual color change. It can widely and rapidly be scale because 1) no special instrumentation of any kind is required, neither nucleic acid extraction equipment nor a RT-PCR instrument, 2) it utilizes reagents and supplies readily available in large quantities, and 3) is a straightforward protocol with minimal steps that can be executed quickly and reliably. It also utilizes the same streamlined sample preparation as the FloodLAMP EasyPCR(TM) Test. Both are supply chain robust, "open source" protocol tests, meaning designated laboratories may obtain the test components directly from vendors. Together, the two tests can be used in an integrated program for screening and rapid confirmation in large populations by a broad range of laboratories.
The FloodLAMP QuickColor(TM) COVID-19 Test uses a set of specific primers that target ORF1ab, N and E genes for the detection of SARS-CoV-2 RNA. It uses Loop Mediated Isothermal Amplification (LAMP), a nucleic acid amplification technique wherein DNA amplification is carried out at a constant temperature of approximately 65°C. Samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step. The resulting inactivated sample is directly used as input in the LAMP reaction. The amplification reaction mix includes a reverse transcriptase (RT) polymerase to create complementary cDNA from RNA. The cDNA is subsequently amplified by a high strand displacement DNA polymerase. The amplified DNA products lower the pH of the reaction. A phenol red pH indicating dye is included in the amplification reaction mix, thus causing the reaction solution to visibly change from an initial bright pink to a bright yellow when sufficient amplification occurs. Reactions that change color to yellow indicate that SARS-CoV-2 RNA is present.
## Materials Provided and Storage
The FloodLAMP QuickColor(TM) COVID-19 Test utilizes standard chemicals available from multiple vendors, with the exception of the LAMP primers and Colorimetric LAMP master mix. Designated CLIA labs may order components directly from vendors.
## Materials Required but Not Provided
The FloodLAMP QuickColor(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1. No specialized instruments are needed. Only ordinary laboratory equipment such as pipettes, centrifuges, and heaters are needed.
#### Table 1: Validated reagents used with the Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | :---: | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease-free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5 M | Sodium Chloride | Thermo Fisher | 24740011 |
| Guanidine HCl | 6 M | Guanidine Hydrochloride | Sigma-Aldrich | SRE0066 |
| Colorimetric LAMP MM\* | - | Colorimetric LAMP Master Mix | New England Biolabs | M1804 |
||
\* Item may not be substituted for equivalent. Only the specified vendor and catalog number may be utilized.
The FloodLAMP QuickColor(TM) COVID-19 Test uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. All 18 primers are mixed together and are input into a single amplification reaction. Primer names and sequences are listed in Table 2. Primers may be purchased pre-blended from the vendor LGC Biosearch Technologies with the product names LAMP\_S2-As1e, LAMP\_S2-N2, LAMP\_S2-E1. Alternatively, primers may be purchased as individual custom oligos. Appropriate validation of primer mixes from custom oligos is required. See Primer Preparation below for more information.
#### Table 2: Primer names and sequences
| Primer Name | Sequence (5’-3’) |
| :---- | :---- |
| **ORF1ab gene (AS1e)** | |
| Orf1ab\_FIP | TCAGCACACAAAGCCAAAAATTTATTTTTCTGTGCAAAGGAAATTAAGGAG |
| Orf1ab\_BIP | TATTGGTGGAGCTAAACTTAAAGCCTTTTCTGTACAATCCCTTTGAGTG |
| Orf1ab\_F3 | CGGTGGACAAATTGTCAC |
| Orf1ab\_B3 | CTTCTCTGGATTTAACACACTT |
| Orf1ab\_LF | TTACAAGCTTAAAGAATGTCTGAACACT |
| Orf1ab\_LB | TTGAATTTAGGTGAAACATTTGTCACG |
| **N Gene (N2)** | |
| N2\_FIP | TTCCGAAGAACGCTGAAGCGGAACTGATTACAAACATTGGCC |
| N2\_BIP | CGCATTGGCATGGAAGTCACAATTTGATGGCACCTGTGTA |
| N2\_F3 | ACCAGGAACTAATCAGACAAG |
| N2\_B3 | GACTTGATCTTTGAAATTTGGATCT |
| N2\_LF | GGGGGCAAATTGTGCAATTTG |
| N2\_LB | CTTCGGGAACGTGGTTGACC |
| **E Gene (E1)** | |
| E1\_FIP | ACCACGAAAGCAAGAAAAAGAAGTTCGTTTCGGAAGAGACAG |
| E1\_BIP | TTGCTAGTTACACTAGCCATCCTTAGGTTTTACAAGACTCACGT |
| E1\_F3 | TGAGTACGAACTTATGTACTCAT |
| E1\_B3 | TTCAGATTTTTAACACGAGAGT |
| E1\_LF | CGCTATTAACTATTAACG |
| E1\_LB | GCGCTTCGATTGTGTGCGT |
||
### Standard Lab Equipment and Consumables
* 70% ethanol
* 10% bleach, prepared daily
* 96-well PCR reaction plates (Applied Biosystems \# 4346906, 4366932, 4346907, Eppendorf \# 951020303 or equivalent)
* Optical strip caps (Applied Biosystems \# 4323032 or equivalent)
* Optical plate seal (Applied Biosystems \# 4311971 or equivalent)
* PCR strip tubes and caps (USA Scientific catalog \# 1402-2500 or equivalent)
* 5 mL transport tubes or equivalent (sterile)
* 1.5 mL microcentrifuge tubes or equivalent (nuclease-free)
* Aerosol resistant micropipette tips (nuclease-free)
* Micropipettes (calibrated)
* Bottle top dispenser for 1 mL volume (optional, calibrated)
* 96-well cold block
* Cold blocks for 5 mL and 1.5 mL \- 2.0 mL tubes, or ice
* Vortex mixer
* 96-well plate centrifuge or equivalent
* Mini centrifuge for 1.5 mL tubes or equivalent
* 2 x Thermal cycler, water bath, dry heat bath or equivalent (calibrated)
* Class II Biological Safety Cabinet (BSC)
## Warnings and Precautions
Materials or chemicals required for the use of the FloodLAMP QuickColor(TM) COVID-19 Test should be closely examined by the user. The user should carefully read all warnings, instructions or Safety Data Sheets provided by the supplier and follow the general safety precautions when handling biohazards, chemicals and other materials.
### General Precautions
* The FloodLAMP QuickColor(TM) COVID-19 Test is for *in vitro* diagnostic use (IVD) only. Rx Only.
* For use under COVID-19 Emergency Use Authorization Only.
* Standard precautions and procedures should be taken when handling and disposing of human samples.
* This test has not been FDA cleared or approved; the test has been authorized by FDA under an Emergency Use Authorization (EUA) for use by laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA) of 1988, 42 U.S.C. §263a, to perform high complexity tests.
* This test has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens.
* This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of *in vitro* diagnostic tests for detection and/or diagnosis of COVID19 under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
* Standard precautions and procedures should be taken when handling and extracting human samples.
* Standard precautions and procedures should be taken when using laboratory equipment.
* Standard precautions and procedures should be taken when disposing of waste.
* Dispose of reagents according to local regulations.
* Do not use reagents after their recommended stability time frame.
* Ensure reagents are stored at the recommended temperatures as described below and in the vendor product information and manuals.
### Contamination Precautions
* Avoid contamination by following good laboratory practices, wearing proper personal protective equipment, segregating workflow, and decontaminating workspace appropriately.
* Ensure that surfaces and equipment used for all test steps have been properly cleaned with 10% bleach and 70% ethanol.
* Ensure all consumables are DNase and RNase free except for sample collection tubes which may be sterile.
* Use only calibrated pipettes and filter tips that are sterile and PCR clean.
* After completion of the test, dispose of the amplification reaction plates or tubes. **Do not open tubes** or remove the seals on plates after heating amplification reactions.
## Limitations
* The use of this assay as an *in vitro* diagnostic under the FDA COVID-19 Emergency Use Authorization (EUA) is limited to laboratories that are certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, to perform high complexity tests by Rx only.
* Use of this assay is limited to personnel who are trained in the procedure. Failure to follow these instructions may lead to erroneous results.
* The performance of the FloodLAMP QuickColor(TM) COVID-19 Test was established using Nasopharyngeal Swab specimen type collected in saline. Nasal swabs, oropharyngeal swabs, mid-turbinate nasal swabs specimens are also considered acceptable specimen types for use with the test but performance has not been established.
* Samples must be collected according to recommended protocols and transported and stored as described herein.
* Samples should not be collected in UTM or VTM or Liquid Amies transport media.
* The effect of vaccines, antiviral therapeutics, antibiotics, chemotherapeutic or immunosuppressant drugs have not been evaluated.
* Detection of SARS-CoV-2 RNA may be affected by sample collection methods, patient factors (e.g., presence of symptoms), and/or stage of infection.
* False-positive results may arise from various reasons, including, but not limited to the following:
* Contamination during specimen collection, handling, or preparation
* Contamination during assay preparation
* Incorrect sample labeling
* False-negative results may arise from various reasons, including, but not limited to the following:
* Improper sample collection or storage
* Degradation of SARS-CoV-2 RNA
* Presence of inhibitory substances
* Use of extraction reagents or instrumentation not approved with this assay
* Incorrect sampling window
* Failure to follow instructions for use
* Mutations in SARS-CoV-2 target sequences
* Nucleic acid may persist even after the virus is no longer viable.
* This test cannot rule out diseases caused by other bacterial or viral pathogens.
* Performance has not yet been established in asymptomatic individuals and will be established during a post-authorization study.
* Use of the test in a general, asymptomatic population for serial screening is intended to be used as part of an infection control plan that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. Negative results should not be treated as definitive and do not preclude current or future infection obtained through community transmission or other exposures. Negative results must be considered in the context of an individual’s recent exposures, history, and presence of clinical signs and symptoms consistent with COVID-19.
* This test should not be used within 30 minutes of administering nasal or throat sprays.
* Positive results must be reported to appropriate public health authorities, following state and national guidelines.
* The clinical performance of the test has not been established in all circulating variants, and test performance may vary depending on the prevalence of variants circulating at the time of patient testing.
* Negative test results do not exclude possibility of exposure to or infection with SARS-CoV-2 virus. Patient handling will be directed by healthcare professionals.
## Conditions of Authorization for the Laboratory
The FloodLAMP QuickColor(TM) COVID-19 Test Letter of Authorization, along with the authorized Fact Sheet for Healthcare Providers, the authorized Fact Sheet for Patients, and authorized labeling are available on the FDA website: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas)
However, to assist clinical laboratories running the FloodLAMP QuickColor(TM) COVID-19 Test, the relevant Conditions of Authorization are listed below:
* Authorized laboratories1 using the FloodLAMP QuickColor(TM) COVID-19 Test will include all authorized Fact Sheets with test result reports. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
* Authorized laboratories1 using the FloodLAMP QuickColor(TM) COVID-19 Test will use the FloodLAMP QuickColor(TM) COVID-19 Test as outlined in the FloodLAMP QuickColor(TM) COVID-19 Test Instructions for Use. Deviations from the authorized procedures, including the authorized clinical specimen types, authorized control materials, authorized other ancillary reagents and authorized materials required to perform the test are not permitted.
* Authorized laboratories must notify the relevant public health authorities of their intent to run the test prior to initiating testing.
* Authorized laboratories using the FloodLAMP QuickColor(TM) COVID-19 Test will have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
* Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
* All laboratory personnel using the test must be appropriately trained in molecular assay techniques and use appropriate laboratory and personal protective equipment when handling these test components, and use the test in accordance with the authorized labeling.
* FloodLAMP Biotechnologies, PBC authorized distributors, and authorized laboratories using the FloodLAMP QuickColor(TM) COVID-19 Test will ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
1 For ease of reference, this will refer to, “Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a certified laboratories with FDA Emergency Use Authorization FDA for performing SARS-CoV-2 testing
## Specimen Collection and Storage
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19:
[https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html](https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html)
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
* Samples can be stored at room temperature for 56 hours after collection prior to inactivation.
* For longer term storage, samples can be stored at ≤-70oC.
Note: Specimens must be packaged, shipped, and transported according to the current edition of the International Air Transport Association Dangerous Goods Regulation. Follow shipping regulations for UN 3373 Biological Substance, Category B when sending potential 2019-nCoV specimens.
## Running Tests
### Reagent Preparation
The FloodLAMP QuickColor(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1.
#### Table 1: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | :---: | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease- free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5M | Sodium Chloride | Thermo Fisher | 24740011 |
| Guanidine HCl | 6M | Guanidine Hydrochloride | Sigma-Aldrich | SRE0066 |
| Colorimetric LAMP MM\* | - | Colorimetric LAMP Master Mix | New England Biolabs | M1804 |
||
\* Item may not be substituted for equivalent.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
A 100X Inactivation Solution is prepared by mixing the components in Table 3 and vortexing for 30 seconds. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved. Aliquots of 100X Inactivation Solution should be stored in the dark at \-20°C for up to 3 months. Upon thaw, working aliquots of 100X Inactivation Solution should be stored in the dark at room temperature for up to 1 month.
#### Table 3: 100X Inactivation Solution
| Component | Source Concentration | Volume | 100X Concentration |
| :---- | :---: | :---: | :---: |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
For swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 4. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 4: 1X Inactivation Saline Solution
| Component | Volume |
| :---- | :---: |
| 0.9% Saline (154 mM NaCl) in MilliQ Water | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
### Controls Preparation
**One positive and one negative control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes on each heater:
1) A “no template” (negative) control (NTC) is needed to **assure the absence of cross contamination from positive samples, positive controls, or amplicons** and is used **to determine if sample results are valid.** **It consists of 100X Inactivation Solution diluted to 1X in 0.9% saline. This NTC is the same solution added to dry swabs (see Table 3 and Table 4 above for the components).**
2) A positive template control is needed to **assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water.** Stock and working aliquots of the positive control are produced from the sources listed in Table 5 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at \-80°C, or at most 1 month at \-20°C.
#### Table 5: Components for Positive Template Control
| Material | Vendor | Catalog \# | Volume |
| ----- | :---: | :---: | :---: |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µL |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µL |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895 µL |
||
### 10X LAMP Primer Mix Preparation
The FloodLAMP QuickColor(TM) COVID-19 Test uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. Primer names and sequences are shown above in Table 2. All 18 primers are mixed together and input into a single amplification reaction.
Primers may be purchased from the vendor LGC Biosearch Technologies as 3 pre-blended sets, or the primers may be purchased as 18 individual custom oligos. Table 6 below lists the primer products to be ordered.
The LGC Biosearch primer products are provided already blended for each target (6 primers per tube) and dried such that upon resuspension with 1 mL of nuclease-free water, the primers for each target are at 30X concentration. One resuspended tube for each of the 3 targets (i.e. primer blends) are mixed together to yield a 3 mL total volume that contains all individual primers at 10X concentration. This 3 mL of 10X LAMP Primer Mix provides for 1,200 reactions at 2.5 µL per reaction.
Alternatively to the pre-blended LGC Biosearch products, primers may be purchased as individual custom oligos. Custom oligos may be blended to form 30X Primer Set Mixes as intermediates or all mixed together for the 10X LAMP Primer Mix. The FIP and BIP primers for each target require purification by HPLC or an equivalent process. Appropriate validation of primer mixes from custom oligos is required. Primers may be stored at 4°C for up to one month, or at \-20°C for up to 1 year.
#### Table 6: 10X LAMP Primer Mix Components
| Vendor | Item | Catalog number | Quantity | #Reactions |
|---------|------|----------------|-----------|------------|
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP AS1e 6 primer set at 30X (ORF1ab gene) | LAMP_S2-AS1e-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LB | Custom Order | 250 nmol | 25,000 |
||
### Sample Preparation
\* For wet swab specimens (swabs in saline or unprocessed swab elution):
1) If samples are frozen, thaw unless no ice crystals are present and then keep on ice, cold block or at 4°C.
2) Pulse vortex each sample and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
3) Wipe the outside of the sample tube with 70% ethanol.
For dry swab specimens:
1) Wipe the outside of the sample tube with 70% ethanol.
### Sample Inactivation
1) Place the inactivation heater (a thermal cycler, water bath, dry heat bath or equivalent) in the BSC, turn on, and set the temperature to hold at 100 °C.
2) \* For wet swab specimens: transfer 1 mL or available volume of each sample to an appropriately labeled 1.5 mL or 5mL tube and securely cap.
3) \* For wet swab specimens: add 10μL per 1 mL sample volume of 100X Inactivation Solution to each sample tube.
4) For dry swab specimens (DO NOT DO FOR WET SWAB SPECIMENS): add 1 mL of 1X Inactivation Solution to each sample tube.
5) Vortex for 30 seconds.
6) Place sample tubes into the inactivation heater for 8 minutes.
7) Remove sample tubes from the inactivation heater and let cool at room temperature for 10 minutes.
8) Place sample tubes on ice, in the refrigerator, or on a cold block at 4°C until ready to perform amplification reaction.
Note: Testing of inactivated specimens must be conducted the same day inactivation is performed. For long term storage, keep the original specimen at ≤-70°C.
### Colorimetric LAMP Amplification Reaction Preparation
1) Place a 96-well PCR plate or PCR strip tubes onto a cold block or ice.
2) Thaw frozen reagents until ice crystals are not present.
3) Pulse vortex thawed reagents and briefly spin down in a centrifuge.
4) Store on ice, in the refrigerator, or on a cold block at 4°C until ready to use.
5) Combine components of Primer-Guanidine Solution per volumes listed in Table 7, or proportionally scaled for the number of reactions to be run.
NOTE: Component volumes should be scaled proportionally for the number of reactions.
NOTE: The Primer-Guanidine Solution may be prepared in advance and stored at \-20°C
for up to 1 month.
6) Pulse vortex and briefly spin down in a centrifuge.
7) Prepare the Colorimetric LAMP Amplification Reaction Mix by adding the Colorimetric LAMP MM to the Primer-Guanidine Solution per the volumes listed in Table 8.
8) Vortex the Colorimetric LAMP Amplification Reaction Solution for 10 seconds and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
9) Add 23 µL of the Colorimetric LAMP Amplification Reaction Solution into the wells of the PCR plate or PCR strip tubes.
NOTE: Reaction plates/strip tubes comprising the Colorimetric LAMP Amplification Reaction Solution may be prepared in advance, capped/sealed, and stored at \-20°C for up to 3 days prior to addition of the sample. A heated plate sealer may be used to seal plates. Alternatively, a manually applied foil or optical seal may be used.
#### Table 7: Primer-Guanidine Solution
| Component | Volume (1 reaction) | Volume (1 reaction x 100) 1 x 96-plate w/ 4% overage |
| ----- | :---: | :---: |
| 10X LAMP Primer Mix | 2.5 µL | 250 µL |
| Guanidine HCl (400 mM) | 2.5 µL | - |
| Guanidine HCl (6 M) | - | 16.7 µL |
| Nuclease-free Water | 5.5 µL | 783 µL |
| **TOTAL VOLUME** | **10.5 µL** | **1050 µL** |
||
#### Table 8: Colorimetric LAMP Amplification Reaction
| Component | Volume (1 reaction) | Volume (100 reactions) |
| ----- | :---: | :---: |
| Primer-Guanidine Solution | 10.5 µL | 1050 µL |
| Colorimetric LAMP MM | 12.5 µL | 1250 µL |
| **SUBTOTAL VOLUME** | **23 µL** | **2300 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **25 µL** | - |
||
### Sample Addition and Heating
NOTE: Ensure that positive and negative controls are included in each batch run (i.e. in each PCR plate or group of strip tubes that are heated together).
1) Turn on the amplification heater (a thermal cycler, water bath, dry heat bath or equivalent) and set the temperature to hold at 65°C.
NOTE: Amplification heater should be located in a separate, dedicated BSC or area of the lab. Proper cross contamination prevention practices are required, such as glove changes, to prevent amplicon contamination.
2) Add 2 μL of each sample into a separate tube in the amplification reaction PCR plate or strip tubes.
3) Mix by pipetting.
4) If using PCR plate, seal with foil seal, optical seal (optionally using heat sealer). If using PCR strip tubes, cap strips.
5) Pulse vortex and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
6) Place the plate or strip tubes in the heater and set timer for 25 minutes (do not use heated lid).
7) Remove the plate or strip tubes from the heater after 25 minutes.
8) Let cool for 1 minute and then interpret the test results.
### Test Controls
All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. An example of the expected appearance of the negative and positive controls after amplification is shown in Figure 1.
_Photo showing negative control (pink, left) and positive control (yellow, right) after amplification._
#### Figure 1: Negative control (left) and positive control (right) after amplification.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and optionally RNAseZAP product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
### Patient Specimen Results Interpretation
NOTE: Patient specimen results can only be interpreted if the positive and negative controls in the plate or group of strip tubes have the expected results.
Test results should be read at least 1 minute and no more than 8 hours after plates or tubes have been removed from heat. Test results may be determined directly from visual inspection of the color of the reaction tubes:
* yellow \- result is positive
* bright pink or red \- result is negative
* any other color \- result is invalid.
Examples are shown below in Figure 2. Edge cases for positive and negative results are shown below in Figure 3. Any color variance stronger than the edge cases should be interpreted as inconclusive. In order to reduce the chance of both false negative and false positive results, this window for color variance is intentionally set to be small.
If the initial test is inconclusive, then one of the following should be performed:
1) repeat the Colorimetric LAMP Amplification Reaction on the inactivated sample. If the repeat test has a positive result then the final interpretation of the test is positive. If the repeat test has a negative or another inconclusive result, then the final interpretation is inconclusive.
2) follow-up test the inactivated sample with the FloodLAMP EasyPCR(TM) COVID-19 Test or another high sensitivity EUA authorized test that comprises the same inactivation protocol. The final interpretation is the result of the follow-up test.
For serial screening of individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, the initial inconclusive test result may be considered the final interpretation.
If the final interpretation of the test result is inconclusive, then "Inconclusive" should be reported and retesting of the individual is recommended.
_Photo (Figure 2): Example of test results showing two negative (pink) and two positive (yellow) tubes. Photo (Figure 3): Edge case test results showing an edge-case negative (pink) and edge-case positive (yellow) tube._
## Performance Evaluation
### Analytical Sensitivity: Limit of Detection (LoD)
The Limit of Detection (LoD) for the FloodLAMP QuickColor(TM) COVID-19 Test was established using gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The negative specimens were confirmed by PCR using the CDC primers. The gamma-irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 12,500 and 6,250 were selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 9. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 12,500 copies/mL.
#### Table 9: LoD Confirmatory Data Results
| Concentration of Contrived Positive Sample | Replicates Detected |
| :---: | :---: |
| 12,500 copies/mL | 95% (20/21) |
| 6,250 copies/mL | 52% (11/21) |
||
### Analytical Sensitivity: Inclusivity (*in silico*)
An inclusivity study was conducted for the ORF1ab, N2, and E1 primer sets against all complete, high coverage SARS-CoV-2 sequences deposited at GISAID as of February 27, 2021. Table 10 summarizes the results of this *in silico* inclusivity analysis. A total of 498,224 sequences were considered. There are 10 sequence isolates that have 1mm to both As1e and E1 and had N2 excluded due to greater than 15 N's, with the other 498,214 sequence isolates all have at least 1 target region that is a complete match.
Each primer set matched at 100% similarity against the SARS-CoV-2 RefSeq reference genome (Wuhan-Hu-1; NC\_045512.1). All three primer sets differed by one or fewer mutations for 99.7% of GISAID sequences, indicating nominal primer hybridization for all SARS-CoV-2 variants under consideration.
#### Table 10: *In Silico* Inclusivity Analysis for LAMP Primers
| Primer | AS1e (ORF1ab gene) | | N2 (N gene) | | E1 (E gene) | |
| :---- | ----- | ----- | ----- | ----- | ----- | ----- |
| **Total Primer Length** | 195 | | 169 | | 168 | |
| **Total \# of Strains Evaluated** | 498,224 | | 498,224 | | 498,224 | |
| **100% Match** | 474,717 | 95.3% | 479,548 | 96.3% | 462,538 | 92.8% |
| **1 Mismatch** | 19,301 | 3.9% | 15,698 | 3.2% | 30,626 | 6.1% |
| **2 Mismatches** | 338 | 0.1% | 161 | 0.0% | 1,455 | 0.3% |
| **3 Mismatches** | 9 | 0.0% | 5 | 0.0% | 103 | 0.0% |
| **\> 3 Mismatches** | 0 | 0.0% | 0 | 0.0% | 1 | 0.0% |
| **Total Strains Removed** | 3,859 | 0.8% | 2,812 | 0.6% | 3,501 | 0.7% |
||
### Evaluation of Impact of Viral Mutations
The As1e, E1 and N2 primer regions of all SARS-CoV-2 genomes present in GISAID as of 2/26/2021 were evaluated to assess the potential impact of genomic variants on LAMP primer binding. This analysis was performed with the Primer Monitoring Tool from New England Biolabs ([primer-monitor.neb.com](http://primer-monitor.neb.com)), which continually monitors registered primer sets for overlapping variants in sequences from GISAID. Results are summarized by region and locus below in Table 11, including the 30 countries with most sequences in GISAID. Sequences were aligned to the SARS-CoV-2 reference sequence (NC\_045512.2) using minimap2 (minimap2 \-t 16 \-x asm5 \-a). Variant sites (excluding Ns) were identified using samtools mpileup and summarized by region and genome position. Genomic positions having \>= 40 global variant observations are shown (column labels). When present, box labels indicate the fraction of variants observed at a given locus.
The aggregate of current published mutations is not expected to reduce performance of the FloodLAMP QuickColor(TM) COVID-19 Test by more than 5% from that established by the performance evaluation in this EUA submission. Further, the use of 3 primer sets targeting different regions in the SARS-CoV-2 genome should make the test robust to new genetic variants.
#### Table 11: Variant Analysis of LAMP Primers
_Heatmap charts showing variant frequency at LAMP primer binding sites across 30 countries for AS1e, N2, and E1 primer sets, based on GISAID sequences aligned to the SARS-CoV-2 reference genome._
### Analytical Specificity: Cross-Reactivity (*in silico*)
*In silico* cross-reactivity analysis was performed by aligning the primer sequences of the FloodLAMP QuickColor(TM) COVID-19 Test against sequences of other coronaviruses and common respiratory flora using the BLASTn alignment tool from NCBI. Results of this analysis are presented in Tables 12A, 12B, and 12C.
The % identity range (\# identical bases/ \# primer bases) is shown for each primer and organism. Darker font indicates % identity greater than 80%. Organisms with \>= 50% identity primer hits are shown. This analysis is not intended to predict amplification. Near perfect homology across B3, F3, FIP and BIP is necessary to support successful amplification. With the exception of SARS-CoV, simultaneous homologies do not occur between any of the primers and microorganisms screened. With respect to clinical relevance of the *in silico* cross-reactivity analysis, there are no known circulating strains of SARS-CoV circulating in humans, thus the overall probability for the test to produce a cross-reactive signal is negligible.
#### Table 12A: *In Silico* Cross-Reactivity Analysis for AS1e Primers
| Organism Group | Organism Name | Organism ID | As1_B3 (22 bp) | As1e_BIP (49 bp) | As1_F3 (18 bp) | As1e_FIP (51 bp) | As1_LB (27 bp) | As1_LF (28 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 47%-55% | 100% | 43%-53% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| | SARS coronavirus | NC_004718 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 72%-89% | 29% | 52%-67% | |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 77% | | 89% | 37%-51% | 52%-89% | |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 59%-73% | 33%-35% | 89% | 33%-45% | 52% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-73% | 31% | 72%-83% | 29%-59% | 52% | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | 83% | | | |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 59%-82% | 39% | | 29%-41% | 67% | 61% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-82% | | 72% | 39%-87% | 59% | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 59%-82% | 31% | 72% | 31% | 52%-67% | |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | 72%-78% | | 70% | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | 72% | 29%-35% | 78% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.15 | NW_017264789.1 | 59% | | | 78% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.11 | NW_017264785.1 | 77% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 77% | | | 35% | 63% | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59% | 43%-49% | 72% | 29%-57% | 63%-74% | 68% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | 49% | 72% | 31%-41% | 56%-74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | 31%-43% | 74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 73% | | 72% | 29%-39% | 52% | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 59%-68% | 31%-37% | 72% | 29%-35% | 56%-67% | 57%-71% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | 37%-41% | 72% | 29%-41% | 52%-63% | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.14 | NW_017264788.1 | | | | 35% | | 71% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | | | | 29%-47% | 70% | 68% |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59%-68% | 35% | | 29%-43% | | 68% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 68% | 37% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 33%-49% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | 43% | | 38% | | 68% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 64% | | | | | 57% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | | | | 33%-35% | 59% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 59% | | | | | 50% |
| | Bordetella pertussis 18323 | NC_018518.1 | | | | | | 57% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | | 52% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | 39%-47% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.54 | NW_017264828.1 | | 47% | | | | |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | | 31% | | 31%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | | | | 33%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.19 | NW_017264793.1 | | | | 38% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | | | | 35% | | |
| | Respiratory syncytial virus | NC_001803.1 | | | | 33% | | |
||
#### Table 12B: *In Silico* Cross-Reactivity Analysis for N2 Primers
| Organism Group | Organism Name | Organism ID | N2_B3 (25 bp) | N2_BIP (40 bp) | N2_F3 (21 bp) | N2_FIP (42 bp) | N2_LB (20 bp) | N2_LF (21 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 53% | 100% | 48%-55% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 64% | 53% | 90% | 55% | 85% | 90% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 60%-80% | | 95% | | 75% | 62%-71% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | 40% | 75%-90% | |
| | Bordetella pertussis 18323 | NC_018518.1 | | 35% | | | 65%-80% | 81% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | 56%-72% | 43% | | | | 62%-81% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | 56%-76% | | 62%-71% | 45% | | 62%-81% |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 56%-80% | 35%-68% | 62% | | | 62%-81% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 60%-80% | 35%-45% | 71% | | | 62%-71% |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 60%-72% | 35%-45% | 71%-76% | | | 62%-76% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 56%-76% | | 76% | 36% | 65% | |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 60%-76% | 43% | | 36%-55% | | 62%-76% |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | 60% | | | | 65%-75% | 76% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 68%-64% | | | | | 76% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | 35% | | | 75% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 56%-72% | 48% | 62% | 40% | | 67%-71% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 56%-72% | | 71% | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.17 | NW_017264791.1 | 56%-72% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | 60%-72% | | 71% | | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 56%-68% | 35% | | | | 62%-71% |
| | Human parainfluenza virus 1 | NC_003461.1 | | | 71% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 60%-68% | | | | | 62%-71% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 60%-68% | 50% | | 43% | | 62%-67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 68% | | | | | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 60%-68% | | 62% | | | 62% |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 56% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 56%-60% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 64% | 35% | | | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 60%-64% | 43%-50% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 60% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.51 | NW_017264825.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.67 | NW_017264841.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 56% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.21 | NW_017264795.1 | 52% | | | | | |
||
#### Table 12C: *In Silico* Cross-Reactivity Analysis for E1 Primers
| Organism Group | Organism Name | Organism ID | E1_B3 (22 bp) | E1_BIP (44 bp) | E1_F3 (23 bp) | E1_FIP (42 bp) | E1_LB (19 bp) | E1_LF (18 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 45%-57% | 100% | 45%-62% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 95% | 55% | 100% | 43%-62% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | | | | 40%-50% | | 72%-89% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | | | | 84% | 72% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | | | 36%-40% | | 78%-83% |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-82% | | 43% | | | 72% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | | | | 43%-50% | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | | | | | | 78% |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | | 45% | | 43%-48% | | 72%-78% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 77% | | | 36%-43% | | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59%-73% | | | 38%-48% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-73% | | 65% | 43% | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 73% | 41% | | 48% | | 72% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 59% | | | 43%-48% | | 72% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | | 36%-50% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | | 65% | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | 59%-68% | | | | | 72% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | | | 40% | 68% | 72% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 70% | | 40%-50% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | | | 70% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 59%-64% | | | 40% | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59% | | | 40%-43% | | |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 0%-59% | 0% | 0% | 0%-36% | 0% | 0% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | 59% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.20 | NW_017264794.1 | 59% | | | | | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | 34% | 57% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.30 | NW_017264804.1 | | | | 50% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.69 | NW_017264843.1 | | | | 50% | | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | | 43% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | | | | 40% | | |
||
### Analytical Specificity: Cross-Reactivity (*wet testing*)
Wet testing was performed to demonstrate that the FloodLAMP QuickColor(TM) COVID-19 Test does not react with related pathogens, high prevalence disease agents and normal or pathogenic flora that are reasonably likely to be encountered in a clinical specimen. SARS-CoV, RSV, Flu, Human Metapneumovirus. and Streptococcus Salivarius were tested for potential cross-reactivity, as shown in Table 13. Gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) was spiked onto dried AN swab specimens to produce contrived Positve Controls. Negative Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and cross-reactivity organisms were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol.
All wet testing showed no cross-reactivity with the viral pathogens and common respiratory flora, as shown in Table 13.
#### Table 13: Wet Testing Cross-Reactivity Results
| Organism | Description | BEI Number | Detected Replicates |
| ----- | ----- | :---: | :---: |
| SARS-CoV | UV-inactivated virus | NR-3882 | 0/3 |
| Human Metapneumovirus | Genomic RNA | NR-49122 | 0/3 |
| RSV | Genomic RNA | NR-43976 | 0/3 |
| Influenza B | Genomic RNA | NR-45848 | 0/3 |
| Streptococcus salivarius | Bacterial cell culture | HM-121 | 0/3 |
||
### Analytical Specificity: Interfering Substances
Exogenous and endogenous substances were tested for potential interference with the FloodLAMP QuickColor(TM) COVID-19 Test. Gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) was spiked onto dried AN swab specimens to produce contrived Positve Controls. Negative Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 14 and Supporting Data.
#### Table 14: Interfering Substances Results
| Interfering Substance | Active Ingredient | Concentration | % Agreement with Expected Results | |
| :---: | :---: | :---: | :---: | :---: |
| | | | **Positive Control Spiked** | **Negative Control Unspiked** |
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
## Clinical Evaluation
The clinical evaluation of the FloodLAMP QuickColor(TM) COVID-19 Test utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The FloodLAMP QuickColor(TM) COVID-19 Test showed a positive agreement of 90% and a negative agreement of 100%. The 4 false negative results were specimens with high Ct values as previously measured by the comparator test, indicating low viral load. A summary of the clinical performance is below in Table 15.
#### Table 15: Clinical Evaluation Results
| FloodLAMP QuickColor(TM) COVID-19 Test Results | Comparator \- High Sensitivity EUA Authorized Test | | |
| :---: | :---: | :---: | :---: |
| | **Positive** | **Negative** | **Total** |
| Positive | 36 | 0 | 36 |
| Negative | 4 | 40 | 44 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 90.0% (36/40) 95% CI: 76.3% to 97.2% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## Support
FloodLAMP Biotechnologies, PBC support center
eua.support@floodlamp.bio
650-394-5233
# 5,817 2021-05-18_Pre-EUA Sub - FloodLAMP Pooled Swab Collection DTC.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-05-18_Pre-EUA Sub - FloodLAMP Pooled Swab Collection DTC.md
file_date: 2021-05-18
title: Pre-EUA Sub - FloodLAMP Pooled Swab Collection DTC
category: regulatory
subcategory: fl-fda-submissions
tags:
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notes:
summary_short: The Pre-EUA submission for the FloodLAMP Pooled Swab Collection Kit DTC outlines an unsupervised, direct-to-consumer system for pooling 1–4 dry anterior nasal swabs for SARS-CoV-2 testing at designated CLIA high-complexity laboratories. It describes the kit components, ordering/registration and accessioning workflows (including optional use of the FloodLAMP Mobile App for pooling, identity, and results delivery), and planned usability and stability/rehydration validation for use with authorized molecular tests. It frames intended use for asymptomatic screening programs and specifies reporting, labeling, manufacturing, and recordkeeping expectations for an EUA pathway.
CONTENT
***INTERNAL TITLE:*** Home Specimen Collection Molecular Diagnostic Template
## A. PURPOSE FOR SUBMISSION
Emergency Use Authorization (EUA) request for distribution and/or use of the **FloodLAMP Pooled Swab Collection Kit DTC** for the **unsupervised collection** of **1 to 4 pooled nasal swabs** in a **dry tube** to transport viral SARS-CoV-2 RNA, from **any individual, including individuals without symptoms or other reasons to suspect COVID-19**. The collection kit is for use in conjunction with molecular diagnostic testing performed at a clinical laboratory using an in vitro diagnostic (IVD) test for the detection of SARS-CoV-2 that is authorized for use with the **FloodLAMP Pooled Swab Collection Kit DTC**.
Testing is limited to laboratories designated by **FloodLAMP Biotechnologies, PBC** that are certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meet requirements to perform high complexity tests.
Test results may be delivered to the user via the **FloodLAMP Mobile App or Web Portal**. Individuals with positive or inconclusive will be referred to a healthcare provider. The direct to consumer home collection system is intended to enable individuals and organizations to access information about their COVID-19 infection status that could aid with determining if self-isolation or quarantine is appropriate and to assist with healthcare decisions after discussion with a healthcare provider.
The **FloodLAMP Pooled Swab Collection Kit DTC** is for use by unsupervised adults 18 years and older, to self-collect dry anterior nasal swab specimens, including for use by such individuals without symptoms or other reasons to suspect COVID-19. Collection for minors under the age of 18 may be assisted by pre-authorized individuals, including by a parent, guardian or other responsible person who is contributing a nasal swabs specimen to the same pool as the minor.
The **FloodLAMP Pooled Swab Collection Kit DTC** is not a substitute for visits to a healthcare provider. The information provided by this kit when combined with an authorized test should not be used to start, stop, or change any course of treatment unless advised by your healthcare provider.
## B. APPLICANT
FloodLAMP Biotechnologies, a DE Public Benefit Corporation
| Mailing Address: 4860 Alpine Rd. Portola Valley, CA 94028 | Laboratory Address: 930 Brittan Ave San Carlos, CA 94070 | Randall J. True, CSO Phone: (415) 269-2974 Email: randy@floodlamp.bio |
| :---- | :---- | :---- |
## C. PROPRIETARY AND ESTABLISHED NAMES
Proprietary Name - **FloodLAMP Pooled Swab Collection Kit DTC**
Established Name - **FloodLAMP Pooled Swab Collection Kit DTC**
## D. REGULATORY INFORMATION
### Approval/Clearance Status:
The **FloodLAMP Pooled Swab Collection Kit DTC and FloodLAMP Mobile App** are not cleared, approved, or subject to an approved investigational device exemption.
### Product Code:
*QJR*
## E. PROPOSED INTENDED USE
### 1) Intended Use:
***The proposed IU will be finalized based on, among other things, the data and recommendations from Public Health authorities at the time of authorization – example text is provided below.***
***Example text for a home collection kit where the manufacturer does not hold the COVID-19 NAAT test EUA:***
The **FloodLAMP Pooled Swab Collection Kit DTC** is a direct to consumer (DTC) product for **self-collecting pooled anterior nasal swabs in a dry tube** at home (which includes a community based setting), **including individuals without symptoms or other reasons to suspect COVID-19**. Specimens collected using the **FloodLAMP Pooled Swab Collection Kit DTC** are transported at ambient temperature for testing at a laboratory. SARS-CoV-2 RNA from the **nasal swabs** is maintained in the specimen packaging and is suitable for use in molecular diagnostic testing performed using an in vitro diagnostic (IVD) test for the detection of SARS-CoV-2 that has been issued an EUA for use with Home Collection Kits, that includes the **FloodLAMP Pooled Swab Collection Kit DTC**.
Testing is limited to laboratories designated by **FloodLAMP Biotechnologies** and certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests. Testing is also limited to molecular diagnostic tests that are authorized for use with Home Collection Kits for collection of nasal swab specimens, including the **FloodLAMP Pooled Swab Collection Kit DTC**.
The **FloodLAMP Pooled Swab Collection Kit DTC** is only for use under the Food and Drug Administration’s Emergency Use Authorization.
***Example text for a home collection kit where the manufacturer also holds the COVID-19 NAAT test EUA (e.g., an already issued EUA is being revised to authorize home specimen collection as an option):***
The **FloodLAMP QuickColor(TM) COVID-19 Test** is a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assay that indicates the presence of the SARS-CoV-2 viral RNA with a simple visual color change. The **FloodLAMP EasyPCR(TM) COVID-19 Test** is a real-time reverse transcriptase polymerase chain reaction (RT-qPCR) assay that utilizes a RT-PCR instrument. These tests are RNA extraction-free tests intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs **from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests.**
These tests are also for use with the **FloodLAMP Pooled Swab Collection Kit DTC** for **self-collecting pooled anterior nasal swabs in a dry tube** at home (which includes a community based setting), **including individuals without symptoms or other reasons to suspect COVID-19**. Specimens collected using the **FloodLAMP Pooled Swab Collection Kit DTC** are transported at ambient temperature for testing at a laboratory.
Testing is limited to \[***specify laboratory/laboratories***\] certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in **upper respiratory specimens** during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The **FloodLAMP QuickColor(TM) and EasyPCR(TM) COVID-19 Tests** are intended for use by **qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of in vitro diagnostic procedures**. The **FloodLAMP QuickColor(TM) and EasyPCR(TM) COVID-19 Tests** are only for use under the Food and Drug Administration’s Emergency Use Authorization.
### 2) Special Conditions for Use Statements:
For Emergency Use Authorization (EUA) only.
**For prescription use and over-the-counter use**.
For in vitro diagnostic use only.
For use **unsupervised** by people 18 years of age or older.
For use by **minors under the age of 18 with assistance by individuals pre-authorized by a parent or guardian.**
The **FloodLAMP Pooled Swab Collection Kit DTC** is only authorized for use in conjunction with an in vitro diagnostic (IVD) test for the detection of SARS-CoV-2 that has been issued an EUA and is authorized for use with this collection device.
## F. DEVICE DESCRIPTION
### 1) Device Description:
The **FloodLAMP Pooled Swab Collection Kit DTC** consists of **nasal swabs, barcoded transport tube, zip-seal biohazard safety bag, and instructions**. Some kit configurations include multiple transport tubes and biohazard safety bags for multiple collections. Additionally, the kit may include other tubes for simultaneous collection of individual (non-pooled) swabs, along with a barcode label and additional zip-seal bag.
### 2) Home Collection Kit Ordering and Processing:
The **FloodLAMP Pooled Swab Collection Kit DTC** is available direct to consumer (DTC) without a prescription for any individual 18 years and older. Individuals may receive kits by purchasing through an authorized distributor or as a part of a screening program. Instructions included with the kit guide users on how to properly collect the anterior nasal swab specimens. After collection of all swabs in the pool, the transport tube is capped and placed inside the biohazard bag, which is then sealed. The biohazard bag with specimens is returned to a designated location and placed inside a secure receptacle or given to responsible program staff. The biohazard bag may also be couriered or placed inside an appropriate labeled mailer for shipping to a designated location for processing. The time from collection to receipt for processing is not to exceed 48 hours.
If using the **FloodLAMP Mobile App**, the following steps are performed to complete a pooled collection event:
- all participants sign up for an account on a computer or mobile device, confirm their identity via email or text message, set a password, login to the app, and digitally sign a consent;
- a single individual (the "pool sponsor"), who may be a participant in the pool, initiates a collection event and oversees the proper collection of specimens by all participants in the pool;
- participants are instructed to swab both nostrils per the printed instructions which are reproduced in the app;
- next, the pool sponsor scans the barcode of the transport tube used for collection of the swab specimens for the collection event;
- next, the pool sponsor enters the names, emails, or phone numbers of the other participants contributing specimens to the pool;
- if this collection event is the first time the pool sponsor is including a participant in the pool, the participant is required to provide authorization via the app;
- after all participants are added, the pool sponsor completes a collection confirmation consisting of questions that are required to be checked.
If not using the **FloodLAMP Mobile App**, the registration of which individuals contribute specimens to the pools may be accomplished through secure lookup tables containing barcodes and PII in a process managed by administrators of the serial screening program.
Barcoded specimen tubes are received at the clinical laboratory for testing and undergo the following accessioning prior to acceptance for testing:
- biohazard bags are opened and barcoded transport tubes removed;
- transport tubes are inspected and if cap is missing, tube is improperly capped, or tube is cracked or otherwise damaged, then the tube is intake scanned for intake and rejected for testing;
- participants with specimens in rejected tubes are notified, and if appropriate, requested to provide another specimen;
- tubes that are not rejected are placed into a queue for processing.
Clinical laboratories may use an existing LIS or use the lightweight LIS provided in the **FloodLAMP Mobile App**. The app LIS is accessed by switching to "staff mode" which is only available to permitted users. Staff users can place intake scanned tubes into batches both physically and digitally, for example in batches of 94 to run in an amplification plate. The status and results for individual tubes or batches of tubes is set by staff users. After completion of the test (amplification reaction), results (positive, negative, inconclusive/invalid) can be entered by scanning tube barcodes or imported from a file (for example the output file from a RT-PCR instrument). All data is protected by secure login to the **FloodLAMP Mobile App**.
Test results are communicated back to individuals that used the **FloodLAMP Pooled Swab Collection Kit DTC** via the **FloodLAMP Mobile App.** Users set their notification preference as email or text message. When a new result is available, they receive a short message to check the app for that new result. From the home screen in the app, users select "Results" to see their test results. Additionally, administrators receive an email with information on a positive pool including the participants names and contact information.
### 3) Specimen Collection Control:
Though it may also be used for individual specimen collection, the primary use case for the **FloodLAMP Pooled Swab Collection Kit DTC** is for pooled collection as part of a serial screening program. The pool sponsor who registers the collection event in the **FloodLAMP Mobile App** is instructed to observe all participants contributing specimens to the pool to control for proper nasal swabbing technique. This oversight provides a baseline level of specimen collection control.
The **FloodLAMP EasyPCR(TM) COVID-19 Test** which is intended for use with the **FloodLAMP Pooled Swab Collection Kit DTC** has an internal process control to assure sufficient specimen quantity and quality. It consists of a primer/probe set targeting the human RNaseP gene that is included in a single PCR amplification reaction. The RNAseP Internal Process Control uses a fluorescent reporter in a separate channel from the SARS-CoV-2 channel (i.e. in duplex).
### 4) Partnering Laboratories:
| Laboratory | EUA Assay | Lab Testing Capacity (per day or week) |
| :---- | :---- | :---- |
| **Lab Name** Address Phone: CLIA \#: | Assay Name **Identify if Commercial Assay or LDT** | |
||
### 5) Test Result Reporting:
All test results will be reported to healthcare providers and relevant public health authorities in accordance with local, state, and federal requirements, using appropriate LOINC and SNOMED codes, as defined by the [Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests](https://www.cdc.gov/csels/dls/sars-cov-2-livd-codes.html) provided by CDC.
Public health reporting will be supported by the **FloodLAMP Mobile App**, through an API or a results export file. Alternatively, reporting may be done through the CDC's SimpleReport application ([https://simplereport.gov/](https://simplereport.gov/)). For pooled results, the reporting occurs during deconvolution testing of individual samples, according to local public health requirements.
### 6) Mobile Applications and Software:
The **FloodLAMP Mobile App** requires 4 MB of device memory and an internet connection. The **FloodLAMP Mobile App** is supported in IOS, Android and mobile web browsers.
IOS is supported from versions 12 through 14. Android is supported from version 5.1 through version 1. Mobile browser testing occurs on safari and chrome using the most recent stable release.
End-to-end testing and validation occurs on the oldest and most recent supported devices for all platform changes. FloodLAMP tests each user stage (onboarding and account creation, sample collection, pooling and deposit, and results) during server and platform updates. All permutations of required and non-required fields are tested for corresponding error codes and successful database entries.
Records are not stored on user devices and are stored on a secure cloud based database.
## G. PRODUCT MANUFACTURING
The **FloodLAMP Pooled Swab Collection Kit DTC** [has been] validated using only the components referenced in this submission.
### 1) Overview of Manufacturing and Distribution:
The product will be manufactured at **Eralab Scientific Instrument (HK) Co., Limited by Ningbo Dasky Life Science** personnel consistent with practices for the production of **diagnostic collection kits** based on **CE standards**. Material manufactured by **Ningbo Dasky Life Science** may be bottled and kitted by **FloodLAMP Biotechnologies** at their manufacturing facility.
The current manufacturing capabilities include the ability to manufacture approximately **50,000 products per week**. In the event of a surge in demand, this could be increased to **4.9 million products per week within a two week timeframe**.
The product will be distributed by **FloodLAMP Biotechnologies and its distribution partners**.
### 2) Components Included with the Home Collection Kit
Components manufactured by **Eralab Scientific Instrument (HK) Co., Limited** and supplied with the home collection kit include:
#### Kit components
| | | | |
|--------------------|------------------------|-----------|-----------------|
| **Name** | **Description** | **Quantity** | **Material Supplier** |
| Biohazard safety bag | Zip-seal biohazard safety bag | 1 | Various |
| Sterile Collection Tube | Sterile collection tube with QR code | 1 | Various |
| Nasal Swab | Foam or spun polyester swab | 4 | Various |
| Instructions for self collection | Printed card with graphical instructions for self collection | 1 | Printed |
| Fact sheet for individuals | Contains information on risks and benefits | 1 | Printed |
| Return shipping mailer (optional) | Postage paid return mailer | 1 | Various |
||
### 3) Collection Device Stability:
No collection reagents are used in the **FloodLAMP Pooled Swab Collection Kit DTC**.
## H. PERFORMANCE EVALUATION
### 1) Home Collection Sample Stability Study:
Shipping stability of foam and dry spun polyester swabs has been demonstrated by Quantigen Biosciences with support from The Gates Foundation and UnitedHealth Group. The Quantigen study demonstrated 56-hour stability for dry anterior nasal foam and spun polyester swabs when subjected to both summer and winter thermal excursions. Quantigen Biosciences has granted a right of reference to the stability data to any sponsor, such as FloodLAMP Biotechnologies, PBC pursuing an EUA for which a claimed specimen type is foam or dry spun polyester swabs. Therefore, the stability of anterior nasal samples collected using foam or dry spun polyester swabs were not evaluated in the sample stability study.
**Dry Swab Rehydration Validation:**
The rehydration protocol for dry swabs collected with the **FloodLAMP Pooled Swab Collection Kit DTC** varies depending upon the downstream test chemistry of the COVID-19 NAAT test EUA. Principally, it comprises addition of between 1 mL and 3 mL of solution/media to the tube of pooled dry swabs, with less than 1 mL potentially for individual swabs. The solution/media may contain an inactivation/lysis chemical or it may be VTM or saline solution. After addition of the solution/media, the tube is agitated to facilitate extraction of the specimen from the swab. Typically, 30 seconds of vortexing is recommended. The specific volume, composition of solution/media, and agitation protocol must be validated for all COVID-19 NAAT test EUAs using the **FloodLAMP Pooled Swab Collection Kit DTC**.
For the **FloodLAMP QuickColor(TM) and EasyPCR(TM) COVID-19 Tests**, the rehydration protocol for pools of up to 4 dry swabs collected with the **FloodLAMP Pooled Swab Collection Kit DTC** comprises:
1. addition of \[1\] mL of 1X Inactivation Saline Solution;
2. vortex for 30s at 3-5,000 rpm.
Following are the steps of heat inactivation, cooling of samples, and amplification. Please see the test IFUs for the complete SOP.
For validation of the dry swab rehydration protocol for the **FloodLAMP QuickColor(TM) and EasyPCR(TM) COVID-19 Tests** for pools of up to 4 dry swabs collected with the **FloodLAMP Pooled Swab Collection Kit DTC**, contrived positives specimens at 20,000 copies/swab were prepared by
### 2) General Acceptance Criteria:
\* Please see acceptance criteria in section F-2 above and reference to the dry swab stability study in H-1.
### 3) Human Usability Study: Pooled Self-Collection Validation
PROPOSED USABILITY STUDY
- Testing will include a minimum of 30 participants in each arm and will take place in an actual or simulated home environment.
- Study Arm 1 will provide only printed IFU instructions with the collection kit and include barcoded collection tubes that have been pre-registered to the participant. This arm assesses usability of a workflow for a serial screening program that uses pre-registration of collection kits.
- Study Arm 2 will provide printed IFU instructions with the collection kit and require the participant to register the kit using the **FloodLAMP Mobile App**.
- The entire workflow will be performed by each individual participant using the collection kit, including kit registration, sample collection, packaging of the sample, and return of the sample (by mail or dropoff depending upon the study arm).
- The participants will be observed either in person or by recorded video conference during sample collection and all difficulties will be noted.
- Participants will collect pooled samples of between 1 and 4 swab specimens.
- After the entire process is completed, the user will be given the attached 12 question survey assessing the ease of use of the kit and sample collection as well as understanding of the consequences if steps are not performed correctly. The participant will be able to provide comments if needed.
- The laboratory personnel will inspect the packaging and specimens upon delivery and note all packaging errors and acceptability of the sample for testing.
- The samples collected during the study will be tested for specimen adequacy using the **FloodLAMP EasyPCR(TM) COVID-19 Test** which includes an internal human sample control (RNaseP). The RNaseP Ct value will be used to determine if sufficient sample was collected by the user. \[To CDRH Reviewers: Is it acceptable to utilize the FloodLAMP EasyPCR(TM) COVID-19 Test for determining the pass/fail of specimen adequacy? It is not yet an EUA authorized test but a full EUA submission is included along with this pre-EUA for review. The test uses the CDC primers from the EUA authorized SalivaDirect(TM) Test. In the clinical evaluation performed by the Stanford University Clinical Lab, the test showed a 98% sensitivity. The LoD was determined at 3,100 copies/mL.\]
- Participants will include individuals representing varying education levels and ages. Participants with prior medical or laboratory training will be excluded. ~~Participants who have prior experience with self-collection should be excluded.~~ \[To CDRH Reviewers: Is it acceptable to strike this exclusion since self-collection has become much more widespread?\]
- The study will have pre-defined acceptance criteria and errors identified in the study will be mitigated by modifying the instructions.
#### Inclusion and Exclusion Criteria for Usability Study (both arms)
| | |
|------------------------------------|------------------------------------|
| **Inclusion Criteria** | **Exclusion Criteria** |
| Participant is 18 years or older. | Participant has participated in a prior COVID-19 collection kit usability study. |
| Participant resides in the United States. | Participant is suspected of COVID-19. |
| Participant speaks English. | Participant is experiencing symptoms of COVID-19. |
| Participant is willing to read the study information and informed consent. | Participant has received a positive COVID-19 test result. |
| Participant is willing to sign the informed consent. | Participant has prior medical or laboratory training. |
| Participant is willing to complete the survey. | Participant regularly uses home use diagnostic tests, such as glucose meters. |
| Participant is willing to have the interview recorded. | Participant does not speak English. |
||
#### Inclusion and Exclusion Criteria for Usability Study (additional for arm 2)
| | |
|------------------------------------|------------------------------------|
| **Inclusion Criteria** | **Exclusion Criteria** |
| Participant has a valid email address. | Participant is a professional software developer or UX/UI designer. |
| Participant has access to an iOS or Android mobile device. | - |
| Participant has access to a stable internet connection. | - |
||
### 4) User Labeling:
**You should submit for review your packaging and directions for your specimen collection kit. FDA will review these documents for their ease of use and clarity of instructions. We recommend all directions be written at a 7th grade reading level or below.**
The print version of the Instructions for Use for the **FloodLAMP Pooled Swab Collection Kit DTC** are included as a pdf document with this submission.
## I. UNMET NEED ADDRESSED BY THE PRODUCT
**This section will be completed by FDA.**
## J. APPROVED/CLEARED ALTERNATIVE PRODUCTS
Currently no methods for specimen self-collection in conjunction with a laboratory-based molecular in vitro diagnostic EUA test for the detection of the SARS-CoV-2 have been approved/cleared by FDA.
## K. BENEFITS AND RISKS:
**This section will be completed by FDA.**
## L. FACT SHEET FOR HEALTHCARE PROVIDERS AND PATIENTS:
**As set forth in the EUAs, Fact Sheets for Patients and Healthcare Providers generally are to be provided with the assays that will be used with the home collection kit *- see examples for authorized EUA tests on our website and templates will be made available.***
## M. INSTRUCTIONS FOR USE/ PROPOSED LABELING/PACKAGE INSERT:
**Include Instructions for Use, Box Labels, Vial Labels and any other proposed labeling for the test and/or home collection kit. You should also include copies of any questionnaires used to determine eligibility of the patient to receive the home collection kit.**
## N. RECORD KEEPING AND REPORTING INFORMATION TO FDA:
If authorized, conditions would likely be included in the EUA to require the following -
**FloodLAMP Biotechnologies** will track adverse events and report to FDA under 21 CFR Part 803. A website is available to report adverse events, and this website is referenced through the **FloodLAMP Biotechnologies** Product Support website: **floodlamp.bio/support**. Each report of an adverse event will be processed according to **FloodLAMP Biotechnologies**’s Non-Conformance Reporting Requirements, and Medical Device Reports will be filed with the FDA as required. Through a process of inventory control, **FloodLAMP Biotechnologies** will also maintain records of device usage/purchase. **FloodLAMP Biotechnologies** will collect information on the performance of the test, and report to FDA any suspected occurrence of false positive or false negative results of which **FloodLAMP Biotechnologies** becomes aware. **FloodLAMP Biotechnologies** will maintain records associated with this EUA and ensure these records are maintained until notified by FDA. Such records will be made available to FDA for inspection upon request.
# 1,515 2021-05-18_Pre-EUA Sub - FloodLAMP Pooled Swab Collection Kit DTC.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-05-18_Pre-EUA Sub - FloodLAMP Pooled Swab Collection Kit DTC.md
file_date: 2021-05-18
title: Pre-EUA Sub - FloodLAMP Pooled Swab Collection Kit DTC
category: regulatory
subcategory: fl-fda-submissions
tags: collection
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summary_short: The FloodLAMP Pooled Swab Collection Kit DTC instructions describe how up to four people can self-collect anterior nasal swabs into a single barcoded/QR-coded tube, with step-by-step workflows for both a mobile app–guided and non-app version. It explains kit contents, hygiene and swabbing steps, participant association and tube scanning in the app, and how to package and return specimens via collection point or prepaid mailer. It includes EUA-required limitations stating the product is authorized only for home collection/maintenance of anterior nasal swabs for SARS-CoV-2 nucleic acid detection during the active emergency declaration.
CONTENT
***INTERNAL TITLE:*** FloodLAMP Pooled Swab Collection Kit DTC
**FloodLAMP Biotechnologies**
A Public Benefit Corporation
FloodLAMP Pooled Swab Collection Kit DTC
For IVD Use. For use under emergency use authorization only.
## Mobile App Version
For use with the FloodLAMP Mobile App
### Your kit includes:
_Diagram of swabs_
Swabs
_Diagram of QR coded tube_
QR coded tube
_Diagram of Biohazard bag_
Biohazard bag
_Diagram of Fact sheet_
Fact sheet
_Diagram of Return shipping mailer_
Return shipping mailer (optional)
### Getting started
- Ensure you and everyone contributing samples washes their hands!
- Inspect contents of kit and ensure you have enough swabs and tubes for the collection.
- Follow the instructions inside this sheet
### Returning your kit
- Contact your program coordinator for kit return details
1. Get the app
Download the FloodLAMP app and register for an account, then login to the app. First time users will need to sign the FloodLAMP consent form. You can associate minors with your account profile.
2. Begin collection
Tap the “Collect” button from the app home screen. Follow the swabbing instructions, which are listed here in steps 3-8.
3. Sanitize
Wash your hands thoroughly for 20 seconds and dry them completely before collecting your sample.
4. Open the kit
Open your kit and distribute swabs to each participant who will be adding samples to the tube.
5. Open swab packs
Each participant should open their swab pack. Be careful not to touch the absorbent end with your hands.
6. Swab the first nostril
Each participant should insert the swab tip into their first nostril until the absorbent end is no longer visible. Swab the sides of the nostril in a circular motion 4 times. Make sure to twist the swab as you go.
7. Swab the other nostril
Each participant should repeat the previous steps with the same swab in the second nostril.
8. Put swabs in tube
Each participant should place their swab in the barcoded tube and snap off the end of the swab at the break point.
9. Cap tube
Once each participant has added their swab, securely tighten the cap onto the tube.
10. Scan and add participants
Complete the Collect work flow in the app. You can add up to 4 swabs in each tube, and associate the partipants using their FloodLAMP registered email addresses. Minors will be registered under their guardian’s account.
11. Put the tube in the biohazard bag
Securely close the zippered bag, then thoroughly wash or sanitize your hands.
12. Return the biohazard bag
By collection point: If your kit does not include a return mailer, bring your biohazard bag to the collection point designated by your program administrator.
By mail: If your kit includes a return mailer, seal the biohazard bag in the return mailer. This packaging is specially designed for carrying samples suspected of carrying infectious substances. Do NOT replace it.
Note: Your return shipping has already been paid.
### Need help?
Contact support@floodlamp.bio or select “Support” from the FloodLAMP app menu.
FloodLAMP.bio
This product has not been FDA cleared or approved, but has been authorized for emergency use by FDA under an EUA;
This product has been authorized only for the home collection and maintenance of anterior nasal swab specimens as an aid in detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens; and,
The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of medical devices under Section 564(b)(1) of the Federal Food, Drug and Cosmetic Act, 21 U.S.C. §360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
## Non-Mobile App Version
### Your kit includes:
_Diagram of swabs_
Swabs
_Diagram of QR coded tube_
QR coded tube
_Diagram of Biohazard bag_
Biohazard bag
_Diagram of Fact sheet_
Fact sheet
_Diagram of Return shipping mailer_
Return shipping mailer (optional)
### Getting started
- Ensure you and everyone contributing samples washes their hands!
- Inspect contents of kit and ensure you have enough swabs and tubes for the collection.
- Follow the instructions inside this sheet
### Returning your kit
- Contact your program coordinator for kit return details
1. Sanitize
Wash your hands thoroughly for 20 seconds and dry them completely before collecting your sample.
2. Open the kit
Open your kit and distribute swabs to each participant who will be adding samples to the tube.
3. Open swab packs
Each participant should open their swab pack. Be careful not to touch the absorbent end with your hands.
4. Swab the first nostril
Each participant should insert the swab tip into their first nostril until the absorbent end is no longer visible. Swab the sides of the nostril in a circular motion 4 times. Make sure to twist the swab as you go.
5. Swab the other nostril
Each participant should repeat the previous steps with the same swab in the second nostril.
6. Put swabs in tube
Each participant should place their swab in the barcoded tube and snap off the end of the swab at the lower break point. You can add up to 4 swabs in each tube.
7. Cap tube
Once each participant has added their swab, securely tighten the cap onto the tube.
8. Put the tube in the biohazard bag
Securely close the zippered bag, then thoroughly wash or sanitize your hands.
9. Return the biohazard bag
By collection point: If your kit does not include a return mailer, bring your biohazard bag to the collection point designated by your program administrator.
By mail: If your kit includes a return mailer, seal the biohazard bag in the return mailer. This packaging is specially designed for carrying samples suspected of carrying infectious substances. Do NOT replace it.
Note: Your return shipping has already been paid.
### Need help?
Contact support@floodlamp.bio or select “Support” from the FloodLAMP app menu.
FloodLAMP.bio
This product has not been FDA cleared or approved, but has been authorized for emergency use by FDA under an EUA;
This product has been authorized only for the home collection and maintenance of anterior nasal swab specimens as an aid in detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens; and,
The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of medical devices under Section 564(b)(1) of the Federal Food, Drug and Cosmetic Act, 21 U.S.C. §360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
# 1,317 2021-05-18_Pre-EUA Sub - FloodLAMP Proposed Pooling and Asymptomatic Screening Study.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-05-18_Pre-EUA Sub - FloodLAMP Proposed Pooling and Asymptomatic Screening Study.md
file_date: 2021-05-18
title: Pre-EUA Sub - FloodLAMP Proposed Pooling and Asymptomatic Screening Study
category: regulatory
subcategory: fl-fda-submissions
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summary_short: The Pre-EUA document outlines proposed validation studies to support swab pooling (up to four swabs) and serial asymptomatic screening claims for the FloodLAMP EasyPCR and QuickColor COVID-19 tests, aligned to FDA pooling/serial testing guidance. It specifies LoD and high-viral-load pooling experiments with replicate counts, acceptance criteria (e.g., ≥95% detection, Ct shift limits, invalid-rate thresholds), and use of inactivated virus controls. It also describes an IRB-approved asymptomatic screening study design using self-collected duplicate anterior nares swabs with a comparator EUA PCR test and app-based consent/kit logistics.
CONTENT
## Proposed Pooling Study
From FDA Guidance Document "Pooling and Serial Testing Amendment Letter" (4-20-2021) - Appendix B: Swab pooling up to n=5
“Validation of Expected Limit of Detection (LoD)” and “Validation of High Viral Concentrations”. As part of the notification to FDA, summary data must be submitted, including the percent of positive pools detected, the Ct score difference, and the line data including the Ct score for each pool and individual sample tested.
### 1) Validation of Expected Limit of Detection (LoD)
- Use inactivated virus of a known quantity represented as copies/mL
- Zeptometrix NATSARS(COV2)-ST at 1e6 copies/mL OR
- BEI gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287).
- Prepare negative swabs by collecting from healthy individuals.
- Sample volumes for 4 swab pools of 2 mL of 1X Inactivation Saline Solution.
- Prepare positive swabs by spiking a known amount of inactivated virus onto the swab prior to immersion in the 1X Inactivation Saline Solution.
- Add remaining 4 negative swabs.
- The final concentration of inactivated virus in the 1X Inactivation Saline Solution is approximately 3x the LoD of the assay.
- **FloodLAMP EasyPCR(TM) COVID-19 Test**: 10,000 copies/mL (~3 x 3,100)
- **FloodLAMP QuickColor(TM) COVID-19 Test**: 40,000 copies/mL (~3 x 12,500)
- Test 20 independent extraction replicates of individual positive swabs in 1 mL of 1X Inactivation Saline Solution (same volume used in the LoD study as described in single swab protocol in EUA submission and IFU).
- Test 20 replicates of 4 swab pools each containing a single positive swab and 3 negative swabs in 2 mL of 1X Inactivation Saline Solution.
- Results criteria:
- ≥95% of pooled replicates are detected as positive using the swab pooling protocol;
- The Ct score difference for **FloodLAMP EasyPCR(TM) COVID-19 Test** between the pooled and single swab protocols does not exceed 1.7 Ct;
- The invalid rate in the swab pooling protocol does not exceed 5%.
### 2) Validation of High Viral Concentrations
- Prepare 3 positive swabs simulating high viral concentrations by spiking to a final concentration of 1e6 copies/mL of inactivated virus in 1X Inactivation Saline Solution.
- Prepare 2 negative swabs by collecting from healthy individuals.
- Combine 4 swabs into high viral concentration 4 swab pool and add 2 mL of 1X Inactivation Saline Solution.
- Test 10 replicates of inactivated high viral concentration sample.
- Results criteria:
- All 10 replicates are detected as positive;
- The invalid rate does not exceed 5%.
## Proposed Asymptomatic Screening Study
The following clinical study is proposed as a condition of authorization for the serial screening indication of **FloodLAMP EasyPCR(TM) and QuickColor(TM) COVID-19 Tests** which specifies anterior nasal respiratory specimens from individuals without known or suspected COVID-19 when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week, such as those implemented by schools, workplaces and community groups. A point-in-time asymptomatic claim will be requested provided the performance evaluation data from the study supports such a claim.
FloodLAMP has obtained IRB approval to conduct the following clinical study from WCG IRB ("FloodLAMP COVID-19 Test Validation Protocol" 20210401, Study Number 1306140). The IRB Protocol includes several variations in sample collection sites and methods.
### Inclusion and Exclusion Criteria for Asymptomatic Screening Study
| **Inclusion Criteria** | **Exclusion Criteria** |
|------------------------------------|------------------------------------|
| The specimen is an anterior nasal swab using the swab and QR code labeled tubes, nasal swabs included with the FloodLAMP Pooled Swab Collection Kit DTC. | The specimen was not properly collected, identified, transported, processed, or stored according to the instructions provided by the sponsor. |
| The swab specimen can be tested within 56 hours or less after collection. If frozen, specimens are to be stored at ≤-70℃ until tested. | The specimen was not collected under informed consent. |
| The subject is suspected of COVID, whether or not symptomatic. | |
| The subject is not experiencing symptoms and/or has not notified a physician that they suspect they have COVID . | |
| The subject has had a positive COVID test within the last 10 days. | |
| The specimen is from a consenting male or female (including pregnant women) subject. | |
| The specimen is from a subject ages 2 to 13 and has been collected by a parent or guardian OR age 14 and above and has been self-collected. | |
||
The study will utilize an enrichment strategy to obtain specimens from 20 positive and 20 negative subjects. Subject recruitment will be conducted via internet advertisements seeking participation by individuals who are asymptomatic and have recently received a COVID-19 test result. An eligibility questionnaire will select for subjects to meet the 20 positives and 20 negatives. The questionnaire will include symptom screening questions.
Eligible subjects will register using the **FloodLAMP Mobile App**, sign the Research Subject Information and Consent Form, then be mailed a version of the FloodLAMP Home Collection Kit for self-collection and sample return.
Duplicate anterior nares swabs will be self-collected with the order being randomized and at least 10 but no more than 30 minutes between collection of the two swabs. One swab will be used to run the comparator test (EUA purified PCR test) and the other will be used to run the **FloodLAMP EasyPCR(TM) and QuickColor(TM) COVID-19 Tests**.
# 17,554 2021-10-01_Instructions for Use - FloodLAMP QuickColor COVID-19 Test v1.2.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-10-01_Instructions for Use - FloodLAMP QuickColor COVID-19 Test v1.2.md
file_date: 2021-10-01
title: Instructions for Use - FloodLAMP QuickColor COVID-19 Test v1.2
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summary_short: The FloodLAMP QuickColor COVID-19 Test Instructions for Use v1.2 (draft) provides updated procedures for an extraction-free, colorimetric RT-LAMP assay with visual interpretation (including photo-based review) for routine weekly screening in CLIA high-complexity labs. It details reagents, primer preparation, inactivation and amplification steps, controls, and revised guidance for handling inconclusive results using a triplicate repeat and defined result-mapping rules. It also summarizes analytical and clinical performance claims consistent with prior versions, including a 12,500 copies/mL LoD and 90% positive agreement with 100% negative agreement in an 80-specimen evaluation.
CONTENT
***INTERNAL TITLE:*** FloodLAMP QuickColor(TM) COVID-19 Test
Instructions for Use v1.2 \- DRAFT
IVD
COVID-19 Emergency Use Authorization Only
For *in vitro* diagnostic (IVD) Use
www.floodlamp.bio
FloodLAMP Biotechnologies, PBC | 4860 Alpine Rd. Portola Valley, CA USA
## Table of Contents
| | |
|---------|------|
| Intended Use | 3 |
| Principles of Procedure | 3 |
| Materials Provided and Storage | 4 |
| Materials Required but Not Provided | 4 |
| • Standard Lab Equipment and Consumables | 6 |
| Warnings and Precautions | 6 |
| • General Precautions | 6 |
| • Contamination Precautions | 7 |
| Limitations | 7 |
| Conditions of Authorization for the Laboratory | 9 |
| Specimen Collection and Storage | 10 |
| Running Tests | 11 |
| • Reagent Preparation | 11 |
| • Controls Preparation | 12 |
| • 10X LAMP Primer Mix Preparation | 13 |
| • Sample Preparation | 15 |
| • Sample Inactivation | 15 |
| • Colorimetric LAMP Amplification Reaction Preparation | 15 |
| • Sample Addition and Heating | 16 |
| • Test Controls | 17 |
| • Patient Specimen Results Interpretation | 18 |
| Performance Evaluation | 19 |
| • Analytical Sensitivity: Limit of Detection (LoD) | 19 |
| • Analytical Sensitivity: Inclusivity (*in silico*) | 19 |
| • Evaluation of Impact of Viral Mutations | 20 |
| • Analytical Specificity: Cross-Reactivity (*in silico*) | 22 |
| • Analytical Specificity: Cross-Reactivity (wet testing) | 26 |
| • Analytical Specificity: Interfering Substances | 26 |
| Clinical Evaluation | 27 |
| Support | 27 |
||
FloodLAMP QuickColor(TM) COVID-19 Test
For COVID-19 Emergency Use Authorization Only
Instructions for Use
## Intended Use
FloodLAMP QuickColor(TM) COVID-19 Test is a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week, such as those implemented by schools, workplaces and community groups. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The FloodLAMP QuickColor(TM) COVID-19 Test is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures. The FloodLAMP QuickColor(TM) COVID-19 Test is only for use under the Food and Drug Administration’s Emergency Use Authorization.
## Principles of Procedure
The FloodLAMP QuickColor(TM) COVID-19 Test is a RNA extraction-free reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) molecular assay that indicates the presence of the SARS-CoV-2 viral RNA with a simple visual color change. It can widely and rapidly be scale because 1) no special instrumentation of any kind is required, neither nucleic acid extraction equipment nor a RT-PCR instrument, 2) it utilizes reagents and supplies readily available in large quantities, and 3) is a straightforward protocol with minimal steps that can be executed quickly and reliably. It also utilizes the same streamlined sample preparation as the FloodLAMP EasyPCR(TM) Test. Both are supply chain robust, "open source" protocol tests, meaning designated laboratories may obtain the test components directly from vendors. Together, the two tests can be used in an integrated program for screening and rapid confirmation in large populations by a broad range of laboratories.
The FloodLAMP QuickColor(TM) COVID-19 Test uses a set of specific primers that target ORF1ab, N and E genes for the detection of SARS-CoV-2 RNA. It uses Loop Mediated Isothermal Amplification (LAMP), a nucleic acid amplification technique wherein DNA amplification is carried out at a constant temperature of approximately 65°C. Samples are first treated with a TCEP-based Inactivation Solution followed by a heat inactivation step. The resulting inactivated sample is directly used as input in the LAMP reaction. The amplification reaction mix includes a reverse transcriptase (RT) polymerase to create complementary cDNA from RNA. The cDNA is subsequently amplified by a high strand displacement DNA polymerase. The amplified DNA products lower the pH of the reaction. A phenol red pH indicating dye is included in the amplification reaction mix, thus causing the reaction solution to visibly change from an initial bright pink to a bright yellow when sufficient amplification occurs. Reactions that change color to yellow indicate that SARS-CoV-2 RNA is present.
## Materials Provided and Storage
The FloodLAMP QuickColor(TM) COVID-19 Test utilizes standard chemicals available from multiple vendors, with the exception of the LAMP primers and Colorimetric LAMP master mix. Designated CLIA labs may order components directly from vendors.
## Materials Required but Not Provided
The FloodLAMP QuickColor(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1. No specialized instruments are needed. Only ordinary laboratory equipment such as pipettes, centrifuges, and heaters are needed.
#### Table 1: Validated reagents used with the Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | :---: | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease-free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5 M | Sodium Chloride | Thermo Fisher | 24740011 |
| Guanidine HCl | 6 M | Guanidine Hydrochloride | Sigma-Aldrich | SRE0066 |
| Colorimetric LAMP MM\* | - | Colorimetric LAMP Master Mix | New England Biolabs | M1804 |
||
\* Item may not be substituted for equivalent. Only the specified vendor and catalog number may be utilized.
The FloodLAMP QuickColor(TM) COVID-19 Test uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. All 18 primers are mixed together and are input into a single amplification reaction. Primer names and sequences are listed in Table 2. Primers may be purchased pre-blended from the vendor LGC Biosearch Technologies with the product names LAMP\_S2-As1e, LAMP\_S2-N2, LAMP\_S2-E1. Alternatively, primers may be purchased as individual custom oligos. Appropriate validation of primer mixes from custom oligos is required. See Primer Preparation below for more information.
#### Table 2: Primer names and sequences
| Primer Name | Sequence (5’-3’) |
| :---- | :---- |
| **ORF1ab gene (AS1e)** | |
| Orf1ab\_FIP | TCAGCACACAAAGCCAAAAATTTATTTTTCTGTGCAAAGGAAATTAAGGAG |
| Orf1ab\_BIP | TATTGGTGGAGCTAAACTTAAAGCCTTTTCTGTACAATCCCTTTGAGTG |
| Orf1ab\_F3 | CGGTGGACAAATTGTCAC |
| Orf1ab\_B3 | CTTCTCTGGATTTAACACACTT |
| Orf1ab\_LF | TTACAAGCTTAAAGAATGTCTGAACACT |
| Orf1ab\_LB | TTGAATTTAGGTGAAACATTTGTCACG |
| **N Gene (N2)** | |
| N2\_FIP | TTCCGAAGAACGCTGAAGCGGAACTGATTACAAACATTGGCC |
| N2\_BIP | CGCATTGGCATGGAAGTCACAATTTGATGGCACCTGTGTA |
| N2\_F3 | ACCAGGAACTAATCAGACAAG |
| N2\_B3 | GACTTGATCTTTGAAATTTGGATCT |
| N2\_LF | GGGGGCAAATTGTGCAATTTG |
| N2\_LB | CTTCGGGAACGTGGTTGACC |
| **E Gene (E1)** | |
| E1\_FIP | ACCACGAAAGCAAGAAAAAGAAGTTCGTTTCGGAAGAGACAG |
| E1\_BIP | TTGCTAGTTACACTAGCCATCCTTAGGTTTTACAAGACTCACGT |
| E1\_F3 | TGAGTACGAACTTATGTACTCAT |
| E1\_B3 | TTCAGATTTTTAACACGAGAGT |
| E1\_LF | CGCTATTAACTATTAACG |
| E1\_LB | GCGCTTCGATTGTGTGCGT |
||
### Standard Lab Equipment and Consumables
* 70% ethanol
* 10% bleach, prepared daily
* 96-well PCR reaction plates (Applied Biosystems \# 4346906, 4366932, 4346907, Eppendorf \# 951020303 or equivalent)
* Optical strip caps (Applied Biosystems \# 4323032 or equivalent)
* Optical plate seal (Applied Biosystems \# 4311971 or equivalent)
* PCR strip tubes and caps (USA Scientific catalog \# 1402-2500 or equivalent)
* 5 mL transport tubes or equivalent (sterile)
* 1.5 mL microcentrifuge tubes or equivalent (nuclease-free)
* Aerosol resistant micropipette tips (nuclease-free)
* Micropipettes (calibrated)
* Bottle top dispenser for 1 mL volume (optional, calibrated)
* 96-well cold block
* Cold blocks for 5 mL and 1.5 mL \- 2.0 mL tubes, or ice
* Vortex mixer
* 96-well plate centrifuge or equivalent
* Mini centrifuge for 1.5 mL tubes or equivalent
* 2 x Thermal cycler, water bath, dry heat bath or equivalent (calibrated)
* Class II Biological Safety Cabinet (BSC)
## Warnings and Precautions
Materials or chemicals required for the use of the FloodLAMP QuickColor(TM) COVID-19 Test should be closely examined by the user. The user should carefully read all warnings, instructions or Safety Data Sheets provided by the supplier and follow the general safety precautions when handling biohazards, chemicals and other materials.
### General Precautions
* The FloodLAMP QuickColor(TM) COVID-19 Test is for *in vitro* diagnostic use (IVD) only. Rx Only.
* For use under COVID-19 Emergency Use Authorization Only.
* Standard precautions and procedures should be taken when handling and disposing of human samples.
* This test has not been FDA cleared or approved; the test has been authorized by FDA under an Emergency Use Authorization (EUA) for use by laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA) of 1988, 42 U.S.C. §263a, to perform high complexity tests.
* This test has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens.
* This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of *in vitro* diagnostic tests for detection and/or diagnosis of COVID19 under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
* Standard precautions and procedures should be taken when handling and extracting human samples.
* Standard precautions and procedures should be taken when using laboratory equipment.
* Standard precautions and procedures should be taken when disposing of waste.
* Dispose of reagents according to local regulations.
* Do not use reagents after their recommended stability time frame.
* Ensure reagents are stored at the recommended temperatures as described below and in the vendor product information and manuals.
### Contamination Precautions
* Avoid contamination by following good laboratory practices, wearing proper personal protective equipment, segregating workflow, and decontaminating workspace appropriately.
* Ensure that surfaces and equipment used for all test steps have been properly cleaned with 10% bleach and 70% ethanol.
* Ensure all consumables are DNase and RNase free except for sample collection tubes which may be sterile.
* Use only calibrated pipettes and filter tips that are sterile and PCR clean.
* After completion of the test, dispose of the amplification reaction plates or tubes. **Do not open tubes** or remove the seals on plates after heating amplification reactions.
## Limitations
* The use of this assay as an *in vitro* diagnostic under the FDA COVID-19 Emergency Use Authorization (EUA) is limited to laboratories that are certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. § 263a, to perform high complexity tests by Rx only.
* Use of this assay is limited to personnel who are trained in the procedure. Failure to follow these instructions may lead to erroneous results.
* The performance of the FloodLAMP QuickColor(TM) COVID-19 Test was established using Nasopharyngeal Swab specimen type collected in saline. Nasal swabs, oropharyngeal swabs, mid-turbinate nasal swabs specimens are also considered acceptable specimen types for use with the test but performance has not been established.
* Samples must be collected according to recommended protocols and transported and stored as described herein.
* Samples should not be collected in UTM or VTM or Liquid Amies transport media.
* The effect of vaccines, antiviral therapeutics, antibiotics, chemotherapeutic or immunosuppressant drugs have not been evaluated.
* Detection of SARS-CoV-2 RNA may be affected by sample collection methods, patient factors (e.g., presence of symptoms), and/or stage of infection.
* False-positive results may arise from various reasons, including, but not limited to the following:
* Contamination during specimen collection, handling, or preparation
* Contamination during assay preparation
* Incorrect sample labeling
* False-negative results may arise from various reasons, including, but not limited to the following:
* Improper sample collection or storage
* Degradation of SARS-CoV-2 RNA
* Presence of inhibitory substances
* Use of extraction reagents or instrumentation not approved with this assay
* Incorrect sampling window
* Failure to follow instructions for use
* Mutations in SARS-CoV-2 target sequences
* Nucleic acid may persist even after the virus is no longer viable.
* This test cannot rule out diseases caused by other bacterial or viral pathogens.
* Performance has not yet been established in asymptomatic individuals and will be established during a post-authorization study.
* Use of the test in a general, asymptomatic population for serial screening is intended to be used as part of an infection control plan that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. Negative results should not be treated as definitive and do not preclude current or future infection obtained through community transmission or other exposures. Negative results must be considered in the context of an individual’s recent exposures, history, and presence of clinical signs and symptoms consistent with COVID-19.
* This test should not be used within 30 minutes of administering nasal or throat sprays.
* Positive results must be reported to appropriate public health authorities, following state and national guidelines.
* The clinical performance of the test has not been established in all circulating variants, and test performance may vary depending on the prevalence of variants circulating at the time of patient testing.
* Negative test results do not exclude possibility of exposure to or infection with SARS-CoV-2 virus. Patient handling will be directed by healthcare professionals.
## Conditions of Authorization for the Laboratory
The FloodLAMP QuickColor(TM) COVID-19 Test Letter of Authorization, along with the authorized Fact Sheet for Healthcare Providers, the authorized Fact Sheet for Patients, and authorized labeling are available on the FDA website: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas)
However, to assist clinical laboratories running the FloodLAMP QuickColor(TM) COVID-19 Test, the relevant Conditions of Authorization are listed below:
* Authorized laboratories1 using the FloodLAMP QuickColor(TM) COVID-19 Test will include all authorized Fact Sheets with test result reports. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
* Authorized laboratories1 using the FloodLAMP QuickColor(TM) COVID-19 Test will use the FloodLAMP QuickColor(TM) COVID-19 Test as outlined in the FloodLAMP QuickColor(TM) COVID-19 Test Instructions for Use. Deviations from the authorized procedures, including the authorized clinical specimen types, authorized control materials, authorized other ancillary reagents and authorized materials required to perform the test are not permitted.
* Authorized laboratories must notify the relevant public health authorities of their intent to run the test prior to initiating testing.
* Authorized laboratories using the FloodLAMP QuickColor(TM) COVID-19 Test will have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
* Authorized laboratories will collect information on the performance of the test and report to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA-Reporting@fda.hhs.gov) and FloodLAMP Biotechnologies, PBC support center (via email: eua.support@floodlamp.bio) any suspected occurrence of false positive or false negative results and significant deviations from the established performance characteristics of the test of which they become aware.
* All laboratory personnel using the test must be appropriately trained in molecular assay techniques and use appropriate laboratory and personal protective equipment when handling these test components, and use the test in accordance with the authorized labeling.
* FloodLAMP Biotechnologies, PBC authorized distributors, and authorized laboratories using the FloodLAMP QuickColor(TM) COVID-19 Test will ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
1 For ease of reference, this will refer to, “Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a certified laboratories with FDA Emergency Use Authorization FDA for performing SARS-CoV-2 testing
## Specimen Collection and Storage
Upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs should be collected using standard procedures and recommendations. Swab specimens should be collected in 0.9% saline, PBS, or dry tubes. Specimens should not be collected in UTM, VTM, or Liquid Amies.
Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19:
[https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html](https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html)
The stability study of the nasal swab sample transported in saline has been conducted by Quantigen Biosciences, with support from The Gates Foundation and UnitedHealth Group. Quantigen Biosciences has granted a right of reference to any sponsor wishing to pursue an EUA to leverage their COVID-19 swab stability data as part of that sponsor’s EUA request.
* Samples can be stored at room temperature for 56 hours after collection prior to inactivation.
* For longer term storage, samples can be stored at ≤-70oC.
Note: Specimens must be packaged, shipped, and transported according to the current edition of the International Air Transport Association Dangerous Goods Regulation. Follow shipping regulations for UN 3373 Biological Substance, Category B when sending potential 2019-nCoV specimens.
## Running Tests
### Reagent Preparation
The FloodLAMP QuickColor(TM) COVID-19 Test is to be used with the reagents or equivalents listed in Table 1.
#### Table 1: Validated reagents used with Test
| Item | Concentration | Chemical Composition | Vendor | Catalog Number |
| :---- | :---: | :---- | :---- | :---- |
| TCEP | .5 M | tris(2-carboxyethyl)phosphine hydrochloride | Sigma-Aldrich Millipore Sigma | 646547-10X1ML |
| EDTA | .5 M | Ethylenediaminetetraacetic acid | Thermo Fisher | 15575020 |
| NaOH | 10 N | Sodium Hydroxide | Sigma-Aldrich | SX0607N-6 |
| Nuclease- free Water | - | Ultrapure Water, nuclease-free | Thermo Fisher | 10977015 |
| NaCl | 5M | Sodium Chloride | Thermo Fisher | 24740011 |
| Guanidine HCl | 6M | Guanidine Hydrochloride | Sigma-Aldrich | SRE0066 |
| Colorimetric LAMP MM\* | - | Colorimetric LAMP Master Mix | New England Biolabs | M1804 |
||
\* Item may not be substituted for equivalent.
Stocks of TCEP, EDTA, NaOH, and NaCl may be prepared from powder form at the specified concentration using nuclease-free, MilliQ or equivalent molecular biology grade water.
0.9% Saline (154 mM) may be prepared by diluting 15.4 mL of 5 M NaCl in MilliQ or equivalent molecular biology grade water to a final volume of 500 mL. Equivalent preparations or commercial saline products may be utilized, with appropriate validation.
A 100X Inactivation Solution is prepared by mixing the components in Table 3 and vortexing for 30 seconds. Equivalent preparations utilizing components with different source concentrations may be used such that the final 100X Concentration is achieved. Aliquots of 100X Inactivation Solution should be stored in the dark at \-20°C for up to 3 months. Upon thaw, working aliquots of 100X Inactivation Solution should be stored in the dark at room temperature for up to 1 month.
#### Table 3: 100X Inactivation Solution
| Component | Source Concentration | Volume | 100X Concentration |
| :---- | :---: | :---: | :---: |
| TCEP | 0.5 M | 10 mL | 250 mM |
| EDTA | 0.5 M | 4 mL | 100 mM |
| NaOH | 10 N | 2.3 mL | 1.15 N |
| Nuclease-free Water | - | 3.7 mL | - |
| **TOTAL VOLUME** | - | **20 mL** | - |
||
For swabs that are collected or eluted in 0.9% saline solution or equivalent, the 100X Inactivation Solution should be added at 1/100th the sample solution volume.
For dry swabs, a preparation of 1X Inactivation Saline Solution should be prepared per Table 4. 1X Inactivation Saline Solution should be kept at room temperature and used within 24 hours of preparation from components or 100X Inactivation Solution.
#### Table 4: 1X Inactivation Saline Solution
| Component | Volume |
| :---- | :---: |
| 0.9% Saline (154 mM NaCl) in MilliQ Water | 1000 mL |
| 100X Inactivation Solution | 10 mL |
| **TOTAL VOLUME** | **1010 mL** |
||
### Controls Preparation
**One positive and one negative control** will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes on each heater:
1) A “no template” (negative) control (NTC) is needed to **assure the absence of cross contamination from positive samples, positive controls, or amplicons** and is used **to determine if sample results are valid.** **It consists of 100X Inactivation Solution diluted to 1X in 0.9% saline. This NTC is the same solution added to dry swabs (see Table 3 and Table 4 above for the components).**
2) A positive template control is needed to **assure proper functioning of reagents and the absence of significant RNAse contamination. It consists of synthetic viral RNA at a concentration of approximately 100,000 cp/mL diluted in total human RNA and nuclease-free water.** Stock and working aliquots of the positive control are produced from the sources listed in Table 5 or equivalents. Working aliquots should be diluted prior to use to 100,000 cp/mL. Positive control aliquots should be stored for at most 3 months at \-80°C, or at most 1 month at \-20°C.
#### Table 5: Components for Positive Template Control
| Material | Vendor | Catalog \# | Volume |
| ----- | :---: | :---: | :---: |
| SARS-CoV2 Positive Control RNA | Twist | 102019 | 5 µL |
| Total Human RNA | Thermo Fisher | 4307281 | 100 µL |
| Nuclease-free Water | Thermo Fisher | 10977015 | 4,895 µL |
||
### 10X LAMP Primer Mix Preparation
The FloodLAMP QuickColor(TM) COVID-19 Test uses 18 LAMP primers targeted for 3 different SARS-CoV-2 genes, with 6 primers for each target. Primer names and sequences are shown above in Table 2. All 18 primers are mixed together and input into a single amplification reaction.
Primers may be purchased from the vendor LGC Biosearch Technologies as 3 pre-blended sets, or the primers may be purchased as 18 individual custom oligos. Table 6 below lists the primer products to be ordered.
The LGC Biosearch primer products are provided already blended for each target (6 primers per tube) and dried such that upon resuspension with 1 mL of nuclease-free water, the primers for each target are at 30X concentration. One resuspended tube for each of the 3 targets (i.e. primer blends) are mixed together to yield a 3 mL total volume that contains all individual primers at 10X concentration. This 3 mL of 10X LAMP Primer Mix provides for 1,200 reactions at 2.5 µL per reaction.
Alternatively to the pre-blended LGC Biosearch products, primers may be purchased as individual custom oligos. Custom oligos may be blended to form 30X Primer Set Mixes as intermediates or all mixed together for the 10X LAMP Primer Mix. The FIP and BIP primers for each target require purification by HPLC or an equivalent process. Appropriate validation of primer mixes from custom oligos is required. Primers may be stored at 4°C for up to one month, or at \-20°C for up to 1 year.
#### Table 6: 10X LAMP Primer Mix Components
| Vendor | Item | Catalog number | Quantity | # Reactions |
|--------|------|----------------|-----------|-------------|
| Order one of the following primer sets |||||
| LGC Biosearch Technologies | SARS-CoV-2 LAMP ASIe 6 primer set at 30X (ORF1ab gene) | LAMP_S2-ASIe-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP ASIe 6 primer set at 30X (ORF1ab gene) | LAMP_S2-ASIe-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP N2 6 primer set at 30X (N gene) | LAMP_S2-N2-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-48 | 6-48 nmol | 1,200 |
| LGC Biosearch Technologies | SARS-CoV-2 LAMP E1 6 primer set at 30X (E gene) | LAMP_S2-E1-480 | 60-480 nmol | 12,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | Orf1ab_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | N2_LB | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_FIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_BIP | Custom Order | 1,000 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_F3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_B3 | Custom Order | 125 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LF | Custom Order | 250 nmol | 25,000 |
| LGC Biosearch Technologies, Eurofins Genomics, Integrated DNA Technologies, Sigma | E1_LB | Custom Order | 250 nmol | 25,000 |
||
### Sample Preparation
\* For wet swab specimens (swabs in saline or unprocessed swab elution):
1) If samples are frozen, thaw unless no ice crystals are present and then keep on ice, cold block or at 4°C.
2) Pulse vortex each sample and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
3) Wipe the outside of the sample tube with 70% ethanol.
For dry swab specimens:
1) Wipe the outside of the sample tube with 70% ethanol.
### Sample Inactivation
1) Place the inactivation heater (a thermal cycler, water bath, dry heat bath or equivalent) in the BSC, turn on, and set the temperature to hold at 100 °C.
2) \* For wet swab specimens: transfer 1 mL or available volume of each sample to an appropriately labeled 1.5 mL or 5mL tube and securely cap.
3) \* For wet swab specimens: add 10μL per 1 mL sample volume of 100X Inactivation Solution to each sample tube.
4) For dry swab specimens (DO NOT DO FOR WET SWAB SPECIMENS): add 1 mL of 1X Inactivation Solution to each sample tube.
5) Vortex for 30 seconds.
6) Place sample tubes into the inactivation heater for 8 minutes.
7) Remove sample tubes from the inactivation heater and let cool at room temperature for 10 minutes.
8) Place sample tubes on ice, in the refrigerator, or on a cold block at 4°C until ready to perform amplification reaction.
Note: Testing of inactivated specimens must be conducted the same day inactivation is performed. For long term storage, keep the original specimen at ≤-70°C.
### Colorimetric LAMP Amplification Reaction Preparation
1) Place a 96-well PCR plate or PCR strip tubes onto a cold block or ice.
2) Thaw frozen reagents until ice crystals are not present.
3) Pulse vortex thawed reagents and briefly spin down in a centrifuge.
4) Store on ice, in the refrigerator, or on a cold block at 4°C until ready to use.
5) Combine components of Primer-Guanidine Solution per volumes listed in Table 7, or proportionally scaled for the number of reactions to be run.
NOTE: Component volumes should be scaled proportionally for the number of reactions.
NOTE: The Primer-Guanidine Solution may be prepared in advance and stored at \-20°C
for up to 1 month.
6) Pulse vortex and briefly spin down in a centrifuge.
7) Prepare the Colorimetric LAMP Amplification Reaction Mix by adding the Colorimetric LAMP MM to the Primer-Guanidine Solution per the volumes listed in Table 8.
8) Vortex the Colorimetric LAMP Amplification Reaction Solution for 10 seconds and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
9) Add 23 µL of the Colorimetric LAMP Amplification Reaction Solution into the wells of the PCR plate or PCR strip tubes.
NOTE: Reaction plates/strip tubes comprising the Colorimetric LAMP Amplification Reaction Solution may be prepared in advance, capped/sealed, and stored at \-20°C for up to 3 days prior to addition of the sample. A heated plate sealer may be used to seal plates. Alternatively, a manually applied foil or optical seal may be used.
#### Table 7: Primer-Guanidine Solution
| Component | Volume (1 reaction) | Volume (1 reaction x 100) 1 x 96-plate w/ 4% overage |
| ----- | :---: | :---: |
| 10X LAMP Primer Mix | 2.5 µL | 250 µL |
| Guanidine HCl (400 mM) | 2.5 µL | - |
| Guanidine HCl (6 M) | - | 16.7 µL |
| Nuclease-free Water | 5.5 µL | 783 µL |
| **TOTAL VOLUME** | **10.5 µL** | **1050 µL** |
||
#### Table 8: Colorimetric LAMP Amplification Reaction
| Component | Volume (1 reaction) | Volume (100 reactions) |
| ----- | :---: | :---: |
| Primer-Guanidine Solution | 10.5 µL | 1050 µL |
| Colorimetric LAMP MM | 12.5 µL | 1250 µL |
| **SUBTOTAL VOLUME** | **23 µL** | **2300 µL** |
| Sample | 2 µL | - |
| **REACTION VOLUME** | **25 µL** | - |
||
### Sample Addition and Heating
NOTE: Ensure that positive and negative controls are included in each batch run (i.e. in each PCR plate or group of strip tubes that are heated together).
1) Turn on the amplification heater (a thermal cycler, water bath, dry heat bath or equivalent) and set the temperature to hold at 65°C.
NOTE: Amplification heater should be located in a separate, dedicated BSC or area of the lab. Proper cross contamination prevention practices are required, such as glove changes, to prevent amplicon contamination.
2) Add 2 μL of each sample into a separate tube in the amplification reaction PCR plate or strip tubes.
3) Mix by pipetting.
4) If using PCR plate, seal with foil seal, optical seal (optionally using heat sealer). If using PCR strip tubes, cap strips.
5) Pulse vortex and briefly spin down in a centrifuge to collect the liquid at the bottom of the tube.
6) Place the plate or strip tubes in the heater and set timer for 25 minutes (do not use heated lid).
7) Remove the plate or strip tubes from the heater after 25 minutes.
8) Let cool for 1 minute and then interpret the test results.
### Test Controls
All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. An example of the expected appearance of the negative and positive controls after amplification is shown in Figure 1.
_Photo showing negative control (pink, left) and positive control (yellow, right) after amplification._
#### Figure 1. Negative control (left) and positive control (right) after amplification.
If the negative and positive controls do not appear as expected, the specimen results of the corresponding plate or batch should be considered invalid. In the event of a failure of either the positive or negative control, the lab should discard some or all of the consumables utilized for associated run, including the filter tips, tubes, plates, seals, and aliquots of reagents. Additionally, all pipettes, BSC, and appropriate lab surfaces should be thoroughly cleaned with freshly made 10% bleach solution, 70% ethanol, and optionally RNAseZAP product. In the event of the failure of the positive control, the working aliquot of positive control material should be discarded. Additionally, the lab should review the expiration of the batch of positive control aliquots and verify their integrity by performing qualification reactions of one or more positive control aliquots. If controls continue to fail, labs should not perform additional tests on clinical specimens or report results. Invalid test results should be repeated by performing another amplification reaction.
### Patient Specimen Results Interpretation
NOTE: Patient specimen results can only be interpreted if the positive and negative controls in the plate or group of strip tubes have the expected results.
Test results should be read at least 1 minute and no more than 8 hours after plates or tubes have been removed from heat. Test results may be determined directly from visual inspection of the color of the reaction tubes or from photographs:
* yellow \- result is positive
* bright pink or red \- result is negative
* any other color \- result is inconclusive.
Examples are shown below in Figure 2. Edge cases for positive and negative results are shown below in Figure 3. Any color variance stronger than the edge cases should be interpreted as inconclusive. In order to reduce the chance of both false negative and false positive results, this window for color variance is intentionally set to be small.
If the initial test is inconclusive, then one of the following should be performed:
1) repeat the Colorimetric LAMP Amplification Reaction on the inactivated samplein triplicate. Results of the repeat tests are to be interpreted according to Table 9 below.
#### Table 9: Initial Inconclusive Repeat Results Interpretation
| Repeat Triplicate Results | Final Sample Result Reported |
| :---: | :---: |
| 3 Positive | Positive |
| 2 Positive, 1 Inconclusive | Positive |
| 1 Positive, 2 Inconclusive | Inconclusive |
| 3 Negative | Negative |
| Any other results | Inconclusive |
||
2) follow-up test the inactivated sample with the FloodLAMP EasyPCR(TM) COVID-19 Test or another high sensitivity EUA authorized test that comprises the same inactivation protocol. The final interpretation is the result of the follow-up test.
For serial screening of individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, the initial inconclusive test result may be considered the final interpretation.
If the final interpretation of the test result is inconclusive, then "Inconclusive" should be reported and retesting of the individual is recommended.
_Photo (Figure 2): Example of test results showing two negative (pink) and two positive (yellow) tubes. Photo (Figure 3): Edge case test results showing an edge-case negative (pink) and edge-case positive (yellow) tube._
## Performance Evaluation
### Analytical Sensitivity: Limit of Detection (LoD)
The Limit of Detection (LoD) for the FloodLAMP QuickColor(TM) COVID-19 Test was established using gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) spiked into negative real specimens. The negative specimens were confirmed by PCR using the CDC primers. The gamma-irradiated virus was spiked into the specimen prior to the heat inactivation step, and carried through the entire assay. The concentration of spike was such that the contrived positive sample was at 100,000 copies/mL after the inactivation step. The stock contrived positive was diluted into inactivated negative sample matrix to produce the concentrations for the LoD study. A preliminary LoD run was performed using the concentrations ranging from 100,000 copies/mL to 3,100 copies/mL. Concentrations of 12,500 and 6,250 were selected for confirmatory LoD runs. LoD run details are provided in Supporting Data, with the results summarized below in Table 10. The LoD, defined as the concentration at which at least 95% of the samples are positive, was determined at 12,500 copies/mL.
#### Table 10: LoD Confirmatory Data Results
| Concentration of Contrived Positive Sample | Replicates Detected |
| :---: | :---: |
| 12,500 copies/mL | 95% (20/21) |
| 6,250 copies/mL | 52% (11/21) |
||
### Analytical Sensitivity: Inclusivity (*in silico*)
An inclusivity study was conducted for the ORF1ab, N2, and E1 primer sets against all complete, high coverage SARS-CoV-2 sequences deposited at GISAID as of February 27, 2021. Table 11 summarizes the results of this *in silico* inclusivity analysis. A total of 498,224 sequences were considered. There are 10 sequence isolates that have 1mm to both As1e and E1 and had N2 excluded due to greater than 15 N's, with the other 498,214 sequence isolates all have at least 1 target region that is a complete match.
Each primer set matched at 100% similarity against the SARS-CoV-2 RefSeq reference genome (Wuhan-Hu-1; NC\_045512.1). All three primer sets differed by one or fewer mutations for 99.7% of GISAID sequences, indicating nominal primer hybridization for all SARS-CoV-2 variants under consideration.
#### Table 11: *In Silico* Inclusivity Analysis for LAMP Primers
| Primer | AS1e (ORF1ab gene) | | N2 (N gene) | | E1 (E gene) | |
| :---- | ----- | ----- | ----- | ----- | ----- | ----- |
| **Total Primer Length** | 195 | | 169 | | 168 | |
| **Total \# of Strains Evaluated** | 498,224 | | 498,224 | | 498,224 | |
| **100% Match** | 474,717 | 95.3% | 479,548 | 96.3% | 462,538 | 92.8% |
| **1 Mismatch** | 19,301 | 3.9% | 15,698 | 3.2% | 30,626 | 6.1% |
| **2 Mismatches** | 338 | 0.1% | 161 | 0.0% | 1,455 | 0.3% |
| **3 Mismatches** | 9 | 0.0% | 5 | 0.0% | 103 | 0.0% |
| **\> 3 Mismatches** | 0 | 0.0% | 0 | 0.0% | 1 | 0.0% |
| **Total Strains Removed** | 3,859 | 0.8% | 2,812 | 0.6% | 3,501 | 0.7% |
||
### Evaluation of Impact of Viral Mutations
The As1e, E1 and N2 primer regions of all SARS-CoV-2 genomes present in GISAID as of 2/26/2021 were evaluated to assess the potential impact of genomic variants on LAMP primer binding. This analysis was performed with the Primer Monitoring Tool from New England Biolabs ([primer-monitor.neb.com](http://primer-monitor.neb.com)), which continually monitors registered primer sets for overlapping variants in sequences from GISAID. Results are summarized by region and locus below in Table 12, including the 30 countries with most sequences in GISAID. Sequences were aligned to the SARS-CoV-2 reference sequence (NC\_045512.2) using minimap2 (minimap2 \-t 16 \-x asm5 \-a). Variant sites (excluding Ns) were identified using samtools mpileup and summarized by region and genome position. Genomic positions having \>= 40 global variant observations are shown (column labels). When present, box labels indicate the fraction of variants observed at a given locus.
The aggregate of current published mutations is not expected to reduce performance of the FloodLAMP QuickColor(TM) COVID-19 Test by more than 5% from that established by the performance evaluation in this EUA submission. Further, the use of 3 primer sets targeting different regions in the SARS-CoV-2 genome should make the test robust to new genetic variants.
#### Table 12: Variant Analysis of LAMP Primers
_Heatmap charts showing variant frequency at LAMP primer binding sites across 30 countries for AS1e, N2, and E1 primer sets, based on GISAID sequences aligned to the SARS-CoV-2 reference genome._
## Analytical Specificity: Cross-Reactivity (*in silico*)
*In silico* cross-reactivity analysis was performed by aligning the primer sequences of the FloodLAMP QuickColor(TM) COVID-19 Test against sequences of other coronaviruses and common respiratory flora using the BLASTn alignment tool from NCBI. Results of this analysis are presented in Tables 13A, 13B, and 13C.
The % identity range (\# identical bases/ \# primer bases) is shown for each primer and organism. Darker font indicates % identity greater than 80%. Organisms with \>= 50% identity primer hits are shown. This analysis is not intended to predict amplification. Near perfect homology across B3, F3, FIP and BIP is necessary to support successful amplification. With the exception of SARS-CoV, simultaneous homologies do not occur between any of the primers and microorganisms screened. With respect to clinical relevance of the *in silico* cross-reactivity analysis, there are no known circulating strains of SARS-CoV circulating in humans, thus the overall probability for the test to produce a cross-reactive signal is negligible.
#### Table 13A: *In Silico* Cross-Reactivity Analysis for AS1e Primers
| Organism Group | Organism Name | Organism ID | As1_B3 (22 bp) | As1e_BIP (49 bp) | As1_F3 (18 bp) | As1e_FIP (51 bp) | As1_LB (27 bp) | As1_LF (28 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 47%-55% | 100% | 43%-53% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| | SARS coronavirus | NC_004718 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 72%-89% | 29% | 52%-67% | |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 77% | | 89% | 37%-51% | 52%-89% | |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 59%-73% | 33%-35% | 89% | 33%-45% | 52% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-73% | 31% | 72%-83% | 29%-59% | 52% | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | 83% | | | |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 59%-82% | 39% | | 29%-41% | 67% | 61% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-82% | | 72% | 39%-87% | 59% | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 59%-82% | 31% | 72% | 31% | 52%-67% | |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | 72%-78% | | 70% | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | 72% | 29%-35% | 78% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.15 | NW_017264789.1 | 59% | | | 78% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.11 | NW_017264785.1 | 77% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 77% | | | 35% | 63% | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59% | 43%-49% | 72% | 29%-57% | 63%-74% | 68% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | 49% | 72% | 31%-41% | 56%-74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | 31%-43% | 74% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 73% | | 72% | 29%-39% | 52% | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 59%-68% | 31%-37% | 72% | 29%-35% | 56%-67% | 57%-71% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | 37%-41% | 72% | 29%-41% | 52%-63% | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.14 | NW_017264788.1 | | | | 35% | | 71% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | | | | 29%-47% | 70% | 68% |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59%-68% | 35% | | 29%-43% | | 68% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 68% | 37% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 33%-49% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | 43% | | 38% | | 68% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 64% | | | | | 57% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | | | | 33%-35% | 59% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 59% | | | | | 50% |
| | Bordetella pertussis 18323 | NC_018518.1 | | | | | | 57% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | | 52% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | | | | | | 50% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | 39%-47% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.54 | NW_017264828.1 | | 47% | | | | |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | | 31% | | 31%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | | | | 33%-45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.19 | NW_017264793.1 | | | | 38% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | | | | 35% | | |
| | Respiratory syncytial virus | NC_001803.1 | | | | 33% | | |
||
#### Table 13B: *In Silico* Cross-Reactivity Analysis for N2 Primers
| Organism Group | Organism Name | Organism ID | N2_B3 (25 bp) | N2_BIP (40 bp) | N2_F3 (21 bp) | N2_FIP (42 bp) | N2_LB (20 bp) | N2_LF (21 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 53% | 100% | 48%-55% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 64% | 53% | 90% | 55% | 85% | 90% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 60%-80% | | 95% | | 75% | 62%-71% |
| | Rothia mucilaginosa DY-18 DNA | NC_013715.1 | | | | 40% | 75%-90% | |
| | Bordetella pertussis 18323 | NC_018518.1 | | 35% | | | 65%-80% | 81% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | 56%-72% | 43% | | | | 62%-81% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | 56%-76% | | 62%-71% | 45% | | 62%-81% |
| | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | 56%-80% | 35%-68% | 62% | | | 62%-81% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | 60%-80% | 35%-45% | 71% | | | 62%-71% |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 60%-72% | 35%-45% | 71%-76% | | | 62%-76% |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 56%-76% | | 76% | 36% | 65% | |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 60%-76% | 43% | | 36%-55% | | 62%-76% |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | 60% | | | | 65%-75% | 76% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | 68%-64% | | | | | 76% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | 35% | | | 75% | |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 56%-72% | 48% | 62% | 40% | | 67%-71% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 56%-72% | | 71% | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.17 | NW_017264791.1 | 56%-72% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | 60%-72% | | 71% | | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 56%-68% | 35% | | | | 62%-71% |
| | Human parainfluenza virus 1 | NC_003461.1 | | | 71% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 60%-68% | | | | | 62%-71% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 60%-68% | 50% | | 43% | | 62%-67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | 68% | | | | | |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | 60%-68% | | 62% | | | 62% |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 56% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 56%-60% | | | | | 67% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | 64% | 35% | | | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 60%-64% | 43%-50% | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 60% | | | | | 62% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.25 | NW_017264799.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.51 | NW_017264825.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.66 | NW_017264840.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.67 | NW_017264841.1 | 60% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 56% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.21 | NW_017264795.1 | 52% | | | | | |
||
#### Table 13C: *In Silico* Cross-Reactivity Analysis for E1 Primers
| Organism Group | Organism Name | Organism ID | E1_B3 (22 bp) | E1_BIP (44 bp) | E1_F3 (23 bp) | E1_FIP (42 bp) | E1_LB (19 bp) | E1_LF (18 bp) |
|---|---|---|---|---|---|---|---|---|
| Same genetic family | SARS coronavirus 2 | NC_045512.2 | 100% | 45%-57% | 100% | 45%-62% | 100% | 100% |
| | SARS coronavirus | NC_004718 | 95% | 55% | 100% | 43%-62% | 100% | 100% |
| | Human coronavirus HKU1 | NC_006577.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus NL63 | NC_005831.2 | 0% | 0% | 0% | 0% | 0% | 0% |
| | Human coronavirus OC43 strain ATCC VR-759 | NC_006213.1 | 0% | 0% | 0% | 0% | 0% | 0% |
| Other high priority organisms | Candida albicans SC5314 chromosome R sequence | NC_032096.1 | | | | 40%-50% | | 72%-89% |
| | Pseudomonas aeruginosa PAO1 | NC_002516.2 | | | | | 84% | 72% |
| | Legionella pneumophila subsp. pascullei strain NCTC12273, chromosome: 1 | NZ_LR134380.1 | 59%-73% | | | 36%-40% | | 78%-83% |
| | Candida albicans SC5314 chromosome 2 sequence | NC_032090.1 | 59%-82% | | 43% | | | 72% |
| | Candida albicans SC5314 chromosome 4 sequence | NC_032092.1 | | | | 43%-50% | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.12 | NW_017264786.1 | | | | | | 78% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.7 | NW_017264781.1 | | | | | | 78% |
| | Staphylococcus epidermidis ATCC 12228 | NC_004461.1 | | 45% | | 43%-48% | | 72%-78% |
| | Haemophilus influenzae NCTC8143, chromosome: 1 | NZ_LN831035.1 | 77% | | | 36%-43% | | |
| | Candida albicans SC5314 chromosome 1 sequence | NC_032089.1 | 59%-73% | | | 38%-48% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.3 | NW_017264777.1 | 59%-73% | | 65% | 43% | | |
| | Streptococcus pyogenes NCTC8198, chromosome: 1 | NZ_LN831034.1 | 73% | 41% | | 48% | | 72% |
| | Candida albicans SC5314 chromosome 3 sequence | NC_032091.1 | 59% | | | 43%-48% | | 72% |
| | Candida albicans SC5314 chromosome 7 sequence | NC_032095.1 | | | | 36%-50% | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.4 | NW_017264778.1 | | | | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.5 | NW_017264779.1 | | | 65% | | | 72% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.9 | NW_017264783.1 | 59%-68% | | | | | 72% |
| | Streptococcus pneumoniae NCTC7465, chromosome: 1 | NZ_LN831051.1 | 59%-68% | | | 40% | 68% | 72% |
| | Candida albicans SC5314 chromosome 6 sequence | NC_032094.1 | | | 70% | | 40%-50% | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.13 | NW_017264787.1 | | | 70% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.1 | NW_017264775.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.2 | NW_017264776.1 | 68% | | | 45% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.6 | NW_017264780.1 | 68% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.16 | NW_017264790.1 | 59%-64% | | | 40% | | |
| | Candida albicans SC5314 chromosome 5 sequence | NC_032093.1 | 59% | | | 40%-43% | | |
| | Chlamydia pneumoniae TW-183 | NC_005043.1 | 0%-59% | 0% | 0% | 0%-36% | 0% | 0% |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.10 | NW_017264784.1 | 59% | | | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.20 | NW_017264794.1 | 59% | | | | | |
| | Mycobacterium tuberculosis H37Rv | NC_000962.3 | | 34% | 57% | | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.30 | NW_017264804.1 | | | | 50% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.69 | NW_017264843.1 | | | | 50% | | |
| | Mycoplasma pneumoniae FH chromosome | NZ_CP010546.1 | | | | 43% | | |
| | Pneumocystis jirovecii RU7 chromosome Unknown supercont1.8 | NW_017264782.1 | | | | 40% | | |
||
### Analytical Specificity: Cross-Reactivity (*wet testing*)
Wet testing was performed to demonstrate that the FloodLAMP QuickColor(TM) COVID-19 Test does not react with related pathogens, high prevalence disease agents and normal or pathogenic flora that are reasonably likely to be encountered in a clinical specimen. SARS-CoV, RSV, Flu, Human Metapneumovirus. and Streptococcus Salivarius were tested for potential cross-reactivity, as shown in Table 14. Gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) was spiked onto dried AN swab specimens to produce contrived Positve Controls. Negative Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and cross-reactivity organisms were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol.
All wet testing showed no cross-reactivity with the viral pathogens and common respiratory flora, as shown in Table 14.
#### Table 14: Wet Testing Cross-Reactivity Results
| Organism | Description | BEI Number | Detected Replicates |
| ----- | ----- | :---: | :---: |
| SARS-CoV | UV-inactivated virus | NR-3882 | 0/3 |
| Human Metapneumovirus | Genomic RNA | NR-49122 | 0/3 |
| RSV | Genomic RNA | NR-43976 | 0/3 |
| Influenza B | Genomic RNA | NR-45848 | 0/3 |
| Streptococcus salivarius | Bacterial cell culture | HM-121 | 0/3 |
||
### Analytical Specificity: Interfering Substances
Exogenous and endogenous substances were tested for potential interference with the FloodLAMP QuickColor(TM) COVID-19 Test. Gamma-irradiated SARS-CoV-2 virus cell lysate (BEI NR-52287) was spiked onto dried AN swab specimens to produce contrived Positve Controls. Negative Control dried swabs obtained simultaneously were confirmed to be SARS-CoV-2 negative by PCR using the CDC primers. The gamma-irradiated SARS-CoV-2 virus and interfering substances were spiked into the dried swabs prior to the heat inactivation step, and carried through the full test protocol.
All interfering substance testing showed no disagreement with expected positive and negative results, as shown in Table 15 and Supporting Data.
#### Table 15: Interfering Substances Results
| Interfering Substance | Active Ingredient | Concentration | % Agreement with Expected Results | |
| :---: | :---: | :---: | :---: | :---: |
| | | | **Positive Control Spiked** | **Negative Control Unspiked** |
| Blood | N/A | 1% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Congestion Spray | Acetaminophen, Guaifenesin, Phenylephrine HCI | 20% v/v | 100% (3/3) | 100% (3/3) |
| Nasal Allergy Spray | Oxymetazoline HCl | 15% v/v | 100% (3/3) | 100% (3/3) |
| Lozenges | Menthol | 10% w/v | 100% (3/3) | 100% (3/3) |
| Mucin | N/A | 0.5% w/v | 100% (3/3) | 100% (3/3) |
||
## Clinical Evaluation
The clinical evaluation of the FloodLAMP QuickColor(TM) COVID-19 Test utilized confirmed clinical anterior nares swab specimens. 40 positive and 40 negative clinical specimens were evaluated and compared to a high sensitivity EUA authorized test run on the original fresh samples. The FloodLAMP QuickColor(TM) COVID-19 Test showed a positive agreement of 90% and a negative agreement of 100%. The 4 false negative results were specimens with high Ct values as previously measured by the comparator test, indicating low viral load. A summary of the clinical performance is below in Table 16.
#### Table 16: Clinical Evaluation Results
| FloodLAMP QuickColor(TM) COVID-19 Test Results | Comparator \- High Sensitivity EUA Authorized Test | | |
| :---: | :---: | :---: | :---: |
| | **Positive** | **Negative** | **Total** |
| Positive | 36 | 0 | 36 |
| Negative | 4 | 40 | 44 |
| Total | 40 | 40 | 80 |
| Positive Agreement | 90.0% (36/40) 95% CI: 76.3% to 97.2% | | |
| Negative Agreement | 100% (40/40) 95% CI: 91.2% to 100% | | |
||
## Support
FloodLAMP Biotechnologies, PBC support center
eua.support@floodlamp.bio
650-394-5233
METADATA
last updated: 2026-03-10_105730
file_name: _archive-combined-files_fl-fda-correspondence_44k.md
category: regulatory
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CONTENT
# _archive-combined-files_fl-fda-correspondence_44k (13 files, 43,897 tokens)
# 5,839 _AI_FDA Deprioritization of COVID-19 Diagnostic EUAs.md
METADATA
last updated: 2026-03-02 RT initial creation
file_name: _AI_FDA Deprioritization of COVID-19 Diagnostic EUAs.md
file_date: 2026-03-02
title: FloodLAMP FDA Deprioritization of COVID-19 Diagnostic EUAs (CDRH/OHT7)
category: regulatory
subcategory: fl-fda-correspondence
tags: fda-deprioritization, eua, covid-diagnostics, cdrh, oht7, decline-to-review, gao
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notes: Created by ChatGPT 5.2 Pro Extended during archive preparation. **NOT HUMAN VERIFIED - MAY CONTAIN ERRORS** Comprehensive analysis of FDA CDRH/OHT7's deprioritization practices for COVID-19 diagnostic EUA submissions, drawing from FDA's Booz Allen independent assessment, GAO-22-104266, FDA town hall transcripts, Food and Drug Law Journal analysis (Gibbs & Javitt), Reuters reporting, and ProPublica reporting.
summary_short: FDA CDRH/OHT7 deprioritization of COVID-19 diagnostic EUA submissions -- history, mechanics, emergence as a policy tool, comparison with 510(k) processes, prior emergency precedents, scale (558 EUA requests declined to review by Sept. 2021 per GAO), and independent analyses of transparency, resource constraints, and relationship to Omicron-era testing shortages.
CONTENT
***INTERNAL TITLE:*** FDA "Deprioritization" of COVID-19 Diagnostic EUAs (CDRH/OHT7)
History, mechanics, how it emerged, how it compares to 510(k), prior emergencies, and what analyses say.
## Executive summary
- During COVID-19, FDA's device center (CDRH)--specifically the in-vitro diagnostics review function (often referenced in FDA materials as OHT7)--created an explicit **triage + deprioritization** system to manage an unprecedented surge of SARS-CoV-2 test requests. ([U.S. Food and Drug Administration][1])
- In FDA's own post-event assessment materials, "deprioritization" is not just an informal concept; it was operationalized via **two streamlined negative actions**:
- **Decline to Review** (for low-priority files--e.g., highly manual / low-volume, or low manufacturing capacity), and
- **Decline to Issue** (for higher-priority tests with unresolved critical deficiencies, especially validation/performance data problems). ([U.S. Food and Drug Administration][1])
- FDA publicly telegraphed these priorities in town halls. In March 2021, for example, FDA explicitly warned that some submissions would be "very low priority" and "might be deprioritized," while encouraging developers to pursue point-of-care or at-home pathways. ([U.S. Food and Drug Administration][2])
- The scale was large: GAO reported FDA had **declined to review 558 EUA requests** for COVID-19 tests as of **Sept. 30, 2021** (including **230 LDTs**). ([Government Accountability Office][3])
- "Deprioritization" as used in EUA review is **not the same thing** as what happens in a 510(k). In 510(k), FDA uses formal completeness gates like **Refuse to Accept (RTA)** to focus resources on submissions that meet a minimum threshold for substantive review, and the program operates under performance goals and structured review steps--not open-ended discretionary triage in the same way. ([U.S. Food and Drug Administration][4])
- Independent and semi-independent analyses (FDA-commissioned assessment, GAO, academic/legal analysis, investigative journalism) repeatedly identify **resource constraints, backlog management, changing public-health needs, and test-quality concerns** as drivers--while also critiquing **transparency, predictability, and "wasted effort"** when priorities changed without clear notice. ([U.S. Food and Drug Administration][1])
- On the question of whether deprioritization contributed to the Omicron test shortage: there is clear documentation of **severe shortages and long lines** during Omicron, but public sources do **not** establish a simple one-to-one causal link from EUA deprioritization decisions in spring/summer 2021 to the January 2022 shortage. The strongest public record supports a **multi-factor explanation**, including demand shocks and manufacturing/investment incentives. ([Reuters][5])
---
## 1) Who at FDA was doing this
**CDRH** (Center for Devices and Radiological Health) is FDA's center responsible for medical devices, including most in vitro diagnostics (IVDs). In the COVID diagnostics context, FDA's own EUA process description references **OHT7** as the office making recommendations on authorization/denial, with additional legal/policy signoffs (OCC and OCET) and different signature authorities depending on the type of decision. ([U.S. Food and Drug Administration][1])
GAO's review of FDA's COVID test oversight highlights the staffing surge and strain: FDA increased staff working on COVID test EUAs and reallocated from other work, with effects on non-COVID diagnostic reviews; FDA officials told GAO they began shifting staff back to non-COVID work around May 2021. ([Government Accountability Office][3])
---
## 2) What "deprioritization" meant in practice
### 2.1 FDA's internal definition (as reflected in FDA-published assessment materials)
FDA's EUA assessment materials (an FDA "perspective" document sharing Booz Allen Hamilton's independent assessment and FDA's response) describe a **front-end triage** and **formal prioritization factors**--followed by **deprioritization processes** that allowed FDA to dispose of certain submissions faster. ([U.S. Food and Drug Administration][1])
The assessment document lays out:
**Prioritization factors** (Table 3-5):
- **Increases testing capacity** (e.g., large-scale manufacturing/processing, high-throughput, high product volume, or reduced reliance on limited supplies like by using saliva).
- **Expands test accessibility** (e.g., point-of-care, home collection, at-home).
- **Reduces real-world performance concerns** (tests already offered under notification policy where FDA identified performance concerns). ([U.S. Food and Drug Administration][1])
**Deprioritization mechanisms** (the core of the question):
- **Decline to Review**: used for "low-priority files" (example given: highly manual, low-volume tests; or low throughput / low manufacturing capacity). FDA would close the file and communicate the decision and reason. ([U.S. Food and Drug Administration][1])
- **Decline to Issue**: used for priority tests with "critical deficiencies" (e.g., inadequate or missing performance data) that the requestor could not resolve in a reasonable time; FDA would notify deficiencies and allow follow-up if the requestor addressed concerns. ([U.S. Food and Drug Administration][1])
A key detail: the assessment notes that before these mechanisms, FDA processed negative decisions as "Denials" requiring higher-level issuance; the streamlined approach helped reviewers focus on higher-impact and more complete requests. ([U.S. Food and Drug Administration][1])
### 2.2 How this differed from "denial" and from "incomplete submission" handling
The same assessment describes other process changes implemented to handle incomplete submissions and reduce iterative back-and-forth:
- A **content screen** and a process to **close files with requests for information**, allowing requestors to resubmit requested information later. ([U.S. Food and Drug Administration][1])
GAO similarly distinguishes:
- FDA may **decline to issue** if the submission lacks necessary data for substantive review, and
- FDA may **decline to review** if the test is not a priority at that stage of the emergency. ([Government Accountability Office][3])
---
## 3) When and how "deprioritization" emerged as a policy tool during COVID
### 3.1 Spring 2020: triage begins; serology becomes a major stress test
A major early example where "deprioritization" (or a shift in review priority) is discussed in the literature is **serology (antibody) tests**.
A Food and Drug Law Journal analysis (Gibbs & Javitt) describes what it characterizes as a "rollercoaster" for serology EUAs: after FDA required EUAs for serology tests (May 4, 2020), FDA was overwhelmed by submissions and applicants experienced long periods in a "backlog" with limited clarity. ([Food and Drug Law Institute (FDLI)][6])
That paper reports that only a few months after requiring EUA submissions, anecdotal reports emerged that FDA would "deprioritize" serology EUAs; it says FDA put serology reviews on hold before announcing it clearly, leading to months of waiting and wasted effort for some applicants. ([Food and Drug Law Institute (FDLI)][6])
### 3.2 Fall 2020: formalized front-end triage; "Decline to Review" letters become a visible instrument
FDA's EUA assessment materials describe the inflection point:
- **Beginning in Fall 2020**, CDRH instituted a **front-end triage and prioritization process** for all EUA requests due to submission volume far beyond prior emergencies. ([U.S. Food and Drug Administration][1])
- The same assessment states that CDRH did not begin implementing the **Decline to Review** process "until October 2020," after more than 250 EUAs for tests/collection devices had been authorized. ([U.S. Food and Drug Administration][1])
### 3.3 October 7, 2020: public statement--declining to review LDT EUAs "at this time"
An October 7, 2020 FDA virtual town hall transcript captures FDA publicly stating that--given the phase of the pandemic, many authorized tests, and the HHS announcement about LDT premarket review--FDA was **declining to review EUA requests for LDTs at that time**, while continuing to prioritize POC, home collection, at-home, supply-chain-relieving, and high-throughput/widely distributed tests. ([U.S. Food and Drug Administration][7])
The EUA assessment report adds a quantitative detail tied to that policy move: after the August 2020 HHS statement, CDRH **declined to review over 200 LDT EUA requests in October**--framed as allowing CDRH to focus on tests that could not be offered without FDA review/authorization (e.g., home collection, POC, multi-analyte panels). ([U.S. Food and Drug Administration][1])
### 3.4 Early 2021 (including March): explicit language about deprioritization and "what's needed right now"
Two March 2021 town hall excerpts are particularly on-point:
- **March 10, 2021:** Dr. Timothy Stenzel stated that submitting only for high/moderate complexity "is a very low priority and you might be deprioritized," and encouraged moving to the home study / home test pathway if performance supports it. ([U.S. Food and Drug Administration][2])
- **March 31, 2021:** FDA reiterated that prioritization decisions depend on many factors; it again named the accessibility and capacity priorities. Dr. Stenzel added that "at this time [the] pandemic is very different" and that FDA sought to "focus review attention and prioritization" and incentivize development of tests "really needed right now," emphasizing high-volume accurate results in lab or at home/POC. ([U.S. Food and Drug Administration][8])
This aligns closely with the deprioritizations clustering when FDA perceived a shift in market/public-health conditions.
### 3.5 Mid-late 2021: "deprioritized previously" explained (manufacturing capacity / deficiencies)
In an August 4, 2021 town hall transcript, FDA stated that if an EUA request was deprioritized previously, it was likely because the test either:
- had **low manufacturing or testing capacity**, or
- the submission was **deficient** in some way. ([U.S. Food and Drug Administration][9])
That is one of the clearest public "rule-of-thumb" explanations from FDA itself.
### 3.6 By Sept. 30, 2021: the scale--hundreds of EUA requests declined to review
GAO reported that FDA officials said as of **Sept. 30, 2021**, FDA had **declined to review 558 EUA requests** for COVID-19 tests, including **230 LDTs**. ([Government Accountability Office][3])
This provides a public, audited figure consistent with "hundreds" and gives an anchor for the scale of "deprioritization" as "decline to review."
---
## 4) What drove the policy: FDA's stated rationale and operational constraints
Across FDA's assessment materials, town halls, and GAO, the same drivers repeatedly appear:
### 4.1 Unprecedented submission volume and backlog management
The EUA assessment notes that early in the pandemic, when few tests were authorized, "every test was a priority," but as tests proliferated, that level of interaction became unsustainable, necessitating prioritization factors. ([U.S. Food and Drug Administration][1])
GAO reports that FDA received thousands of EUA requests over the period and that review times increased as volume increased. ([Government Accountability Office][3])
### 4.2 Focus on public health impact: accessibility + capacity + supply chain
FDA consistently framed prioritization around tests that:
- expand where/how testing can occur (POC, home collection, at-home), and
- increase national capacity (high throughput, high volume, reduced reliance on scarce supplies). ([U.S. Food and Drug Administration][1])
The EUA assessment also describes how **supply chain monitoring** fed into review priorities, including pivots when swab shortages emerged (e.g., prioritizing saliva specimen approaches). ([U.S. Food and Drug Administration][1])
### 4.3 Manufacturing and testing capacity as an explicit gate
FDA town halls repeatedly tied priority to **capacity**, and FDA's August 2021 town hall made that explicit in the deprioritization explanation. ([U.S. Food and Drug Administration][9])
GAO also captures FDA's later articulation (in the revised 2021 guidance) that FDA viewed authorization of tests with manufacturing capacities below a large threshold as insufficient to scale national capacity--illustrating that capacity was not just a nice-to-have; it became a central criterion. ([Government Accountability Office][3])
### 4.4 Quality and validation concerns (and avoiding prolonged review loops)
FDA's assessment frames "Decline to Issue" as a way to stop spending time on submissions with major unresolved validation problems. ([U.S. Food and Drug Administration][1])
Separately, the legal/academic analysis of serology describes situations in which applicants sometimes had very short windows (e.g., "forty-eight hours") to respond to questions--highlighting the tension between speed and completeness in emergency review. ([Food and Drug Law Institute (FDLI)][6])
---
## 5) Was "deprioritization" used before COVID in other emergencies?
### 5.1 EUA existed pre-COVID and IVD EUAs were issued in multiple emergencies
FDA documents summarizing EUA practice list multiple emergencies in which FDA authorized IVDs under EUA, including:
- influenza A H1N1 (2009),
- avian influenza A H7N9 (2013),
- MERS-CoV (2013),
- Ebola (2014),
- Enterovirus D68 (2015),
- Zika (2016),
- COVID-19 (2020), and
- mpox (2022). ([U.S. Food and Drug Administration][10])
### 5.2 But the "deprioritization" machinery appears to be a COVID-scale response
FDA's EUA assessment explains that the "substantially higher submission volume" during COVID compared to prior public health emergencies made a **formal set of prioritization factors necessary**, and it describes Fall 2020 as the point where triage and streamlined "Decline to Review / Decline to Issue" mechanisms were instituted to manage backlog. ([U.S. Food and Drug Administration][1])
That suggests:
- **Prior PHEs** likely involved prioritization in the ordinary sense (resource focus), but
- **COVID** created enough volume/complexity that "deprioritization" became a structured, named workflow with standardized negative actions, and it became widely visible to submitters.
---
## 6) Is there an equivalent "deprioritization" in 510(k)? Not really--here's the closest analog
### 6.1 EUA vs 510(k) in one sentence
- **EUA** is an emergency, discretionary authorization mechanism where FDA can choose not to review certain categories at a given moment to maximize public health benefit. ([FDA Law Blog][11])
- **510(k)** is a standard premarket pathway with structured acceptance and substantive review steps; FDA focuses resources by screening completeness (RTA) rather than by declining review because a product category is "low priority." ([U.S. Food and Drug Administration][4])
### 6.2 The closest analog: "Refuse to Accept (RTA)" and other gates
FDA's **Refuse to Accept Policy for 510(k)s** explains that its purpose is to determine whether a 510(k) meets a minimum threshold of acceptability and should be accepted for substantive review--explicitly framing this as a way to focus review resources on complete submissions. ([U.S. Food and Drug Administration][4])
FDA's 510(k) submission process page describes that after the acknowledgement letter, the submission routes to the appropriate office and that the lead reviewer conducts acceptance review using the RTA checklist. ([U.S. Food and Drug Administration][12])
**Key distinction:**
RTA is about **administrative/threshold completeness**. COVID EUA "deprioritization" (Decline to Review) was often about **public-health priority and impact**, including volume/capacity and what FDA perceived the country needed at that phase--*even if the submission might be technically complete*. ([U.S. Food and Drug Administration][1])
---
## 7) What analyses and critiques exist about "deprioritization" and its effects?
There is not a single definitive "cost-benefit" study that proves counterfactual outcomes (e.g., "X more tests would have been on shelves by Omicron absent deprioritization"). But there *is* meaningful analysis and documented stakeholder critique.
### 7.1 FDA's own after-action framing (independent assessment shared by FDA)
FDA's published assessment materials (sharing Booz Allen's independent assessment plus FDA perspective) depict deprioritization as a necessary operational response to:
- backlog,
- resource limits,
- incomplete/low-quality submissions, and
- changing PHE needs. ([U.S. Food and Drug Administration][1])
### 7.2 GAO: documented scale + stakeholder concerns about uncertainty (especially LDTs)
GAO documents the "decline to review" scale (558 by Sept. 30, 2021), and notes that laboratory associations expressed unfavorable views of declining to review LDT EUAs because it created uncertainty/confusion, including around insurance coverage and PREP Act liability protections. ([Government Accountability Office][3])
### 7.3 Legal/academic critique: transparency and wasted effort (notably serology)
The Food and Drug Law Journal analysis is explicit that lack of clarity about shifting priorities can waste developer effort and create confusion--particularly in serology, where the authors describe an unannounced shift in review priorities and long periods without meaningful communication. ([Food and Drug Law Institute (FDLI)][6])
### 7.4 Industry/legal commentary: "deprioritization risk" as a planning hazard
A prominent FDA law blog post (Feb 2021) describes deprioritization as a significant risk in pursuing EUAs under changing market conditions, gives examples (including diagnostics), and argues for more transparency--e.g., a public database of deprioritized categories. ([FDA Law Blog][11])
### 7.5 Case reporting: applications told they'd be "deprioritized"
ProPublica reported on an at-home test developer describing an FDA communication that even if deficiencies were fixed, the application would be "deprioritized" (moved to the back of the line). ProPublica also reports FDA officials emphasizing sensitivity/false negatives and blaming shortages partly on lack of sustained government investment in production. ([ProPublica][13])
### 7.6 Example of FDA stopping EUA review and steering to non-EUA pathway
A 2021 report on SQI Diagnostics described FDA deciding it would not continue reviewing an EUA submission under a "tests for management of COVID-19 patients" category, citing high volume and prioritization factors, and encouraging use of a non-EUA pathway. ([Clinical Lab Products][14])
This illustrates deprioritization-like outcomes beyond classic diagnostic testing.
---
## 8) Spring/summer 2021 deprioritization vs Omicron 2022 testing shortages: what can we responsibly say?
### 8.1 The Omicron shortage was real and visible
Reuters reported (Jan 12, 2022) that long lines "snake around entire city blocks" as Americans scrambled for testing, and at-home kits flew off shelves. ([Reuters][5])
### 8.2 What the public record supports about causality
The public evidence supports a **multi-factor story**, roughly:
**A) Demand shock + planning/investment dynamics**
- ProPublica quotes FDA's CDRH director Jeff Shuren attributing differences in test availability partly to **government investment supporting production**, and describing how lack of sustained funding can make manufacturers reluctant to take on the cost/risk of the FDA process at scale. ([ProPublica][13])
**B) Regulatory triage did occur**
- FDA explicitly prioritized certain test types (at-home, POC, high-throughput, high-volume) and deprioritized others, including by closing low-priority files. ([U.S. Food and Drug Administration][1])
**C) The missing link**
What is *not* established in the public sources is a quantified counterfactual:
- "If FDA had reviewed the deprioritized EUAs in spring/summer 2021, there would have been enough additional manufacturing capacity to prevent Omicron shortages."
That could be true for some subset (especially if deprioritized submissions included would-have-scaled at-home/rapid tests), but proving it would require:
- knowing which tests were deprioritized (and why) in that period,
- knowing their realistic manufacturing ramp curves and supply chain constraints, and
- knowing whether demand-side procurement/reimbursement policies would have supported sustained production.
### 8.3 A plausible mechanism (clearly labeled as inference)
Based on FDA's own prioritization factors emphasizing **manufacturing volume** and **accessibility** ([U.S. Food and Drug Administration][1]) and GAO's documentation that FDA used "decline to review" for nonpriority tests ([Government Accountability Office][3]), one plausible mechanism is:
- If deprioritization decisions in 2021 disproportionately excluded tests that could have become high-volume at-home/rapid options by late 2021, then deprioritization could have reduced the set of suppliers going into Omicron.
But the public record also contains the countervailing point that FDA's stated priorities were precisely **at-home/POC/high-volume**, meaning many "low priority" files may not have been the ones that would materially expand at-home capacity. ([U.S. Food and Drug Administration][8])
---
## 9) What's still not publicly knowable (without FOIA / docket-level data)
Even with the above sources, several things are **not fully disclosed in public material**, including:
- A breakdown of *all* "Decline to Review" decisions by **test type**, intended setting, and month (especially the spring-summer 2021 period). GAO provides a cumulative number, not a full taxonomy. ([Government Accountability Office][3])
- The number of serology submissions "rejected or never reviewed" is explicitly described in the legal literature as not publicly disclosed. ([Food and Drug Law Institute (FDLI)][6])
- The internal scoring/weighting of prioritization factors (e.g., exactly how FDA weighed "manufacturing capacity" versus "novelty" versus "unmet need") at different pandemic phases.
---
## 10) Source map (for follow-up)
If you want to go deeper (or build a formal dossier), these are the most "load-bearing" public documents for deprioritization:
1. **FDA perspective sharing Booz Allen independent assessment** (describes triage, prioritization factors, Decline to Review/Issue, supply-chain monitoring, review tracks). ([U.S. Food and Drug Administration][1])
2. **GAO-22-104266** (quantifies declined-to-review volume; documents FDA/HHS policy moves; records stakeholder concerns). ([Government Accountability Office][3])
3. **FDA town hall transcripts** around:
- Oct 7, 2020 (declining to review LDT EUA requests; priorities) ([U.S. Food and Drug Administration][7])
- Mar 10, 2021 (explicit "might be deprioritized" language) ([U.S. Food and Drug Administration][2])
- Mar 31, 2021 (phase change; focus on high-volume, accurate, needed tests) ([U.S. Food and Drug Administration][8])
- Aug 4, 2021 (why a request was deprioritized: low capacity or deficient) ([U.S. Food and Drug Administration][9])
4. **Food and Drug Law Journal analysis (Gibbs & Javitt)** for narrative history and transparency critique, especially serology. ([Food and Drug Law Institute (FDLI)][6])
5. **Reuters (Jan 12, 2022)** as contemporaneous documentation of Omicron-era testing shortages and lines. ([Reuters][5])
[1]: https://www.fda.gov/media/152992/download "https://www.fda.gov/media/152992/download"
[2]: https://www.fda.gov/media/146811/download "https://www.fda.gov/media/146811/download"
[3]: https://www.gao.gov/assets/gao-22-104266.pdf "https://www.gao.gov/assets/gao-22-104266.pdf"
[4]: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/refuse-accept-policy-510ks "https://www.fda.gov/regulatory-information/search-fda-guidance-documents/refuse-accept-policy-510ks"
[5]: https://www.reuters.com/world/us/americans-grapple-with-prolonged-testing-woes-amid-omicron-surge-2022-01-12/ "https://www.reuters.com/world/us/americans-grapple-with-prolonged-testing-woes-amid-omicron-surge-2022-01-12/"
[6]: https://www.fdli.org/wp-content/uploads/2021/12/5-Gibbs-Javitt-Final.pdf "https://www.fdli.org/wp-content/uploads/2021/12/5-Gibbs-Javitt-Final.pdf"
[7]: https://www.fda.gov/media/143084/download "https://www.fda.gov/media/143084/download"
[8]: https://www.fda.gov/media/147394/download "https://www.fda.gov/media/147394/download"
[9]: https://www.fda.gov/media/151937/download "https://www.fda.gov/media/151937/download"
[10]: https://www.fda.gov/media/171779/download "https://www.fda.gov/media/171779/download"
[11]: https://www.thefdalawblog.com/2021/02/beware-eua-deprioritization/ "https://www.thefdalawblog.com/2021/02/beware-eua-deprioritization/"
[12]: https://www.fda.gov/medical-devices/premarket-notification-510k/510k-submission-process "https://www.fda.gov/medical-devices/premarket-notification-510k/510k-submission-process"
[13]: https://www.propublica.org/article/heres-why-rapid-covid-tests-are-so-expensive-and-hard-to-find "https://www.propublica.org/article/heres-why-rapid-covid-tests-are-so-expensive-and-hard-to-find"
[14]: https://clpmag.com/disease-states/infectious-diseases/covid-19/fda-stops-eua-review-of-sqi-covid-19-severity-triage-test/ "https://clpmag.com/disease-states/infectious-diseases/covid-19/fda-stops-eua-review-of-sqi-covid-19-severity-triage-test/"
# 9,443 _AI_FloodLAMP FDA October 2021 Correspondence Analysis.md
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last updated: 2026-03-02 RT initial creation
file_name: _AI_FloodLAMP FDA October 2021 Correspondence Analysis.md
file_date: 2026-03-02
title: FloodLAMP FDA October 2021 Correspondence Analysis
category: regulatory
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tags: fda-correspondence, deprioritization, eua, quickcolor, october-2021, open-protocol
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notes: Created by Claude Opus 4.6 Max and ChatGPT 5.2 Pro Extended during archive preparation. **NOT HUMAN VERIFIED - MAY CONTAIN ERRORS** Comprehensive analysis of FloodLAMP's October 2021 FDA correspondence sequence, synthesizing the full email thread, FDA deficiency letter, meeting notes, and final deprioritization decision, with background from FDA town hall transcripts, open EUA context, and the AI deprioritization research report. Includes factual timeline summary and five interpretive explanations of FDA's rationale.
summary_short: Analysis of FloodLAMP's October 2021 FDA correspondence -- the concentrated sequence of emails, deficiency letter, Zoom meeting (with Anne Wyllie), FloodLAMP's response, and FDA's final deprioritization/closure of EUA210582 for the QuickColor COVID-19 Test. Presents a complete timeline from October 2020 through October 2021, identifies FDA's stated justifications (clinical data gaps, resource triage, deprioritization policy), and offers five interpretive explanations of the FDA's rationale ranging from legitimate resource constraints to structural bias against small/novel entrants, with attention to the Omicron-wave irony five weeks later.
CONTENT
## Prompt (Verbatim)
Review the following files and the thing I want you to hone in on is I'll drag it over as a separate file. Well, you have these files on there all the October 2021 ones there in the archive combined files. So there are really four of these from from 2021, 10/4, 10/13, well two from 10/13 and then one from 10/20. So all the rest of the files are provided as like background and context so you know read and review all of those and then what I want you to do is summarize the interactions in all of those emails and then particularly what justification the FDA gave for not continuing our review and closing our case and refusing our EUA submissions and then... and then try to read between the lines and and use what you understand about the FDA's process and what's happening during the pandemic etc. to try to explain why they would shut us down. I mean Anne Wiley joined the call that we had with them. They knew she was an advisor for us. She was very successful. We submitted multiple times. I believe I discussed that we had the surveillance programs going and the test was successful. I think we even offered to submit that data. So you know this was in October and you know I mean maybe if they knew the Omicron wave was coming they wouldn't have done this. You know who knows but I want to try to understand this better. So both present the facts and then also try to step into their shoes and explain their rationale and you know if if you think it's best create you know a few possibilities of what their rationale and or thinking may have been.
**Files included in context window:**
- _archive-combined-files_fl-fda-correspondence.md
- _AI_FDA Deprioritization of COVID-19 Diagnostic EUAs.md
- _context-commentary_regulatory-fda-townhalls.md
- _context-commentary_regulatory-open-euas.md
- project-description.md
- _context-commentary_regulatory-fl-fda-correspondence.md
## Prompt (Cleaned)
Review all provided files, with particular focus on the October 2021 correspondence in the archive combined files -- the four key communications from 10/4, 10/13 (two that day), and 10/20. The remaining files provide background and context.
Summarize the interactions in all of the emails, and specifically identify what justification the FDA gave for not continuing the review, closing the case, and refusing the EUA submissions.
Then try to read between the lines, using what is known about the FDA's process and the pandemic context, to explain why they would shut FloodLAMP down. Anne Wyllie joined the call with the FDA. They knew she was an advisor. FloodLAMP submitted multiple times, had surveillance programs running with successful results, and offered to submit that data. This was October 2021 -- perhaps if the FDA had known the Omicron wave was coming five weeks later, they would not have made this decision.
Present the facts, then step into the FDA's shoes and explain their rationale. Create several possibilities for what their rationale and thinking may have been.
**Files included in context window:**
- _archive-combined-files_fl-fda-correspondence.md
- _AI_FDA Deprioritization of COVID-19 Diagnostic EUAs.md
- _context-commentary_regulatory-fda-townhalls.md
- _context-commentary_regulatory-open-euas.md
- project-description.md
- _context-commentary_regulatory-fl-fda-correspondence.md
## RESPONSE - Claude Opus 4.6 Max
### Summary of FloodLAMP-FDA Interactions: The October 2021 Correspondence
#### Complete Timeline
**Phase 1: Early Engagement (Oct 2020 - Dec 2020)**
- **Oct 22, 2020**: FloodLAMP sends initial Pre-EUA request describing pooled RT-LAMP screening program.
- **Nov 10, 2020**: FloodLAMP emails Dr. Tim Stenzel proposing a meeting about expanding the open-source EUA approach beyond SalivaDirect, with Anne Wyllie's involvement.
- **Dec 9, 2020**: FloodLAMP engages Stenzel directly at an FDA Town Hall. Stenzel is encouraging: *"I look forward to hearing more about your development"* and confirms the open-source protocol and Rights of Reference model has real potential, calling it *"a pathway that could be very successful."*
**Phase 2: Submissions and First Deprioritization (Mar 2021 - Jun 2021)**
- **Mar 22, 2021**: FloodLAMP submits two full EUAs -- QuickColor LAMP (EUA210252) and EasyPCR (EUA210254) -- as open-source protocol EUAs with clinical validation from Stanford.
- **Apr 2, 2021**: FDA deprioritizes both, declining to review. Justification: *"authorization of the test would have relatively limited impact on testing accessibility or testing capacity."* Signed by Donald J. St. Pierre.
- **May 18, 2021**: FloodLAMP submits Pre-EUA (PEUA210313) for pooled home-collection kit and mobile app, trying to qualify for prioritization.
- **Jun 17, 2021**: FDA responds to Pre-EUA. Critically, states: *"we have not reviewed the validation studies nor the data provided in this pre-EUA."* Flags the QuickColor PPA of 90% as below the 95% threshold. Closes the Pre-EUA.
**Phase 3: The October 2021 Push and Final Closure**
This is the concentrated sequence of four key communications:
**1. Oct 4, 2021 -- FloodLAMP letter to Dr. Tim Stenzel (4 pages)**
Randy True makes a comprehensive case directly to the FDA Director of OIVD. Key points:
- Introduces FloodLAMP and the two complementary tests (LAMP and PCR)
- Describes the open-source protocol approach with Anne Wyllie as advisor
- Reports resubmission of both EUAs (now EUA210581, EUA210582) for persons suspected of COVID and serial screening
- Presents real-world surveillance data: 5 sites in 3 states, ~2,300 people screened, 800 pools, 3 unknown positives detected, no known false negatives
- Highlights manufacturing readiness: 2M tests on hand, 3M more at LGC Biosearch, NEB master mix supply
- Frames $1-2/test pricing as "transformative"
- Describes active commercial sites with EMS and municipal fire departments
- Makes the Test-to-Stay argument for schools
- Requests prioritized review and assistance avoiding immediate denial
**2. Oct 13, 2021 -- FDA sends two communications**
*Morning (8:25 AM):* Lead reviewer Liang Li sends a detailed 6-deficiency letter on EUA210582:
1. **Clinical study design**: wrong specimen type (AN swabs instead of NP), no intended use population description, no low-viral-load samples
2. **PPA of 90%** -- below FDA's 95% threshold
3. **Outdated inclusivity/variant analysis** (Feb 2021 data, no longer representative)
4. **Incomplete cross-reactivity** -- organisms with >80% homology not wet-tested
5. **Insufficient endogenous interfering substances** testing
6. **External controls too concentrated** (8x LoD vs. recommended <5x LoD)
7. **RUO reagent risk** -- cannot recommend RUO-labeled components for authorized test
**Deadline given: October 15, 2021 at noon** -- two business days.
*Late morning (10:15 AM):* Liang Li follows up offering a 30-minute Zoom meeting the next day.
**3. Oct 14, 2021 -- Zoom Meeting**
FloodLAMP: Randy True (CEO), Anne Wyllie (advisor)
FDA: Liang Li, Silke Schlottmann, Kris Roth
Key exchange points:
- Randy requests to **amend the intended use to serial screening only** (removing "suspected of COVID"), which has a lower PPA threshold (~80%)
- Silke asks about designation and **says they would not want the IFU publicly available** -- a direct tension with the open protocol model
- Kris mentions **6 criteria for serial screening** and that the risk-benefit differs for POC/at-home vs. lab-based tests
- Anne Wyllie asks if they could validate with a blinded reference panel; Silke says **the reference panel is no longer available**
- Agreed FloodLAMP would provide written response by Oct 20
**4. Oct 20, 2021 -- FloodLAMP's Written Response**
Randy submits a point-by-point response:
- Requests amendment to remove "persons suspected of COVID" -- serial screening only
- Narrows specimen claim to AN swabs only
- Argues PPA threshold for serial screening is 80%, and performance exceeds all authorized antigen tests
- Presents real-world surveillance data as supporting evidence
- Cites multiple independent validations of the same LAMP components
- Commits to updating inclusivity analysis, addresses cross-reactivity concerns specific to LAMP vs. PCR
- Offers to qualify RUO lots
Crucially, Randy also asks: *"Is the risk-benefit analysis for a high complexity CLIA lab rather than POC setting able to be factored in?"* and notes no response was received from the Oct 4 letter to Tim Stenzel.
**5. Oct 21, 2021 -- FDA Final Decision (one day after FloodLAMP's response)**
Liang Li sends a deprioritization/closure letter signed by Donald J. St. Pierre:
> *"Given the volume of EUA requests the Agency has received, FDA is prioritizing review of EUA requests for tests, taking into account a variety of factors such as the public health need for the product, availability of the product, extent to which the product would serve a significant unmet medical need, and availability and adequacy of the information concerning the likelihood that the product may be safe and effective in diagnosing the disease/condition. Based on these factors, our review of your submission thus far, and the anticipated resources needed to continue review of your EUA request, FDA has determined that further review of your EUA request is not a priority. FDA therefore declines to issue an EUA for the product at this time."*
**6. Oct 28, 2021 -- FloodLAMP appeals**
Randy asks whether the intended use amendment to serial screening was understood before the closure decision, and requests reconsideration. He proposes two paths: (a) if the current clinical data is acceptable for serial screening, FloodLAMP will quickly complete the remaining items; (b) if not, he requests feedback on a new clinical study design.
**7. Oct 29, 2021 -- FDA confirms and closes the door**
Liang Li responds:
> *"We understood the intended use amendment when we sent the Deprioritization Letter. Your current clinical study is not acceptable to support testing a screening population with serial testing."*
Directs FloodLAMP to the updated molecular EUA template or to submit a pre-EUA amendment for study design feedback. The exchange effectively ends here.
---
### FDA's Stated Justifications
The FDA gave three layers of justification, used in combination:
1. **Deprioritization on public health impact grounds**: *"authorization of the test would have relatively limited impact on testing accessibility or testing capacity"* -- used in both the April 2021 and October 2021 closure letters.
2. **Inadequate clinical performance data**: PPA of 90% was below the 95% threshold for the "persons suspected of COVID" intended use, and the clinical study design had deficiencies (wrong specimen type, no population description, no low-viral-load challenge samples).
3. **Inadequate clinical study for serial screening**: Even after FloodLAMP amended to the serial screening intended use (with a lower ~80% PPA bar), FDA determined that the clinical study itself was not designed to support a screening population claim. The study used de-identified remnant clinical samples from Stanford, not a screening population.
4. **Resource calculus**: The October 21 letter adds a new phrase not in the April letter: *"the anticipated resources needed to continue review of your EUA request"* -- suggesting the FDA was also factoring in the additional work (new clinical study, updated analytics, etc.) that would be needed to get FloodLAMP over the finish line.
---
### Reading Between the Lines: Why the FDA Shut FloodLAMP Down
Based on the full documentary record, the broader FDA deprioritization analysis, and the pandemic context, here are several possible explanations -- from most to least charitable to the FDA.
#### Explanation 1: Legitimate Resource Triage Under Genuine Constraints
**The FDA's perspective**: By October 2021, the agency had authorized over 400 COVID-19 tests. Vaccines were widely available. The Delta wave, while severe, appeared to be subsiding. FDA staff were being shifted back to non-COVID review work (GAO documents this starting around May 2021). The agency faced an unprecedented backlog across its entire regulatory portfolio. Every hour spent on a submission that wasn't going to clear quickly was an hour taken from something else.
FloodLAMP's submission, however meritorious its mission, presented a significant review burden: the clinical study needed to be redone, the analytical package needed substantial updating, the RUO reagent question was unresolved, and the open protocol model raised novel designation and quality assurance questions. From a pure resource allocation standpoint, a submission requiring extensive additional work from a small company without an existing EUA track record ranked lower than submissions from entities with complete packages or near-complete packages.
**What makes this plausible**: The GAO data shows 558 tests declined to review by September 30, 2021 -- FloodLAMP was one of hundreds. The FDA was applying this policy broadly, not singling FloodLAMP out. The two-day response window, while harsh, was apparently a standard mechanism during this period.
**What complicates this**: The FDA's own prioritization criteria emphasized tests that "increase testing accessibility" and "expand testing capacity." FloodLAMP's offering -- instrument-free, $1-2/test, open protocol enabling lab proliferation, commodity supply chain -- arguably fit those criteria well. The FDA never substantively engaged with these claims.
#### Explanation 2: The Clinical Data Gap Was Real and Dispositive
**The FDA's perspective**: Regardless of mission, price point, or scalability claims, an IVD EUA requires adequate validation data. FloodLAMP's clinical study had genuine problems:
- 90% PPA, not 95%
- Anterior nasal swabs only, while claiming broad URT specimen types
- No description of study population characteristics
- No low-viral-load challenge samples (the hardest test of sensitivity)
- De-identified remnant samples from Stanford -- not a prospective screening population study
Even at the 80% PPA threshold for serial screening, the FDA's position was that the *study design* was wrong, not just the performance number. A screening population claim requires a study on a screening population, and remnant clinical samples from symptomatic patients tested at a hospital lab don't demonstrate that.
**What makes this plausible**: This is technically sound. FDA templates were clear about these requirements. The June 2021 pre-EUA response explicitly flagged the PPA issue. FloodLAMP had months of advance notice.
**What complicates this**: FloodLAMP asked for guidance on study design repeatedly -- in the May 2021 pre-EUA, in the October 5 interactive review request, and in the October 20 response. The FDA's response to the May pre-EUA was to not review the data at all and close the file. On October 14, when FloodLAMP asked about the clinical requirements, the reference panel that could have helped was "no longer available." And the final closure came one day after FloodLAMP's response -- suggesting the decision was already made before the response was evaluated.
#### Explanation 3: Institutional Discomfort with the Open Protocol Model
**The FDA's perspective**: The open-source protocol EUA was still a novel regulatory construct. SalivaDirect was the only example, and it was backed by Yale -- a major research institution with significant credibility and infrastructure. FloodLAMP was a tiny public benefit corporation asking FDA to authorize a test whose Instructions for Use would be publicly available, whose components were commodity RUO-labeled reagents, and whose deployment model involved designating potentially hundreds of labs.
The October 14 meeting notes are revealing: Silke Schlottmann specifically said *"they would not want us to make IFU publicly available"* -- a direct challenge to the foundational concept of an open protocol EUA. If the IFU isn't public, the protocol isn't open. This suggests the FDA reviewers, or at least some of them, were uncomfortable with the regulatory implications of this model expanding beyond the SalivaDirect precedent.
There were genuine regulatory questions: Who is responsible for quality when any lab can run the protocol? How do you ensure lot-to-lot consistency of RUO reagents? What happens when a designated lab deviates from the protocol? These are legitimate concerns, but they were never worked through -- the submission was closed before they could be.
**What makes this plausible**: The regulatory system is not designed for open-source diagnostics. The standard model assumes a single manufacturer with a quality system controlling its product. The open protocol model disrupts that assumption, and FDA reviewers would reasonably be cautious.
**What complicates this**: Tim Stenzel, the OIVD Director, had explicitly endorsed the open protocol approach on record in the December 2020 town hall. But Stenzel never responded to the October 4 letter, and the review team -- who made the actual decisions -- appeared to be less aligned with the concept.
#### Explanation 4: The "Pandemic Is Ending" Assumption
**The FDA's perspective**: In October 2021, the dominant institutional narrative was one of pandemic management trending toward resolution. Vaccines were widely deployed, boosters were being authorized, therapeutics were in the pipeline. The acute crisis of "we need every test we can get" had passed. The FDA's own town hall language reflected this: *"at this time the pandemic is very different"* (March 2021); tests were being deprioritized because the agency perceived less urgency.
A small company's LAMP test -- which needed substantial additional validation work, wouldn't be POC or at-home, and was instrument-free but still high-complexity CLIA -- simply didn't register as urgent in a world where the pandemic was supposed to be winding down.
**The devastating irony**: Omicron (B.1.1.529) was first reported to the WHO on November 24, 2021 -- approximately five weeks after the FDA closed FloodLAMP's submission. By January 2022, Americans were standing in lines that *"snake around entire city blocks"* trying to get tested. The U.S. experienced the worst testing shortage of the entire pandemic. The very thing FloodLAMP was offering -- massive-scale, low-cost molecular screening using commodity reagents and an open protocol that any CLIA lab could adopt -- was exactly what was needed.
Would FloodLAMP's authorized test have prevented the Omicron testing shortage? Almost certainly not by itself. But the principle behind the decision -- "we don't need more tests right now" -- was catastrophically wrong, and it was applied systematically to FloodLAMP and hundreds of other developers.
#### Explanation 5: Structural Bias Against Small, Mission-Driven Entrants
**The FDA's perspective** (unstated): The FDA's EUA prioritization criteria implicitly favored established diagnostics companies. "High-throughput" meant companies with existing high-volume manufacturing. "Widely distributed" meant companies with existing distribution networks. "POC" and "at-home" meant companies with the capital to run the required usability studies and manufacture consumer devices.
FloodLAMP's claims -- "$1-2/test," "millions of tests by end of year," "10K+/day without automation" -- were extraordinary, but they came from a company with no existing EUA, no manufacturing facility, and two active commercial surveillance sites serving EMS workers. From a risk-averse regulator's perspective, these were aspirational claims from an unproven entity, not demonstrated capacity.
Anne Wyllie's presence on the October 14 call was meant to signal credibility -- she was the developer of SalivaDirect, the most successful open protocol EUA. But the review team had apparently already set their course. The letter to Stenzel went unanswered. The surveillance program data -- while genuinely impressive for a startup -- was a rounding error in national testing volumes.
**What makes this plausible**: Regulators evaluate track record and demonstrated capacity, not potential. The FDA's job is not to pick winners or invest in promising startups; it's to determine whether a specific device meets specific criteria.
**What complicates this**: This is precisely the critique that the GAO, legal scholars, and industry commentators made about the deprioritization regime. It created a circular barrier: you can't demonstrate capacity without authorization, but you can't get authorization without demonstrated capacity. For a small public benefit corporation operating on grants and mission-driven funding, this was a death spiral.
---
### Synthesis
The most likely reality is a combination of all five factors, weighted roughly in this order:
1. **Resource triage was the dominant driver.** The FDA was overwhelmed and had a systematic policy of closing submissions that required extensive additional work. FloodLAMP's submission genuinely needed more work.
2. **The clinical data gap was real but should have been solvable.** FloodLAMP needed a prospective screening population study. The FDA never gave them meaningful feedback on study design despite repeated requests. The June 2021 pre-EUA response didn't review their data at all, and the October process gave them 48 hours to respond to a 6-deficiency letter before closing the case.
3. **The open protocol model created institutional friction** that the review team was not equipped or motivated to work through, particularly in a resource-constrained environment.
4. **The "winding down" assumption** about the pandemic made every submission from a small developer with an incomplete package look like a low-return investment of review resources -- an assumption that proved catastrophically wrong within weeks.
5. **Structural bias** against small/novel entrants was an ambient factor, not a deliberate choice, but it meant FloodLAMP's arguments about potential impact were likely discounted relative to what a large manufacturer with an existing supply chain would have been credited.
The single most telling detail in the entire record may be this: the FDA sent a 6-deficiency letter on October 13, offered a 30-minute call on October 14, received a substantive written response on October 20, and issued a final closure one day later on October 21. The speed of that closure -- particularly the one-day turnaround on a response that proposed a narrowed intended use and addressed multiple deficiencies -- suggests the outcome was predetermined and the "interactive review" was procedural rather than genuinely deliberative. FloodLAMP was being processed through the deprioritization pipeline, not evaluated on the merits of its amended proposal.
## RESPONSE - ChatGPT 5.2 Pro Extended
Below is a fact-first reconstruction of what happened in the October 2021 thread (the four “October files” you pointed to), plus the most important earlier context in the correspondence bundle. I then separate out what FDA **explicitly said** from what can be **inferred** (with clear labels), and I end with a set of plausible “FDA-in-their-shoes” rationales for why they shut this down.
I’m basing this entirely on the archive files you provided; the October 10/14 “meeting notes” are *your* notes (not a verbatim FDA transcript), so I treat them as directional evidence, not quotes.
---
### What happened, chronologically
#### The key pre-October setup (why Oct 2021 isn’t “out of the blue”)
* **Mar 22, 2021:** FloodLAMP submitted two “open protocol” EUA requests (QuickColor LAMP and EasyPCR) and positioned them as low-cost, supply-chain-robust, scalable protocols modeled on SalivaDirect, including a planned blanket Right of Reference (ROR) strategy.
* **Apr 2, 2021:** FDA issued a **final decision** on EUA210252 (and similarly on EUA210254) and **closed** the EUA(s), stating they were deprioritizing because FDA was in “a different phase of the pandemic…where many COVID-19 tests are now authorized,” and FDA was prioritizing tests that would **increase testing accessibility** (POC, home collection, at-home) or **significantly increase testing capacity** (high-throughput). FDA said FloodLAMP’s test would have “relatively limited impact” on accessibility/capacity.
* **May–Jun 2021 (Pre-EUA PEUA210313):** FloodLAMP submitted a pre-EUA that bundled tests + pooled home collection + app. FDA said, due to volume/prioritization, they **did not review the validation studies/data**, but gave “general recommendations,” including (critically) stating FDA believes **~95% positive and negative agreement** is acceptable clinical performance and that QuickColor’s PPA was below that; FDA explicitly said they **did not recommend pursuing** an EUA for QuickColor unless sensitivity improved. They then **closed the pre-EUA** upon issuing the feedback.
* **Oct 5, 2021:** FloodLAMP followed up asking for an **interactive review** and emphasizing real-world surveillance deployment metrics (sites, pools, people screened, positives detected/confirmed, etc.), while noting resubmitted EUAs (EUA210581 / EUA210582).
That’s the backdrop: FDA had already signaled “not priority” in April, and in June had already flagged QuickColor sensitivity as below what they considered acceptable for the use as framed then.
---
### The October 2021 interactions (the four files you flagged)
#### Oct 4, 2021 — FloodLAMP escalates to leadership (email routed to Tim Stenzel)
FloodLAMP sent an email intended for Dr. Tim Stenzel via the FDA templates inbox, asking for a meeting and help avoiding another immediate deprioritization of the resubmitted EUAs.
FloodLAMP’s main points in that email:
* Positioned QuickColor (colorimetric LAMP) and EasyPCR (duplex RT-PCR) as **open protocol** tests using **TCEP + heat inactivation**, with claimed turnaround and throughput (e.g., “10K+/day without automation”), and stated LoDs (LAMP ~12,500 cp/mL; PCR ~3,000 cp/mL).
* Highlighted that earlier EUAs were deprioritized and the May pre-EUA was closed with only brief comments; requested leadership assistance so the resubmissions wouldn’t be “immediate denial of review.”
* Put major emphasis on **public health impact**: pooled home collection (family/exposure unit pooling), “test-to-stay,” low cost ($1–2/person), and ability to scale through manufacturing partners.
* Cited **non-diagnostic surveillance deployments** (5 sites/3 states, ~800 pools, ~2,300 people screened, positives detected/confirmed, and “no known or suspected false negatives”).
* Asked for FDA guidance on CLIA lab expansion / near-site testing and how surveillance programs might coexist with EUA-authorized clinical testing.
#### Oct 13, 2021 — FDA requests additional information + offers a Zoom call
There are two distinct FDA communications on Oct 13:
1. **Lead reviewer email attaching the “Additional Information” letter**
FDA (lead reviewer Liang Li) sent FloodLAMP a formal letter requesting additional information for EUA210582.
2. **Follow-up email offering a 30-minute Zoom meeting the next day**
The same reviewer offered a quick Zoom slot to discuss the submission.
##### What FDA’s Oct 13 “Additional Information” letter actually says
This is the most detailed, “technical deficiencies” document in the October set. It asserts that FloodLAMP had not provided complete information adequate to validate the test and support the claimed performance characteristics, and it lays out deficiencies in six major areas (I’m summarizing, not reproducing the whole letter).
**(1) Clinical evaluation problems** (FDA’s “big bucket”)
* **Intended-use population not described**: FDA couldn’t tell whether the study samples came from the intended population (people “suspected” by their HCP).
* **Specimen-type claims not supported**: FloodLAMP claimed multiple URT swab types (OP/NP/AN/mid-turbinate), but the study used AN swabs, and FDA stated NP is considered the most challenging matrix and expected for NP/general URT claims.
* **Performance below what FDA considered acceptable**: FDA cited FloodLAMP’s PPA/NPA (90% / 100%) and reiterated that FDA believes **95% PPA and NPA** is acceptable clinical performance for the intended use “as you proposed,” and that 90% PPA was below that.
* **No “low positive” / low viral load specimens** in the dataset as FDA defined them (Ct close to comparator LoD); FDA said without these they couldn’t assess performance appropriately.
* FDA asked for root-cause analysis, possible design changes, and potentially new validation if the device/procedure changes.
**(2) Inclusivity / variant analysis outdated**
* FDA said the in silico inclusivity analysis (done Feb 27, 2021) was no longer representative of circulating variants and asked for an updated analysis + risk assessment.
**(3) Cross-reactivity / microbial interference**
* FDA noted specific organisms that had high homology in silico but weren’t covered by wet testing, and asked for tabular in silico data and additional interference testing where needed.
**(4) Endogenous interfering substances**
* FDA said the tested substances were insufficient for common URT cold remedies and listed additional recommended substances.
**(5) External controls**
* FDA recommended the positive control be “challenging” (low positive, <5x LoD) and said the described control (~8x LoD) wasn’t adequate; requested validation data.
**(6) RUO reagents**
* FDA said RUO components are not under 21 CFR Part 820 and therefore can vary; FDA said you may not recommend RUO-labeled materials as test components without additional mitigations, and they gave options (use IVD-labeled materials, qualify specific RUO lots and publish lot numbers, or bring materials under your own QMS by supplying them as kit components).
Finally, FDA set a very short turnaround (by Oct 15 noon ET) and stated that if the response was late or inadequate, they could remove the test from the notification listing and expect suspension of distribution.
(Your Oct 14 meeting notes indicate the written response deadline was effectively aligned to Oct 20 instead, which suggests there was at least some informal flexibility. )
#### Oct 14, 2021 — Zoom meeting (your notes)
Per the meeting notes:
* FDA raised concerns about the **open protocol / designation** concept; specifically, Silke asked about “designation” and “said they would not want us to make IFU publicly available.”
* FloodLAMP described a plan: initially deploy like SalivaDirect, later produce a full reagent kit.
* FloodLAMP communicated a request to **amend intended use** to serial screening only (removing “persons suspected of COVID”).
* FDA asked about data supporting intended population; FloodLAMP said samples were remnant, de-identified, no clinical info.
* FDA (Kris) referenced “6 criteria” for serial screening amendment and said risk-benefit differs for POC/at-home vs lab-based tests; also noted pipetting choices can affect whether something is “POC-like.”
* Anne Wyllie asked about validating with a blinded reference panel; Silke said the reference panel was no longer available.
#### Oct 20, 2021 — FloodLAMP responds (email + attached response letter)
FloodLAMP’s Oct 20 email to FDA explicitly frames the central issue as **risk-benefit**, and that FDA’s thinking (as FloodLAMP understood it) might be: serial-screening “streamlined” pathways don’t apply because this is a **lab** submission rather than POC. FloodLAMP also asked for the “6 criteria” Kris referenced, and reiterated the “open protocol + scalable colorimetric LAMP” impact argument.
FloodLAMP’s attached response letter (the separate Oct 20 response file) did several concrete things:
* **Formally requested intended-use amendment**: remove “persons suspected of COVID,” keep serial screening, and asked for guidance on appropriate screening frequency given performance data.
* **Narrowed specimen claim**: remove NP/OP; use nasal swabs only.
* **Disputed the performance bar for serial screening**: FloodLAMP stated its understanding that the PPA threshold for screening with serial testing is 80% and argued their analytical + clinical results exceeded many authorized antigen tests.
* Provided additional performance framing: noted only high-Ct samples failed in Stanford clinical evaluation; tied this to LoD; and again cited real-world pooled surveillance metrics (pools, people screened, positives found, “no known or suspected false negatives”).
* Said updates on variants/inclusivity would be provided; pushed back on some cross-reactivity assumptions as “PCR-like” rather than LAMP-specific; asked for guidance on interference list given sample-type/intended-use changes.
* On controls, argued the chosen positive-control concentration mirrored SalivaDirect and asked FDA to confirm suitability.
* On RUO reagents, said FloodLAMP would qualify specific lots and post lot numbers.
---
### The actual “shutdown”: what FDA said when it closed the file
Although you didn’t list Oct 21/Oct 29 as separate “October files,” they’re part of the same October correspondence record and they contain the **explicit closure rationale**.
#### Oct 21, 2021 — FDA final decision: EUA210582 closed
FDA told FloodLAMP the additional information “does not demonstrate” the device is adequately validated; the EUA was closed.
In the attached letter, FDA combined two themes:
1. **Substantive deficiency framing**
They said the submission did not adequately demonstrate the device is validated / safe and effective for intended use (implicitly referencing the prior deficiency list).
2. **Resource + prioritization framing (“why stop now”)**
FDA said: given the volume of EUA requests, FDA is prioritizing based on factors including public health need, availability, unmet need, and the adequacy of the information about likely safety/effectiveness; based on those factors, their review so far, and “anticipated resources needed to continue review,” further review was “not a priority,” and FDA declined to issue an EUA “at this time.”
So the closure is best read as: **(a) the file still had major gaps, and (b) closing it was also a triage decision about reviewer time.**
#### Oct 28–29, 2021 — FloodLAMP challenges whether the intended-use amendment was recognized; FDA replies
FloodLAMP pointed out that the closure letter still referenced the “suspected of COVID” intended use and asked FDA to confirm whether the amendment request was understood.
FDA replied that they **did understand** the intended-use amendment when they sent the deprioritization letter, but that FloodLAMP’s “current clinical study is not acceptable to support testing a screening population with serial testing,” and directed FloodLAMP back to the new molecular template or a pre-EUA amendment/supplement for study design feedback.
This matters because it suggests the amendment wasn’t the “unlock”; FDA’s decisive blocker (at least as stated in Oct 29) was **clinical-study acceptability for serial screening**, not merely the wording of intended use.
---
### FDA’s explicit justifications, boiled down
If you strip out tone and just list the agency’s stated reasons across the thread (April → June → Oct), the “why we shut this down” story has three layers:
#### 1) Deprioritization / triage due to pandemic phase + impact criteria
* April 2021: FDA explicitly said the test would have “relatively limited impact” on U.S. testing accessibility/capacity, so review was “not a priority,” and they closed the EUA.
* June 2021: FDA said they didn’t review the validation studies/data in the pre-EUA because of prioritization and closed the pre-EUA after providing limited guidance.
* Oct 2021: FDA again used prioritization language, adding that the “anticipated resources needed to continue review” factored into the decision to stop.
#### 2) “Not adequately validated” — with a very specific deficiency list
The Oct 13 letter reads like FDA saying: **to authorize this, we’d need a lot more (and different) evidence**—especially around clinical performance, intended use population, low viral load positives, and updated variant inclusivity.
#### 3) For serial screening specifically: “your clinical study isn’t acceptable”
Even after FloodLAMP tried to narrow intended use to serial screening and AN swabs, FDA’s Oct 29 email says directly: the current clinical study is not acceptable to support screening with serial testing.
---
### Reading between the lines: plausible “FDA-in-their-shoes” rationales
Everything below is explicitly **inference**—but I’m tying each hypothesis to something concrete in the record.
#### Hypothesis A: FDA saw this as a “high-effort file” with multiple major gaps, so they cut it to protect scarce reviewer capacity
Clues:
* The Oct 13 letter is not “one missing table”; it’s a multi-domain deficiency set (clinical population/specimens/performance, variants, interference, controls, RUO supply chain/QMS).
* On Oct 21, FDA explicitly referenced “anticipated resources needed to continue review” as part of why further review was not a priority.
Interpretation:
* Even if the test might ultimately be authorizable, FDA likely perceived that getting to “yes” would require **new clinical work + multiple analytical studies + QMS/controls/supplier mitigation**, i.e., a lot of back-and-forth. Under triage pressure, those files are the ones you close first.
#### Hypothesis B: The “serial screening pathway” you tried to use may have been treated as mainly justified by *accessibility gains* (POC/at-home), and FDA didn’t see the same benefit for a lab-based test—so the risk-benefit balance didn’t “buy down” the evidence requirements
Clues:
* Your Oct 20 email indicates FDA’s risk-benefit framing on the call sounded like: lab-based reduces benefit relative to POC/at-home.
* Meeting notes record Kris saying risk-benefit is different for POC/at-home vs lab-based tests, and referencing “6 criteria” for serial screening amendment.
Interpretation:
* FDA may have built the serial-screening indication to enable *more testing where testing otherwise wouldn’t happen* (especially at home/near patient), accepting different tradeoffs. If your test still requires a CLIA lab workflow (even if instrument-free), FDA may have categorized it as “not the kind of accessibility expansion that justifies a lower bar.”
#### Hypothesis C: FDA likely discounted your “surveillance deployments” evidence because it wasn’t in the clinical validation form they rely on for EUA decisions (and because it was explicitly non-diagnostic)
Clues:
* You repeatedly offered real-world screening metrics (Oct 4 email and Oct 20 response).
* FDA’s deficiency focus stayed anchored to classic EUA validation constructs: defined intended-use population, comparator-based clinical agreement, low viral load positives, etc.
Interpretation:
* Even genuinely strong field performance can be hard for FDA to credit if it’s not (a) prospectively designed, (b) comparator-grounded in the required way, and (c) clearly within the exact intended use. It may still be persuasive as “supporting evidence,” but not as a substitute for the missing validation pieces FDA flagged.
#### Hypothesis D: QuickColor’s clinical sensitivity and “challenging positives” problem was the real immovable object
Clues:
* In June 2021 FDA already told you QuickColor’s PPA was below what FDA considered acceptable (95%) for the use as framed there, and they did not recommend pursuing unless sensitivity improved.
* In Oct 2021 FDA again emphasized: PPA 90% vs the 95% they “believe is acceptable,” plus no low viral load specimens.
* In Oct 29 FDA said your current clinical study is not acceptable for serial screening.
Interpretation:
* From FDA’s perspective, **false negatives in asymptomatic screening** can have outsized public-health consequences, and they may have judged that (i) 90% PPA plus (ii) a dataset without low viral load positives equals “we cannot responsibly authorize this” without substantial additional work.
#### Hypothesis E: The “open protocol” posture created extra regulatory discomfort: uncontrolled replication + RUO quality + stewardship/designation issues
Clues:
* Your Oct 14 notes: FDA did not want IFU publicly available; asked about designation; this is directly about governance/control of an “open protocol” approach.
* The Oct 13 letter is unusually explicit about RUO reagents and the quality-system implications, and requires a mitigation route.
* The open-EUAs context file underscores that “open EUA” is not just publishing a protocol—it’s an authorization + stewardship pattern with lab designation burdens and supply chain validation complexities.
Interpretation:
* FDA may have been comfortable with SalivaDirect’s model (single steward, specific lab designation commitments, very clearly bounded method), but less comfortable with a commercial entity proposing “open protocol” + eventual kit commercialization + broad dissemination—especially if key inputs were RUO and if performance wasn’t already rock-solid.
* In other words: open can be a public-good feature, but to a regulator it can look like a **control problem** unless governance and quality controls are extremely crisp.
#### Hypothesis F: Timing/phase-of-pandemic thinking likely mattered—but not in the way people assume
Clues:
* FDA repeatedly referenced “different phase of the pandemic” and “many tests now authorized” when deprioritizing.
* Your own internal commentary notes the experience felt like blanket deprioritization and triage driven by staffing/resource constraints.
Interpretation:
* It’s plausible FDA, in Oct 2021, believed the U.S. already had adequate diagnostic molecular capacity and was trying to concentrate on (a) at-home/POC accessibility and (b) high-volume industrialized products, not additional lab-developed-like workflows—even if your workflow was cheaper and operationally elegant.
* This is consistent with your speculation about Omicron: in Oct 2021, they weren’t behaving like an agency preparing for a January 2022 demand shock; they were behaving like an agency trying to **wind down a crushing review backlog** under a “we have enough tests” narrative.
---
### A compact way to summarize “why they shut you down”
If you want a one-paragraph explanation that is faithful to the record **and** captures the implied logic:
FDA appears to have viewed FloodLAMP’s QuickColor EUA as (1) still **not adequately validated** for the claimed intended use—especially due to clinical study limitations (population not characterized, specimen claims not supported, PPA below FDA’s typical bar, and no low-viral-load positives) plus additional analytical/QMS issues (variants/inclusivity, interference, controls, RUO reagents)—and (2) **too resource-intensive** to continue reviewing in a late-2021 triage environment where FDA was prioritizing tests that most clearly expanded accessibility (POC/at-home) or capacity, so they closed the file as “not a priority” rather than continue iterative review.
---
If you want, I can also do a second pass that’s more “forensic,” where I map **each** FDA deficiency (Oct 13 letter items 1–6) to (a) what you offered in the Oct 20 response, (b) what FDA implicitly accepted vs didn’t address, and (c) which items likely triggered “new clinical study required” vs “straightforward paperwork/testing.”
# 1,525 _context-commentary_regulatory-fl-fda-correspondence.md
METADATA
last updated: 2026-03-02 RT
file_name: _context-commentary_regulatory-fl-fda-correspondence.md
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CONTENT
## Context
This subcategory contains FloodLAMP's direct correspondence with the FDA regarding its SARS-CoV-2 diagnostic test EUA submissions, spanning from October 2020 through October 2021. The files include pre-EUA requests, emails to FDA leadership, FDA deficiency letters, meeting notes, FloodLAMP's written responses, and the deprioritization/closure letters that ended FloodLAMP's EUA pursuit. For the submission documents themselves and technical background on the EUA process, see `regulatory/fl-fda-submissions/_context-commentary_regulatory-fl-fda-submissions.md`.
During the COVID-19 pandemic, the FDA's Center for Devices and Radiological Health (CDRH) managed EUA requests for diagnostic tests through a process that evolved substantially as submission volume grew. Communication between the FDA and test developers typically occurred through a combination of formal letters (deficiency notices, final decisions), email exchanges with assigned reviewers, optional pre-EUA feedback, and periodic virtual town halls open to the broader developer community. The FDA also offered short interactive review meetings — typically 30 minutes — to discuss specific submission issues.
For developers seeking EUAs, the process began with either a pre-EUA submission (to get preliminary feedback before a full filing) or a direct EUA submission. The FDA would then triage the submission based on prioritization factors — primarily whether the test would increase testing accessibility (point-of-care, at-home) or significantly expand testing capacity (high-throughput, high-volume manufacturing). Beginning in fall 2020, the FDA formalized a deprioritization system that included two mechanisms: "Decline to Review" for low-priority submissions and "Decline to Issue" for submissions with unresolved critical deficiencies. By September 30, 2021, the FDA had declined to review 558 EUA requests for COVID-19 tests. For more on deprioritization, see the companion research report `regulatory/fl-fda-correspondence/_AI_FDA Deprioritization of COVID-19 Diagnostic EUAs.md`.
FloodLAMP's correspondence documents the full arc of engagement with the FDA: early encouragement from OIVD Director Tim Stenzel on the open-source protocol approach (December 2020), initial EUA submissions and immediate deprioritization (March–April 2021), a pre-EUA that the FDA closed without reviewing the validation data (May–June 2021), a direct appeal to FDA leadership with real-world surveillance data (October 4, 2021), a 6-deficiency letter followed by a 30-minute Zoom meeting and written response (October 13–20, 2021), and final closure one day after FloodLAMP's response (October 21, 2021). The correspondence with the FDA on FloodLAMP's open-source EUA submissions is closely connected to two other regulatory subcategories: the FDA town halls (`regulatory/fda-townhalls`) where FloodLAMP engaged FDA leadership publicly, and the open EUAs concept (`regulatory/open-euas`) that was central to FloodLAMP's regulatory strategy.
## Commentary
FloodLAMP's experience with the FDA during the COVID-19 pandemic was defined by a persistent inability to obtain meaningful regulatory engagement on submissions that, by the FDA's own stated criteria, should have warranted review. The company developed a validated, instrument-free, colorimetric RT-LAMP test at a cost of $1–2 per reaction, designed as an open-source protocol modeled on the SalivaDirect EUA. The test was adopted by EMS agencies and municipal fire departments for routine surveillance screening. Despite multiple submissions, real-world deployment data, and direct appeals to FDA leadership, FloodLAMP received blanket deprioritization along with hundreds of other test developers. Had a meaningful review, let alone an EUA, been obtained in the spring of 2021, the trajectory of the company would have been fundamentally different.
For a detailed factual reconstruction and analysis of the critical October 2021 correspondence sequence that ended FloodLAMP's EUA pursuit, see `regulatory/fl-fda-correspondence/_AI_FloodLAMP FDA October 2021 Correspondence Analysis.md`. That document covers the complete timeline from October 2020 through October 2021, the FDA's stated justifications, and multiple interpretive explanations of the FDA's rationale. For related commentary on the FDA town halls and the open EUA concept, see `regulatory/fda-townhalls/_context-commentary_regulatory-fda-townhalls.md` and `regulatory/open-euas/_context-commentary_regulatory-open-euas.md`.
The first direct interaction with the FDA set the tone for what followed. In a November 2020 phone call for the pre-EUA, the assigned reviewer had not heard of SalivaDirect, DetectaChem, or even LAMP as a technology. The reviewer strongly recommended against pursuing anything involving asymptomatic testing or pooling, and instead recommended the narrowest possible indication: a single symptomatic person suspected of COVID-19. This was the starting position from which FloodLAMP had to make its case for the open-source screening model.
The FDA's rationale for deprioritization consistently came back to being short-staffed and resource-constrained. These were real constraints. But the response to those constraints — blanket deprioritization — failed a basic policy test. At the point FloodLAMP was deprioritized, the country was more than a year into the pandemic. The question the FDA should have been asking was: "Will this decision result in less testing?" When the answer was yes, creative solutions were warranted. The FDA could have established streamlined review tracks for open-protocol tests, created batch review processes for submissions using validated primer sets, facilitated reference panels for small developers, or simply provided actionable feedback rather than closing files without reviewing the data. None of these were pursued. The ITAP (Independent Test Assessment Program) eventually emerged as a partial alternative pathway, but it had limited access and transparency.
The October 4, 2021 letter to OIVD Director Tim Stenzel stands as one of the best summaries of FloodLAMP's case for its test and its work. In that letter, FloodLAMP presented real-world surveillance data from five sites across three states, approximately 2,300 people screened in 800 pools with three unknown positives detected and no known false negatives, alongside manufacturing readiness (2 million tests on hand, 3 million more at LGC Biosearch), $1–2 per test pricing, and active commercial sites with EMS and fire departments. Stenzel never responded. The review team sent a 6-deficiency letter nine days later, offered a 30-minute Zoom call the following day, received a substantive written response on October 20, and issued a final closure on October 21. The speed of that closure, one day after FloodLAMP's response that proposed a narrowed intended use and addressed multiple deficiencies, suggests the outcome was predetermined and the interactive review seemed to be procedural rather than genuinely deliberative.
Five weeks after the FDA closed FloodLAMP's submission, the Omicron variant was reported. By January 2022, the United States experienced the worst testing shortage of the entire pandemic. The principle behind the deprioritization decision — that the country did not need more tests — was catastrophically wrong, and it was applied systematically to FloodLAMP and hundreds of other test developers.
# 736 2020-10-22_Email to FDA CDRH - Request for Guidance.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2020-10-22_Email to FDA CDRH - Request for Guidance.md
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summary_short: The Email to FDA CDRH - Request for Guidance (Oct 22, 2020) outlines FloodLAMP’s pre-EUA request to the FDA for feedback on validating a pooled SARS-CoV-2 RT-LAMP screening program, including proposed pooling levels, turnaround targets, and two assay configurations (fluorimetric and colorimetric) with preliminary LoD data. It’s useful as an early regulatory-facing snapshot of FloodLAMP’s technical approach, intended use in asymptomatic group screening, and the specific guidance and template updates they were seeking to shape an EUA-ready validation plan.
CONTENT
***INTERNAL TITLE:*** Pre-EUA email 10/22 sent to CDRH
FloodLAMP Biotechnologies is a Public Benefit Corporation with a mission to improve public health with scalable, low-cost infectious disease screening programs. Our near-term goal is to help end the COVID-19 crisis through widely accessible SARS-CoV-2 pooled screening. We are based in San Carlos, CA and are engaged in a number of collaborations with mission-driven individuals and organizations.
FloodLAMP is developing an integrated screening program consisting of efficient on-site and at-home pooled sample collection, combined with an ultra-low-cost, low-barrier-to-entry RT-LAMP assay protocol. The assay uses a chemical inactivation (TCEP/EDTA) and a bead purification step to achieve high sensitivity required for pooling. Amplification is via RT-LAMP, with 2 versions of the kit under development: 1) fluorimetric for real-time measurement on qPCR instruments and 2) colorimetric for endpoint visual and camera based readout. Preliminary LoD studies using Zeptometrix inactivated virions spiked into anterior nares swab extract have determined an LoD of 2 copies/ul for the colorimetric assay. We've run thousands of samples to date.
|Concentration (copies/μL)|Positive Samples Detected|
|---|---|
|4| 100% (22/22)|
|2| 100% (19/19)|
|1| 55% (11/20)|
||
Our sample collection materials and procedures are configured to pool up to 10 samples. We plan to pool to even higher levels by pooling pools of 10 in the lab. As a part of the pre-EUA process, we would greatly appreciate your guidance on determining appropriate pool levels and LoD targets for higher-level pooling.
Our screening program is designed for asymptomatic populations that participate in the program as a group, such as a school or employer. During the program's initial phase, all participants will be tested individually or at small pool levels that are appropriate for the estimated prevalence. Immediately following the initial phase, participants that have tested negative will commence ongoing pooled screening, with no more than 3 days between tests and less than 24 hour turnaround (target less than 12 hours). Dedicated lab capacity will be committed to ensure screening continuity and rapid turnaround time.
We understand that FloodLAMP's Screening Program and Test Kits comprise an ambitious plan. We are integrating several of the agency's priorities with the goal of unlocking mass, scalable screening for the U.S.
As a Public Benefit Corporation, we have explicitly committed to open protocols and the public good. We are already living that commitment through important collaborations and by publicly publishing our detailed protocols, workflow, and process videos. We will expand this material in support of our Test Kit IFU to facilitate rapid and reliable adoption of the FloodLAMP Screening Program at scale.
We at FloodLAMP are inspired by the Yale team's groundbreaking work on Saliva Direct - the first open protocol EUA. We plan to build upon their example of openness and accessibility as we seek authorization for the FloodLAMP IVD Test Kit.
We would greatly appreciate feedback and guidance from the FDA in determining a validation plan for the 2 assay configurations, as well as multiple reagent and supplier combinations.
We are using the following templates for our pre-EUA submission. We would greatly appreciate updated versions of these, if they are available.
July 28 Molecular Diagnostic Template for Commercial Manufacturers
July 28 Molecular Diagnostic Template for Laboratories
May 29 Home Specimen Collection Molecular Diagnostic
# 382 2020-11-10_Email to FDA Dir Tim Stenzel - FloodLAMP Pre-EUA.md
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last updated: 2026-03-05 by BA
file_name: 2020-11-10_Email to FDA Dir Tim Stenzel - FloodLAMP Pre-EUA.md
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summary_short: The Email to FDA Dir Tim Stenzel - FloodLAMP Pre-EUA (Nov 10, 2020) is an outreach note requesting a meeting to discuss FloodLAMP’s newly submitted pre-EUA for an ultra-low-cost, LAMP-based SARS-CoV-2 test and how an “open source” EUA model could be expanded beyond SalivaDirect. It highlights key regulatory topics FloodLAMP wanted to align on—especially asymptomatic screening, pooling, and on-site/at-home collection—and proposes forming a consortium of mission-driven developers to produce validated, open-access molecular tests.
CONTENT
*Sent to CDRH email address on Nov 10, received response saying it was forwarded to Tim Stenzel a few days later*
Dr. Stenzel,
I run FloodLAMP Biotechnologies, a Public Benefit Corporation. On Friday we submitted a pre-EUA for an ultra-low-cost, scalable, LAMP-based test based on the Rabe Cepko assay out of Harvard. We are intending to provide this as an \"open source\" protocol, inspired by Dr. Anne Wyllie and the SalivaDirect team. FloodLAMP is collaborating with Dr. Wyllie and Prof. Connie Cepko, who are on our Scientific Advisory Board.
Dr. Wyllie and I would greatly appreciate the chance to meet with you to discuss expanding the open source EUA approach, as well as several overlapping EUA issues for the SalivaDirect and FloodLAMP tests (asymptomatic screening, pooling, and on-site/at-home collection).
We are currently helping a third group who has submitted an EUA and is also seeking to provide their test as an open source protocol, and we continue to receive interest from yet more groups that are interested in taking this approach. Our goal is to build a consortium of like-minded, mission-driven test developers committed to bringing online a suite of properly validated and well supported open-access SARS-CoV-2 molecular tests. As SalivaDirect has shown, these molecular tests can be deployed in a scalable, non-proprietary way that is truly game-changing. We see the potential for these tests to become high-impact public goods, with far-reaching benefits both in pandemic preparedness and broader human health.
There's a lot of hard work to be done to achieve this ambitious goal, and we would like to discuss with you how to most efficiently proceed. Please let us know if you are available soon to discuss.
Best Regards
# 2,047 2020-12-09_FloodLAMP FDA Townhall Engagement on Open Source FDA IVD EUAs and Generic Molecular Tests.md
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summary_short: The “Dialogue on Open Source Testing and FDA IVD Authorization of Generic Molecular Tests” summarizes a December 9, 2020 FDA town hall exchange about using Rights of Reference and “method” EUAs (modeled on SalivaDirect) to enable interoperable, non-proprietary molecular test protocols across laboratories. It outlines how open IVD EUAs could reduce duplicative validation, strengthen supply-chain resilience, and scale testing via a structured lab designation process, positioning FloodLAMP’s strategy to expand this open-access paradigm beyond SalivaDirect.
CONTENT
***INTERNAL TITLE:*** Dialogue on Open Source Testing and FDA IVD Authorization of Generic Molecular Tests
12-9-2020 FDA Town Hall
## Can listen to the 7 minutes of audio [here](https://www.youtube.com/watch?v=-7K-zmy-ouU&t=300s)
## High Level Summary:
FDA authorizations for tests can be made completely open (so any lab can order the ingredients directly from suppliers) and interoperable (through Rights of Reference to the validation data). The potential of this open source/open access paradigm of testing is immense but almost totally unknown to government leadership. It has received no funding out of the billions that has been spent expanding the highly profitable, proprietary status quo of the diagnostics and clinical testing industry. Yet the FDA itself is fully aware of the potential for this open approach and embraced it with the [first "open source protocol" EUA SalivaDirect](https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-issues-emergency-use-authorization-yale-school-public-health). Part of FloodLAMP's mission is to quickly expand this paradigm to several more key open source EUAs, and in doing so unlock and massively expand testing in the United States.
## Transcript:
[**Randy True**](http://www.linkedin.com/in/randy-true-fof), Founder of [FloodLAMP Biotechnologies,](http://www.floodlamp.bio) a Public Benefit Corporation
randy@floodlamp.bio
[**Dr. Timothy Stenzel**](https://www.linkedin.com/in/timothy-stenzel-md-phd-20204521/), FDA Director, Office of In Vitro Diagnostics and Radiological Health
[05:00 Randy True](https://www.youtube.com/watch?v=-7K-zmy-ouU&t=300s): *FloodLAMP is coordinating with other open source test developers. If we establish a consolidated primer set and give a general right of reference, then we won't individually have to repeat certain aspects of the validation, correct? Want to understand that dynamic a bit more in terms of the inclusivity, in silico analysis, and the in silico cross-reactivity and the wet cross-reactivity. Can you give us guidance as we coordinate on this?*
[00:06:34 Dr. Timothy Stenzel, FDA](https://www.youtube.com/watch?v=-7K-zmy-ouU&t=394s): *Yeah, we've seen that is a pathway that could be very successful. Yale's SalivaDirect was the first.*
*As far as the data related to test performance, yes that can be leveraged in multiple ways. The two main ways are that if you seek your own authorization for the path, you can give a right of reference for anyone else who wants to copy you. That wouldn't eliminate the requirement for them--if they're a kit developer, say--for them to come in to get their own authorization. And it wouldn't extend the umbrella of an EUA authorization to any lab that might copy that method.*
*So, looking at the Saliva Direct model, they have in their original submission, they have an IFU that's the sole basis (so to speak) of their kit. And they point to off-the-shelf product that users can purchase. In the case of primers and probes for their test (I think it's the CDC's), they can get that from vendors that produce primary probes under the CDC authorization. So those are very specific catalog numbers, and those are primers and problems that we previously authorized.*
*So again, there's these two different pathways. I want to lay them out very clearly:*
*1) You can get your own, individual authorization for a kit. You can then give anybody (any other developer) the right of reference to that, and they can copy it, and they can pretty much link up and use the data in your submission. There are some elements that if they were to be changed, that we'd want to see. But if they're using the same suppliers and the same catalog numbers for everything that you're using, then that makes it very easy.*
*2) The other way is to have this method authorized, as we did for SalivaDirect. Then we would envision giving you (or any other sponsor) the same sort of flexibility. Yale is actually the one that designates which lab can use their method and are therefore covered by their EUA. And they have commitments to the FDA on what is required and making that determination of designation. And my understanding is they've designated quite a few labs already, and I would refer you to them if anybody wants to know those numbers, but it appears to be a very highly successful program.*
[10:18 Randy True](https://www.youtube.com/watch?v=-7K-zmy-ouU&t=618s): *Yeah, they've been our inspiration for this modality and effort. I guess just one quick follow-up question: So if we get authorization for a test with a certain lysis or inactivation buffer and a certain purification... Like, we're pursuing an ultra-cheap glass milk purification, but we're working with another test developer who is seeking authorization for a magbead based purification that would be highly amenable to automation. If we consolidated on the same primer set and LAMP master mix, then it's my understanding they wouldn't need to repeat the upfront parts. But with respect to the interfering substances, would they need to repeat that? And then if we gave them a general right of reference, then they would end up getting their own EUA that they could control the designations on, and then we would have our own, independent EUA that we controlled the designations on, even though we granted a right of reference. Is that how it would work?*
[11:30 Tim Stenzel, FDA](https://www.youtube.com/watch?v=-7K-zmy-ouU&t=690s): *At a high level you're close. The devil is sometimes in the details. There are certain alterations to a test that may require additional validation. So if they're adding something new that you didn't do, say, then we would want to evaluate the data around that change. And then absolutely developers can give each other right of references as they so wish. They can specify what right they have from their entire EUA--they can have limitations, or they can open it up entirely. But you can basically cross-reference each other's assays to the extent that you want. And there would absolutely be synergy. And if the components are all the same that you use for the core test, then there would absolutely be synergy on reducing any sort of duplication. I look forward to hearing more about your development.*
## Commentary
SalivaDirect is still the only open source IVD EUA. The potential of this new paradigm of testing that's open access, low cost, and supply chain robust, still has not been tapped. Essentially it's "generic" molecular testing. The vast majority of tests are slight variations on a few core protocols. But those are silo'd for commercial reasons. Even with the FDA submission or validation of tests developed at universities, these tests, because they are LDTs not IVDs, are not transferable to another lab and usually face supply chain shortages.
*What's the solution*?
- Several key open source IVD EUAs
- The standardized supply chain to support these tests
- The team and funding to support the lab designation process to rapidly scale
We are coordinating on the standard primers for LAMP and will give a blanket Right of Reference with the first open LAMP EUA, just as the CDC did for PCR. FloodLAMP is in discussions with manufacturers to secure a production scale supply that can be offered at scale with fast turnaround and low cost. The LAMP primer ROR can then be used by both IVD and EUA submissions, and would be available for non-CLIA surveillance testing.
The cross referencing capability Tim Stenzel describes is not well known outside of the industry, as molecular Dx companies (aka IVD Kit Manufacturers) don't openly give these Rights of Reference. They keep the ingredients of their tests trade secret, even when they are the exact same formulation as off-the-shelf RUO products.
The "designation" of labs for an open source IVD EUA is a new process. SalivaDirect has been a big success but they've only been able to designate about 50 of 400+ labs that have requested to use the EUA, over 4 months. That's because of the Yale team's limited resources and the bureaucratic nature of academic institutions. FloodLAMP will build an organization to rapidly designate hundreds of labs.
The simple fact that EUAs can be made fully open is very powerful. This seems to be entirely absent from proposals to quickly scale up testing in the U.S. Wyllie and Grubaugh have created the model with SalivaDirect. It will be far better to not get the next open IVD EUAs through universities because of their institutional bureaucratic nature and their top prioritization of publications, branding and credit. FloodLAMP, a public benefit corporation, is seeking several open EUAs, having filed a pre-EUA on one LAMP test so far.. FloodLAMP is executing on several fronts: technical and scientific, regulatory, the commercial supply chain, and legal aspects. We've built the knowledge and relationships to make generic molecular testing a reality, in Q1 of 2021. FloodLAMP is seeking capital from sources that support our public good mission. Instead of yet another proprietary test that will barely make a dent in the nation's testing capacity, our "product" is a new paradigm of low cost, widely accessible generic molecular testing. This will have great positive impact on the COVID crisis, and has longer term benefits in healthcare more generally.
# 716 2021-03-22_Cover Letter to FDA - FloodLAMP Open Source EUA Submissions.md
METADATA
last updated: 2025-12-16 BA updated metadata after BA fixed inconsistencies
file_name: 2021-03-22_Cover Letter to FDA - FloodLAMP Open Source EUA Submissions.md
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summary_short: The Cover Letter to FDA for FloodLAMP Open Source EUA Submissions summarizes FloodLAMP’s follow-up to a pre-EUA with two full EUA submissions: the QuickColor colorimetric LAMP test and the EasyPCR duplex PCR test, both using a shelf-stable chemical plus heat inactivation workflow. It positions the assays as open-source, supply-chain-resilient protocols (modeled on SalivaDirect) and highlights primer sourcing, clinical performance claims, intended screening use cases, and supporting plans for IRB studies and a companion mobile app.
CONTENT
Dear COVID19DX IVD Team,
I'm pleased to follow up on FloodLAMP Biotechnologies' pre-EUA PEUA201985 with 2 complete COVID-19 IVD EUA submissions. Thank you for the extensive comments and guidance on the pre-EUA.
These new submissions are for direct tests rather than the glass milk purification from our pre-EUA. Both tests utilize the same shelf stable chemical plus heat inactivation protocol. The FloodLAMP QuickColor(TM) COVID-19 Test uses a colorimetric LAMP amplification that is visually read by a simple color change. The FloodLAMP EasyPCR(TM) COVID-19 Test uses a one-step PCR amplification in duplex with an internal control.
Both EUA submissions are configured as open source protocols, building on the model established by SalivaDirect(TM). The chemicals and reagents needed for the tests are readily available in large quantities. The workflow for the tests has been simplified and only a single pipet tip per sample is required, further reducing potential supply chain bottlenecks.
The LAMP primers chosen target 3 different genes in SARS-CoV-2 to ensure robustness and sensitivity. These primer sequences have been widely validated in research, utilized in testing programs, and submitted in other LAMP EUAs. Over the last 3 months, FloodLAMP has partnered with LGC Biosearch to establish the supply of these primers. FloodLAMP configured the primers to be offered as a catalog product by LGC Bioserach, and placed an order for 1.2M reactions in January. A portion of the production primers were delivered to FloodLAMP's lab on March 19. The other portion will be launched shortly as catalog products. With the support of the CDC and FDA, with authorization of our tests, FloodLAMP will offer a blanket right of reference to the LAMP primer validation data for any IVD test developer or CLIA lab, in an effort to further expand access to COVID-19 testing and screening.
The FloodLAMP QuickColor(TM) COVID-19 Test demonstrated 90% sensitivity and 100% specificity in our clinical evaluation. It is ideal for use in serial screening of schools and large populations, as no specialized instrumentation is required. Both tests have very low consumables cost, at $1-2 per reaction, and a modestly trained operator can process 800 reactions per shift without any automation.
FloodLAMP is in the process of obtaining an IRB to perform clinical studies for unsupervised home collection, pooling, and asymptomatic screening. The clinical studies will include usability testing for our mobile app. The app has a patient interface for sign up, consent, sample collection and results. It also has a staff interface for sample intake, barcode scanning, batch control, and results reporting, as well as an api to interface with any LIMS. The app enables accessioning and results reporting without a LIMS, providing a low overhead end-to-end digital solution for a lab running community screening.
FloodLAMP's EUA submissions for these 2 molecular tests provide a combination of performance, ease of use, supply chain robustness, low cost, and scalability. Along with the other testing and screening program elements we've developed, they will significantly increase test capacity and access across the nation.
We look forward to further engaging with the FDA on this important effort.
Sincerely,
Randy True
Founder - FloodLAMP Biotechnologies, Public Benefit Corporation
randy@floodlamp.bio
# 1,309 2021-04-02_FloodLAMP FDA Correspondence - Deprioritization EUA210252 EUA210254.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-04-02_FloodLAMP FDA Correspondence - Deprioritization EUA210252 EUA210254.md
file_date: 2021-04-02
title: FloodLAMP FDA Correspondence - Deprioritization EUA210252 EUA210254
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summary_short: The April 2, 2021 FDA email and attached deprioritization letter notify FloodLAMP that EUA210252 (QuickColor COVID-19 Test) was closed because FDA declined to review it under then-current prioritization criteria. It explains that, in a later phase of the pandemic with many tests already authorized, FDA prioritized requests expected to materially increase U.S. testing accessibility (e.g., POC, home collection, at-home) or capacity (e.g., high-throughput), and judged FloodLAMP’s submission as having relatively limited impact on those factors. The document also notes the same decision and attachment were issued for a related EUA request (EUA210254).
CONTENT
***INTERNAL TITLE:*** 2021-04-02_Email from FDA - Final Decision and Deprioritization
## Email Header
from: Walia, Vijay <Vijay.Walia@fda.hhs.gov>
to: "randy@floodlamp.bio" <randy@floodlamp.bio>
cc: "Caposino, Paula" <Paula.Caposino@fda.hhs.gov>,
"St. Pierre, Don J." <don.st.pierre@fda.hhs.gov>,
"Roth, Kristian" <Kristian.Roth@fda.hhs.gov>,
oir-policy <CDRH-OIR-POPS@fda.hhs.gov>,
"EUA210252@docs.fda.gov" <EUA210252@docs.fda.gov>
date: Apr 2, 2021, 1:18 PM
subject: Final Decision for EUA210252 Request – letter attached
## Email Body
Dear Randall J. True,
Please see attached letter regarding your EUA request, EUA210252. This is the final decision on your EUA request, and your EUA is now closed.
The reason for our decision is that we are currently in a different phase of the pandemic with respect to tests than we were previously, where many COVID-19 tests are now authorized. We prioritize review of EUA requests for tests taking into account a variety of factors, as discussed in the [Emergency Use Authorization of Medical Products and Related Authorities Guidance](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities), such as the public health need for the product and the availability of the product. We have, for example, prioritized review of EUA requests for tests where authorization would increase testing accessibility (e.g., point of care (POC) tests, home collection tests, and at-home tests) or would significantly increase testing capacity (e.g., high-throughput tests).
Regarding your request, FDA determined that review of your EUA request is not a priority because, for example, authorization of the test would have relatively limited impact on testing accessibility or testing capacity in the United States.
For additional information on FDA's priorities with respect to review of EUA requests for COVID-19 tests, see our website’s [FAQs on Testing for SARS-CoV-2](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2#5f9fefc60116f).
Please confirm receipt of this email and attached letter.
Thank you,
Best Regards,
Vijay
**Vijay Walia PhD MBA**
*Scientific Reviewer*
**Division of Chemistry and Toxicology Devices \| OHT7: Office of In Vitro Diagnostics and Radiological Health
Office of Product Evaluation and Quality**
**CDRH \| U.S. FDA **
White Oak, Bldg 66
10903 New Hampshire Ave., Silver Spring, MD 20993
Vijay.Walia@fda.hhs.gov
P: (301) 796-6139
## ATTACHMENT: EUA210252.IVD Deprioritization Letter_Decline to Review - FINAL (DJS).pdf
(text from attached pdf copied below - Same Email and Attachment for EUA210254)
April 2, 2021
Randall J. True
o/b/o FloodLAMP Biotechnologies, a DE Public Benefit Corporation
4860 Alpine Rd.
Portola Valley, CA 94028
Re: EUA210252
Dear Randall J. True:
This letter is in response to your request for an Emergency Use Authorization (EUA) for the
FloodLAMP QuickColor COVID-19 Test, intended for the following use(s): for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests.
Given the volume of EUA requests the Agency has received, FDA is prioritizing review of EUA
requests for tests, taking into account a variety of factors such as the public health need for the product and the availability of the product.(1) Based on your request, FDA has determined that review of your EUA request is not a priority(2) because, for example, authorization of the test would have relatively limited impact on testing accessibility or testing capacity. FDA therefore declines to review the EUA request for the product at this time.
This test has not been authorized to be distributed or used as proposed. FDA is committed to doing everything possible to help combat the COVID-19 outbreak and appreciates your efforts in this matter.
Sincerely,
Donald J. St.Pierre
Deputy Director, New Product Evaluation
OHT7:Office of In Vitro Diagnostics and
Radiological Health
Office of Product Evaluation and Quality
Center for Devices and Radiological Health
Food and Drug Administration
(1) For example, the agency has prioritized review of EUA requests for tests where authorization would increase testing accessibility (e.g., point of care (POC) tests, home collection tests, at-home tests) or would significantly increase testing
capacity (e.g., tests that reduce reliance on test supplies, high-throughput, widely distributed tests). See
[https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-test-development-and-review-faqs-testing-sars-cov-2#priorities](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-test-development-and-review-faqs-testing-sars-cov-2#priorities).
(2) FDA’s current thinking on prioritization of EUA requests is explained in FDA’s guidance, “Emergency Use Authorization for Medical Products and Related Authorities,” available at [https://www.fda.gov/media/97321/download](https://www.fda.gov/media/97321/download).
# 3,507 2021-06-17_FDA Correspondence Summary - Pre-EUA PEUA210313.md
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summary_short: The Pre-EUA (PEUA210313) record compiles FloodLAMP’s May 18, 2021 submission package for QuickColor and EasyPCR tests plus a pooled DTC dry-swab home collection kit and mobile app, submitted after earlier EUA deprioritization. FDA’s June 17, 2021 response states the agency did not review FloodLAMP’s validation data due to prioritization, but provides targeted guidance on study design (e.g., specimen adequacy/usability should be supported by the specific test, and self-collection studies should exclude participants with prior anterior nasal swab experience) and recommends using highly sensitive EUA RT-PCR comparators and ensuring enough low-viral-load positives; it also flags QuickColor’s clinical PPA as below the ~95% agreement level FDA considered acceptable and closes the pre-EUA. The October 5, 2021 follow-up email from FloodLAMP requests an interactive review to clarify serial-screening sensitivity expectations, usability and post-authorization study requirements, and prioritization, citing field surveillance deployment metrics and an open-protocol, low-cost scale-up approach.
CONTENT
## 2021-05-18_Pre-EUA Documents Submitted to FDA CDRH as Attachments
IFU - FloodLAMP Pooled Swab Collection Kit DTC.pdf
Instructions for Use - FloodLAMP EasyPCR COVID-19 Test.pdf
Instructions for Use - FloodLAMP QuickColor COVID-19 Test.pdf
Pre-EUA - FloodLAMP EasyPCR COVID-19 Test
Pre-EUA - FloodLAMP Pooled Swab Collection DTC
Pre-EUA - FloodLAMP Pooled Swab Collection Kit DTC.zip
Pre-EUA - FloodLAMP Proposed Pooling and Asymptomatic Screening Study
Pre-EUA - FloodLAMP QuickColor COVID-19 Test
Supporting Data - FloodLAMP EasyPCR COVID-19 Test.xlsx
Supporting Data - FloodLAMP QuickColor COVID-19 Test.xlsx
The Submission, IFU, and Supporting Data documents for the QuickColor and EasyPCR tests are the same as submitted on 3-22-21, which the FDA replied with a Deprioritization (denial to review).
## 2021-06-17_Email from FDA re FloodLAMP Pre-EUA
Povinelli, Benjamin <[Benjamin.Povinelli@fda.hhs.gov](mailto:Benjamin.Povinelli@fda.hhs.gov)> - postdoc at Oxford
to: "randy@floodlamp.bio" <randy@floodlamp.bio>
cc: "Caposino, Paula" <[Paula.Caposino@fda.hhs.gov](mailto:Paula.Caposino@fda.hhs.gov)>, - FDA reviewer for 13 years
"St. Pierre, Don J." <[don.st.pierre@fda.hhs.gov](mailto:don.st.pierre@fda.hhs.gov)>, - Associate Director, OIVD at FDA
"Roth, Kristian" <[Kristian.Roth@fda.hhs.gov](mailto:Kristian.Roth@fda.hhs.gov)>, - Supervisory Chemist - FDA/CDRH/OIR/ oir-policy <CDRH-OIR-POPS@fda.hhs.gov>,
"PEUA210313@docs.fda.gov" <PEUA210313@docs.fda.gov>
date: Jun 17, 2021, 8:06 AM subject: RE PEUA210313 signed-by: fda.hhs.gov
Good afternoon. Thank you for your pre-EUA submission, PEUA210313. As described in the U.S. Food and Drug Administration’s (FDA or Agency) guidance, “Emergency Use Authorization for Medical Products and Related Authorities,” available at [https://www.fda.gov/media/97321/download](https://www.fda.gov/media/97321/download), FDA prioritizes its pre-EUA activities based on a variety of factors. Given the volume of pre-EUA and EUA requests the Agency has received, we have not reviewed the validation studies nor the data provided in this pre-EUA but we provide some general recommendations below. We found 2 specific questions in your request and we provide answers below:
- Is it acceptable to utilize the FloodLAMP EasyPCRTM COVID-19 Test for determining the pass/fail of specimen adequacy? No, these studies should be designed to support the usability of the test that is subject of the EUA.
- Is it acceptable to strike this exclusion \[regarding self-collection\] since self-collection has become much more widespread? No. FDA recommends that participants in self-collection studies should be excluded if they have prior experience with the sample type (anterior nasal swabs). You may include participants with experience in other self-collection sample types.
In this request, you provided information on the following devices:
1\. FloodLAMP QuickColorTM COVID-19 Test for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week.
2\. The FloodLAMP Pooled Swab Collection Kit DTC is a direct to consumer (DTC) product for self-collecting pooled anterior nasal swabs in a dry tube at home (which includes a community based setting), including individuals without symptoms or other reasons to suspect COVID-19. Specimens collected using the FloodLAMP Pooled Swab Collection Kit DTC are transported at ambient temperature for testing at a laboratory.
3\. FloodLAMP EasyPCRTM COVID-19 Test is a real-time reverse transcriptase polymerase chain reaction (RT-PCR) assay intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when such individuals are tested as part of a testing program that includes testing at regular intervals, at least once per week.
We recommend you refer to the following resources. After reviewing the resources below, if you decide to submit EUAs for each of the tests, please submit your complete requests with information and data adequate to support that your device is validated for its intended use and meets the criteria for issuance of an EUA under Section 564 of the Federal Food Drug and Cosmetic Act. To help facilitate the preparation, submission, and review of your EUA request, we recommend that you use the applicable template (see links below) and that you provide all of the information recommended in the template(s) to support all claims.
- Policy for Coronavirus Disease-2019 Tests. This guidance includes reference to molecular diagnostic templates that include FDA’s recommendations for performance validation testing for SARS-CoV-2 molecular diagnostic tests.
- The templates referenced in the guidance can be found here: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas) . The direct link to the molecular diagnostic template can be found here: [Molecular Diagnostic Template for Commercial Manufacturers](https://www.fda.gov/media/135900/download) (updated July 28, 2020). This template includes all of our comprehensive recommendations on the types of information to provide to support most of your claims. For our recommendations on studies designed to support home collection (i.e., DTC testing), please see our [Home Specimen Collection Molecular Diagnostic Template](https://www.fda.gov/media/138412/download) (May 29, 2020).
- As discussed in our templates, we recommend using only a high sensitivity EUA RT-PCR assay which uses a chemical lysis step followed by solid phase extraction of nucleic acid (e.g., silica bead extraction) as a comparator for the clinical evaluation. We recommend selecting a comparator assay that has established high sensitivity with an internationally recognized standard or FDA SARS-CoV-2 Reference Panel. We refer you to [https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-reference-panel-comparative-data](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/sars-cov-2-reference-panel-comparative-data) and recommend that you select a comparator that is highly sensitive. You propose to use the Panther Fusion SARS-CoV-2 Assay and the Aptima SARS-CoV-2 assays as comparators. These have been shown to be highly sensitive using **nasopharyngeal swabs** collected and transported in media as per the Instructions for Use of each EUA. If you need to select a different comparator, we recommend that you confirm the suitability of the comparator with us through CDRH-EUA-Templates@fda.hhs.gov. In addition, you should ensure that your data set includes an adequate number of challenging/low viral load specimens (20-25% of positives) as defined as those having Ct values within 2-3 cycles of the average Ct at the limit of detection for a given target as based on comparator testing with an appropriately sensitive EUA test. Furthermore, please ensure your comparator test is run as authorized/without any modifications.
- As stated in our template, FDA believes a minimum of 95% positive and negative agreement is acceptable clinical performance. The FloodLAMP QuickColorTM COVID-19 Test demonstrated a lower PPA than what FDA believes is acceptable for this use. Therefore, we do not recommend pursuing an EUA for this test unless you can improve its sensitivity.
- If you plan to include or recommend the use of components that are currently labeled for Research-Use-Only (RUO), we offer the following recommendations. Since RUO components are not designed for clinical testing they should not be used for patient testing without additional mitigations. Further, while some requirements for products are waived during the duration of this EUA, some are not waived and these include parts of 21 CFR 820 (e.g., acceptance activities), and parts of 21 CFR 809.10 (labeling). In your EUA requests, please provide information on how you will mitigate the risks of using or recommending the use of RUO components for example by demonstrating how you will meet these conditions of emergency use authorization for any component needed for your testing that is currently labeled RUO.
- The list of previously issued EUAs for in vitro diagnostic products, which includes previously issued EUAs for SARS-CoV-2 molecular diagnostic tests with claims similar to yours, found here: [https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas](https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas). The instructions for use for devices from test kit manufacturers for which an EUA has been issued are made available and can help you understand the data provided from other manufacturers to demonstrate that their SARS-CoV-2 molecular diagnostic test was adequately validated and support issuance of an EUA.
- For our recommendations on evaluating the potential impact of emerging and future viral mutations of SARS-CoV-2 on COVID-19 tests, we refer you to the following guidance document: Policy for Evaluating Impact of Viral Mutations on COVID-19 tests.
- FAQs on Testing for SARS-CoV-2, that includes frequently asked questions on test development and review, test settings and test uses.
- Virtual Town Hall Series, which takes place every Wednesday from 12:15 pm to 1:15 pm. The purpose of the Virtual Town Hall Series is to help answer technical questions about the development and validation of tests for SARS-CoV-2.
- Lastly, please be advised that FDA is prioritizing review of all EUA requests for tests, taking into account a variety of factors such as the **public health need for the product and the availability of the product**. See [https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-test-development-and-review-faqs-testing-sars-cov-2#priorities](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-test-development-and-review-faqs-testing-sars-cov-2#priorities). Based on the information provided in the request, we cannot determine if all of your tests would meet our highest review priorities.
Upon issuance of this feedback, this pre-EUA is now closed. We look forward to working with you if you decide to submit an EUA request for this device.
## 2021-10-05_Email from FloodLAMP to FDA re Pre-EUA
from: Randy True <randy@floodlamp.bio>
to: "Povinelli, Benjamin" <Benjamin.Povinelli@fda.hhs.gov>
cc: "St. Pierre, Don J." <don.st.pierre@fda.hhs.gov>,
oir-policy <CDRH-OIR-POPS@fda.hhs.gov>,
"PEUA210313@docs.fda.gov" <PEUA210313@docs.fda.gov>
date: Oct 5, 2021, 11:28 AM
subject: Re: RE PEUA210313
Dear Ben, Don,
Thank you for your team's reply to our Pre-EUA in June. I'm following up and would like to request an interactive review in order to obtain guidance on a number of issues, including:
- sensitivity requirement for serial screening indication, in light of our analytical and clinical sensitivity performance data;
- usability study requirements for HCP observed, at-home collection, and DTC;
- post authorization asymptomatic and pooling studies;
- current prioritization in light of our test characteristics, manufacturing capability, and potential for widespread adoption of our QuickColorTM LAMP and EasyPCRTM open protocol EUAs.
Our tests, especially the QuickColorTM LAMP test, have the potential for high impact if authorized. Being open protocol EUA submissions, we are leveraging existing very high volume manufacturing capacity of leading supply partners in the space such as New England Biolabs and LGC Biosearch. The combination of ultra low price point and quick turnaround times enable our tests to materially impact the adoption and effectiveness of testing programs in the U.S. For example, the [Test-to-Stay model](https://www.nytimes.com/2021/09/19/health/coronavirus-school-quarantine-testing.html) to avoid school closures and quarantines is being deployed in many states, but is much more testing resource intensive than standard programs. Authorization of our tests would increase access to the Test-to-Stay model and stretch funding for testing much further. Along with our mobile app and at-home/on-site pcollection kits, FloodLAMP screening programs have distinct advantages over both rapid antigen and central lab PCR programs, with respect to sensitivity and turnaround time.
For a Pre-EUA (PEUA201985) we filed last November, we had a lead reviewer assigned (Dun Liang) and had a helpful phone call with him. In January we received a detailed review of that Pre-EUA. This process was very helpful in proceeding on the validation work and preparation of our full EUA submissions. We're hoping for a similar process here. With the added complexity of the asymptomatic indication, pooling, pooled collection and app integration, it would be helpful to obtain guidance on the studies before proceeding. We recently resubmitted EUAs for our EasyPCRTM and QuickColorTM LAMP tests (EUA210581 and EUA210582), for the persons suspected of COVID and serial screening indications, and are seeking priority review. We would like to be engaged with the interactive Pre-EUA process in parallel to the full EUA review. We would include on the call our regulatory consultant and also our scientific advisor, Dr. Anne Wyllie (developer of SalivaDirectTM).
In support of some elements of our pre-EUA, we'd like to share the real world success of non-diagnostic surveillance deployments of our QuickColorTM LAMP test. This includes to date:
- 5 sites in 3 states;
- testing at an EMS leadership conference, youth summer camp, and municipal fire departments;
- 11 staff trained to run the test, 5 non-technical staff;
- approximately 800 pools run (reactions);
- approximately 2,300 people screened;
- use of our FloodLAMP Mobile App by 84 users to register on-site and at-home pooled collections;
- 3 unknown positives detected and confirmed by reflex diagnostic test;
- 26 known positives confirmed;
- no known or suspected false negatives.
We currently have 2 commercial sites operating, performing routine testing of EMS and municipal staff. Both are in the process of scaling up to screen 1,000+ people at least weekly and expand to support broader community testing including schools and workplaces.
Please let me know if you have any questions and if there's anything we can do to facilitate this process.
Best Regards,
Randy
# 2,327 2021-10-04_FloodLAMP Email to Tim Stenzel - 4 pages.md
METADATA
last updated: 2025-12-18 RT
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summary_short: The FloodLAMP email to FDA CDRH (for Dr. Tim Stenzel) summarizes FloodLAMP’s EUA and pre-EUA history and requests interactive review and prioritization for resubmitted COVID-19 molecular tests (EasyPCR duplex PCR and QuickColor colorimetric LAMP) and a pooled home-collection kit with a mobile app. It highlights reported performance and operational claims (LoDs, turnaround times, high-throughput pooling, low-cost scaling) and describes non-diagnostic surveillance deployments with pooled anterior nares swabs, training approach, and field screening metrics. It also frames an “open protocol”/Right-of-Reference strategy for broader adoption, commercialization, and global tech transfer, and asks for guidance on integrating surveillance programs with EUA-authorized testing and CLIA lab expansion.
CONTENT
from: Randy True
to: CDRH-EUA-Templates
date: Oct 4, 2021, 10:53 AM
subject: email for Dr. Tim Stenzel
Dear CDRH staff,
Can you please pass on the following email to Dr. Stenzel?
Thank you,
Randy True
Dear Dr. Stenzel,
I'm the founder of FloodLAMP, a public benefit corporation. We spoke briefly on a Town Hall about RORs and open protocol EUAs in December. I'm writing to see if you would be available in the near future to discuss the path forward for our EUA and pre-EUA submissions. Having been inspired by the SalivaDirectTM open EUA, Anne Wyllie is a close advisor and collaborator and has agreed to join the meeting. We have the shared goal of increasing access to high quality testing here in the U.S. and abroad, and see enormous potential for the open protocol EUA approach, both for the remainder of this pandemic and in the near future for pandemic preparedness.
On the details of our tests and submissions:
- 2 complementary direct tests, duplex PCR and colorimetric LAMP;
- both tests utilize same TCEP+heat inactivation;
- 45min TAT for LAMP, 90min for PCR;
- high throughput of 10K+/day without automation for small team running LAMP test;
- LoD 12,500 cp/mL LAMP, 3,000 cp/mL for PCR - comparable to many of the great EUAs;
- completed our clinical evaluation with the Stanford CLIA lab;
- submitted full EUAs, as open source protocol EUAs in March;
- committed to offering an open Right of Reference to our 3 target LAMP primers to help establish commercially available, ready-to-use products, similar to what the CDC achieved with PCR primers;
- dry swab collection, up to 4 swabs (preliminary validation at 2X LoD swab spikes with Zeptometrix).
Unfortunately, after submitting the EUAs in March, we received a de-prioritization denial of review. We followed up with a pre-EUA (PEUA210313) for pooled home-collection kit and our mobile app in May in an effort to qualify for prioritization, but only received brief comments and closure of the pre-EUA. I recently emailed the FDA staff on our pre-EUA response email, requesting an interactive review. I also recently resubmitted our full EUAs (EUA210581, EUA210582), for the persons suspected of COVID and serial screening indications. We would greatly appreciate your assistance on avoiding the immediate denial of review for these resubmissions. We'd like to request consideration for prioritization as a high impact, rapid molecular test.
While trying to get under FDA review, we've deployed our pooled AN swab colorimetric LAMP test under surveillance, and have been able to demonstrate good real world performance including 2,300+ people tested and counting (see info below). These deployments have primarily been with pop-up labs and non-technical staff.
We've optimized our test system and wrap-around program components for confirming negatives while efficiently and reliably finding the needle-in-a-haystack positives. Our pool size of 4 is optimal for family or exposure units. The protocol of pooled home collection with drop off at the workplace or school has several significant advantages. First it reduces the burden on the organization's administration because the majority of collection does not need to be done on site (though that option should be available). Also, it offers increased protection from community spread by extending the screening to the family and household members, who if infected would trigger a positive pool result one stage earlier in the transmission chain. At a practical level, a family self-collecting pooled AN swabs and registering that collection on our app is far easier than running 4 antigen tests. It takes 15 seconds instead of 15 minutes, and that convenience is a driver for adoption and durability of participation in a frequent screening program. From the organization's perspective, having direct access to samples and results provides compliance assurance that is usually desirable.
If authorized for emergency use by the FDA, our test systems, pooled collection kit and software will have very high public health impact. We've designed these in an integrated manner from the ground up expressly for the use case that is acutely needed in the current phase of the pandemic – distributed assurance screening of interacting populations. With true sample-to-answer turn around times typically 1 to 1.5 hrs and as low as 45min, and high quality molecular performance, our program is ideal for businesses, schools and entire communities seeking to return to normal safely. The test-to-stay model for keeping kids in school with outbreaks, exposure, and high community prevalence requires much higher volumes of testing than currently available. Pooled central lab PCR is not well suited for test-to-stay because of the longer TAT, and antigen programs do not scale well. On-site and near-site rapid molecular is well suited for this important use case.
To date, rapid molecular has only been available at great cost, for example to professional sports teams. Our tests have the potential to greatly expand access to rapid molecular screening. We have proved this out with our current surveillance deployments in communities of first responders. In keeping with our public benefit mission, we're commercializing at very low cost, $1-2 per person. This pricing is transformative and is a driver for high impact. We're interested in exploring options with CMS, the CDC, and public health departments to offer programs, both from our company directly and through partners, that pass on this low price/high volume approach to the end organizations being screened.
Our current surveillance programs are for municipalities that have extensive experience in COVID-19 testing and are currently running both rapid antigen testing programs and lab-based PCR. The fact that they have chosen to bring up our tests and program, with considerable commitment of human and financial resources, is a testament to the advantages of our offering.
We do understand that the current configuration of our colorimetric LAMP test system does not qualify for CLIA waived status. We are keenly interested in exploring options with the FDA, CMS, and state health departments for CLIA labs to have the capability to extend CLIA licenses to enable on-site and near-site screening under high or moderate complexity. The instrument-free nature of the test system, along with the ability to achieve throughputs of 1-2,000 persons screened per technician shift (without automation), opens up possibilities in the COVID testing space that have not been available to date. We would very much appreciate guidance on the progression of our EUAs toward these objectives.
In terms of commercialization, we are positioned to quickly scale and deploy millions of tests by the end of year. We have 2M tests of production primers on hand, and another 3M at our supplier, LGC Biosearch. We have a close relationship with NEB who can provide the LAMP and PCR master mixes in large quantities. We're leading a 2 phase project in Colombia in partnership with NEB, to validate both EUA submitted tests and deploy the colorimetric LAMP test in a hub and spoke model to remote processing sites. Again due to the fact that we are fully disclosing the constituent components of our test, rather than keeping them trade secret per industry norm, authorization of our test will have high impact globally due to the international recognition of a U.S. FDA EUA. We experienced this firsthand when during India's surge, we sought to donate test kits but were unable to because we did not have an EUA. Also related to global impact, NEB has not only donated a large value of reactions to projects in Africa, and now our project in Latin America, but also seeks to engage in open tech transfer of reagent manufacturing capability to create local resilience. We intend to do the same by sharing our know-how and pilot production processes with low and middle income countries. These systems and processes have been honed over the last year and facilitate decentralized medium scale production at ultra low cost.
In addition to our direct capability to deliver tests, the open source nature of our EUA submissions, like SalivaDirectTM, will position us to achieve high leverage and scale quickly. With the full disclosure of the component chemistry and primer sequences, as with what happened with SalivaDirectTM, we anticipate that the authorization of our colorimetric LAMP test will result in the proliferation of copy-cat tests offered under LDT. Unlike SalivaDirectTM, as a commercial entity, we will offer test kits in addition to designating CLIA labs. It is our goal to bring as many labs as possible under our EUA, thereby improving quality and consistency. We would like to discuss commercialization and designation issues with you in light of the open source protocol EUAs.
Another topic that we would like to discuss is the coordination of our surveillance programs with EUA authorized testing by designated CLIA labs. Prioritized review of our QuickColorTM LAMP test can lead to further impact through facilitating expansion of our surveillance programs. Most interested organizations seeking affordable COVID-19 screening first ask us if we have an EUA. We are very clear in all of our communications and consents that our current test is non-diagnostic. We have disabled negative result reporting to participants through our mobile app at the request of CMS. In our surveillance testing, we intend to continue to implement best practices with respect to training and quality assurance, while adapting to the differing aspects of public health rather than medical needs. We have engaged a leading learning experience firm to improve our training materials. Your guidance with respect to these efforts to rapidly expand accessible and affordable surveillance testing, in light of entering the clinical space as well, would be greatly appreciated.
Thank you for your attention to these issues related to our EUA submissions, and for your service during the crisis. We look forward to meeting and discussing the next steps.
Best Regards,
Randy True
EUA210581 - FloodLAMP EasyPCRTM COVID-19 Test
EUA210582 - FloodLAMP QuickColorTM COVID-19 Test
PEUA210313 - FloodLAMP Pooled Swab Collection Kit DTC, FloodLAMP Mobile App, Asymptomatic and Pooled Study Designs
**Non-diagnostic surveillance deployments of FloodLAMP QuickColorTM test:**
- 5 sites in 3 states;
- testing at a EMS leadership conference, youth summer camp, and municipal fire departments;
- 11 staff trained to run the test, 5 non-technical staff;
- approximately 800 pools run (reactions);
- approximately 2,300 people screened;
- use of our FloodLAMP Mobile App by 84 users to register on-site and at-home pooled collections;
- 3 unknown positives detected and confirmed by reflex diagnostic test;
- 26 known positives confirmed;
- no known or suspected false negatives.
We currently have 2 commercial sites operating, performing routine testing of EMS and municipal staff. Both are in the process of scaling up to screen 1,000+ people at least weekly and expand to support broader community testing including schools and workplaces.
**FloodLAMP Biotechnologies, PBC**
# 4,365 2021-10-13_FDA Request for Additional Information.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-10-13_FDA Request for Additional Information.md
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summary_short: The FDA October 13, 2021 additional information letter for EUA210582 details deficiencies in FloodLAMP’s QuickColor COVID-19 Test validation, including gaps in intended-use population description, unsupported specimen claims, sub-threshold clinical performance, lack of low-viral-load positives, and required updates to inclusivity/variant analysis, cross-reactivity, and interference testing. It also addresses control material expectations and the regulatory risks of relying on RUO-labeled reagents, outlining acceptable alternatives and warning of possible withdrawal or suspension of distribution if adequate data were not provided by the deadline.
CONTENT
## EMAIL ATTACHMENT HEADER
EMAIL ATTACHMENT ORIGINAL FILE NAME: EUA210582-Additional Information-Final.pdf
FLOODLAMP ARCHIVE FILE PATH FOR EMAIL MARKDOWN FILE: regulatory/fl-fda-correspondence/2021-10-13_FloodLAMP FDA Correspondence and 10-14 Meeting Notes.md
FLOODLAMP ARCHIVE FILE FOR EMAIL - GDRIVE URL: [2021-10-13_FloodLAMP FDA Correspondence and 10-14 Meeting Notes](https://docs.google.com/document/d/1Vady3wfPmepEyRTHuS4lKEK7rVFtmcdi6eJAzaVOEYY/edit?usp=drive_link)
## EMAIL ATTACHMENT CONTENT
October 13, 2021
Dear Mr. True,
The U.S. Food and Drug Administration’s (FDA or Agency) Coronavirus Disease 2019 (COVID- 19) testing [guidance](https://www.fda.gov/media/135659/download) describes a policy for laboratories and commercial manufacturers to help accelerate the availability and use of tests they develop in order to achieve more rapid and widespread testing capacity in the United States. With respect to commercial manufacturers of tests intended to detect SARS-CoV-2 RNA, the policy states in part that FDA does not intend to object to their development and distribution where the test has been validated and while the manufacturer is preparing its emergency use authorization (EUA) request, the manufacturer gives notification to FDA, certain labeling information is included in the test reports and instructions for use, and an emergency use authorization (EUA) request is submitted within 15 business days of the notification to FDA. This guidance was most recently updated on May 11, 2020. As outlined in the policy referenced above, you have previously represented to the Agency that your molecular diagnostic test is validated, and notified the Agency that you intend to distribute, a molecular diagnostic test to identify SARS-CoV-2 RNA and submitted a request for an EUA, EUA210582, for that test.
You have not provided complete information to demonstrate that the studies performed are adequate to validate your test and support the claimed performance characteristics for your device. Specifically:
### 1. Clinical Evaluation Supporting the Request for Authorization of the FloodLAMP QuickColor COVID-19 Test:
As per the FDA’s [Molecular Diagnostic Template](https://www.fda.gov/media/135900/download), validation of a new test should include testing nasopharyngeal (NP) swab specimens from at least 30 positive and 30 negative individuals from the intended use population to support an NP swab or general upper respiratory claim for individuals suspected of COVID-19 by their healthcare providers. To support a general upper respiratory tract (URT) specimen claim it is recommended that the clinical study consists of at least 50% NP swabs and 50% nasal swabs. In your EUA submission you provided results from a clinical validation study that included 40 comparator positive, and 40 comparator negative nasal swab samples. However, the information you provided does not support an NP swab or other common URT specimens claim for the FloodLAMP QuickColor COVID-19 Test for the following reasons:
**a. Intended Use Population**
Your test is intended for individuals suspected of COVID-19 by their healthcare providers (“‘suspected” individuals). However, you have not provided a description of your study population. Therefore, it is unclear whether your clinical study was performed with samples from the intended use population. Consequently, we cannot determine whether your clinical study is supportive of your intended use.
**b. Sample Types:**
Per your Intended Use, you are claiming upper respiratory specimens including oropharyngeal (OP), NP, anterior nasal (AN), and mid-turbinate nasal swabs. As per the FDA’s [Molecular Diagnostic Template](https://www.fda.gov/media/135900/download), studies supporting a NP or general upper respiratory specimen claim should be performed with NP swabs as FDA considers this to be the most challenging upper respiratory matrix. However, your clinical study was performed with the AN swab matrix. As such your claim for NP and OP swabs is not currently supported by your clinical evaluation study.
**c. Low performance:**
You achieved a positive percent agreement (PPA) and a negative percent agreement (NPA) between your test and the comparator tested nasal swab specimens of 90% (36/40) and 100% (40/40), respectively. However, as per the FDA’s [Molecular Diagnostic Template](https://www.fda.gov/media/135900/download), FDA believes a minimum of 95% PPA and NPA is an acceptable clinical performance for a test with an intended use as you proposed for your device. A PPA of 90% is below the performance FDA believes is acceptable. The data obtained in your study suggest clinical performance issues with your device, which may put patients at unreasonable risk of harm due to inaccurate results. False negative test results could have a number of consequences, including leading to additional unnecessary diagnostic evaluations, and could negatively impact the effectiveness of infection control activities by incorrectly assessing the infection status of individuals.
**d. Low positive samples:**
According to the FDA’s [Molecular Diagnostic Template](https://www.fda.gov/media/135900/download), specimens representing a wide range of viral load including low positive specimens should be included in the clinical evaluation. It is recommended that approximately 25% of the SARS-CoV-2 comparator positive specimens should have Ct values close to the mean Ct value of the comparator at its confirmed LoD concentration (i.e., within 3 Cts of the mean Ct value at the confirmed LoD) to be considered as challenging samples with low viral load. However, your clinical data set indicated that no low positive samples per the comparator test were tested in your clinical evaluation study. Without data generated from testing a sufficient number of low positive samples with low viral load, we cannot appropriately assess the performance of the FloodLAMP QuickColor COVID-19 Test.
To address the low performance issue, you should perform a root cause analysis and take the steps necessary to resolve the low PPA for your test. In your response, you should provide evidence that the steps taken addressed the issue and improved the clinical performance. If you identify any new risks in your root cause investigation, you should make sure to provide information to show that those risks have been mitigated. Please note that, should any mitigations require you to alter your device design or testing procedure in any way, additional clinical and analytical validation studies with your final device design may be needed.
Once the sensitivity of your test is improved, to support an NP swab or general URT specimens claim for individuals suspected of COVID-19 by their healthcare providers using the FloodLAMP QuickColor COVID-19 Test, please provide clinical validation data from an adequate number of positive and negative samples collected from your intended use population that demonstrate acceptable performance when compared to the results obtained with the comparator test. Please ensure that you provide a clear description of how samples in your clinical study were sourced, including the population characteristics of your study population and the sample numbers for each sample type. For a general URT sample claim as proposed, at least 50% of samples in your clinical study should be NP swab samples. Alternatively, you may adjust your specimen claim to claim AN swabs only if these are easier to source. Please also ensure that your clinical validation data set includes an adequate number of challenging/low viral load specimens (i.e., approximately 25% of the SARS-CoV-2 positive swab specimens, defined as those specimens having Ct values within 3 cycles of the mean Ct value at the comparator’s LoD). Without the additional clinical validation data requested, FDA is unable to determine that the known and potential benefits of your FloodLAMP QuickColor COVID-19 Test outweigh the known and potential risks.
### 2. Inclusivity Study and Variant Analysis
You performed an in silico inclusivity analysis for your test in February 27, 2021. This in silico analysis is no longer representative of the circulating strains and variants at this time. Without an updated analysis for your test, we are unable to assess the performance of your device with the currently circulating SARS-CoV-2 strains and variants. Consequently, we are unable to determine that the benefits of your device outweigh the risks. Please provide an updated inclusivity analysis to support the current number and types of variants and provide the information in the table format below. Furthermore, please provide a specific risk assessment related to the performance of your device with all currently circulating variants of interest and variants of concern.
Please provide your updated in silico analysis results in the following formats:
| Primer | Variant Name | Sequence | Variant Sequence (Mutation Represented by X) | Seq* start | Seq* send | count (Past 30 Days) 30439 U.S. sequences | Frequency (Percent) (Past 30 Days) 30439 U.S. sequences | count (Past 14 Days) 9452 U.S. sequences | Frequency (Percent) (Past 14 Days) 9452 U.S. sequences |
|---|---|---|---|---|---|---:|---:|---:|---:|
| | | | | | | | | | |
| | | | | | | | | | |
||
*position in the genomic sequence
| | Target gene Fwd Primer 1 | Target gene REV Primer | Target gene Probe |
|---|---|---|---|
| Total primer length (nt) | | | |
| Total strains | | | |
| 100% match | | | |
| 1 mismatch | | | |
| 2 mismatches | | | |
| 3 mismatches | | | |
| >3 mismatches | | | |
||
### 3. Cross Reactivity / Microbial Interference
You have provided a cross reactivity study that consists of wet testing as well as a comprehensive in silico analysis. However, some organisms with >80% of homology revealed in your in silico analysis in Table 13 of your submission were not tested in your wet testing (e.g. Candida albicans, Pseudomonas aeruginosa, Legionella pneumophila, and Streptococcus pneumoniae). Therefore, additional information on potential cross- reactivity is needed to support your EUA. In your response to this deficiency, please provide your in silico cross-reactivity data in tabular form identifying the pathogen, strain, accession # (e.g., you may pick one that represents the complete genome of the organism), and individual % homology of F/R primers and probes for all targets across organisms evaluated (not only organisms with ≥ 50% of homology). For all organisms that produce homologies to any of the primers and probes of above 80%, microbial interference testing should be provided as described below or provide a rationale for why such testing can be omitted.
Microbial interference should be tested in the absence and presence of SARS-CoV-2 at no more than 3x LoD and the presence of the potentially interfering organism at high concentration (i.e., viruses ≥ 10^5 copies, PFU, or TCID50/mL, bacteria and fungi ≥ 10^6 CFU/mL).
**Table X.** In silico cross-reactivity testing with the % homology of the FloodLAMP QuickColor COVID-19 Test primers and probes
| Organism | GenBank Accession # | Target 1 Primer-F | Target 1 Primer-R | Target 1 Probe |
|---|---|---|---|---|
| Human coronavirus 229E | | | | |
| Human coronavirus OC43 | | | | |
| Human coronavirus HKU1 | | | | |
| Human coronavirus NL63 | | | | |
| SARS-coronavirus | | | | |
| MERS-coronavirus | | | | |
| Adenovirus (e.g. C1 Ad. 71) | | | | |
| Human Metapneumovirus (hMPV) | | | | |
| Parainfluenza virus 1-4 | | | | |
| Influenza A & B | | | | |
| Enterovirus (e.g. EV68) | | | | |
| Respiratory syncytial virus | | | | |
| Rhinovirus | | | | |
| *Chlamydia pneumoniae* | | | | |
| *Haemophilus influenzae* | | | | |
| *Legionella pneumophila* | | | | |
| *Mycobacterium tuberculosis* | | | | |
| *Streptococcus pneumoniae* | | | | |
| *Streptococcus pyogenes* | | | | |
| *Bordetella pertussis* | | | | |
| *Mycoplasma pneumoniae* | | | | |
| *Pneumocystis jirovecii* (PJP) | | | | |
| *Candida albicans* | | | | |
| *Pseudomonas aeruginosa* | | | | |
| *Staphylococcus epidermis* | | | | |
| *Streptococcus salivarius* | | | | |
||
### 4. Endogenous Interfering Substances:
You have provided an endogenous interfering substances study and stated that the potential interfering substances listed in Table 15 were tested at the indicated concentrations in your interfering substances study. However, the potential interfering substances tested in your study are insufficient to support the interference by commonly used cold remedies and products used in the URT. For a general URT specimen claim, FDA recommends evaluating the additional potentially interfering substances listed below for interference with your test because they can be expected to be commonly found in the URT. In your response, please submit interfering substance study data of the additional substances below to support that the tested substances do not interfere with your test. If new interference is observed, in your response, please provide information to show that any risk to patients has been mitigated. Please refer to the table below for our recommendations on the list of endogenous interfering substances that should be assessed to support your intended use. Each condition should be tested with 3 replicates.
| Potential Interfering Substances | Active Ingredients | Concentration | Negative Samples (Detected) | Positive Samples (Detected) |
|---|---|---|---|---|
| **Respiratory Samples** | | | | |
| Nasal allergy spray | Triamcinolone acetonide | | | |
| Nasal congestion spray | Oxymetazoline HCl | 15% v/v | | |
| Flonase | Fluticasone propionate | | | |
| Saline nasal spray | NaCL, Phenylcarbinol, Nemalkonium Chloride | | | |
| NeilMed Nasogel | | 1.25% | | |
| Cepacol Lozenges (benzocaine/menthol) | Benzocaine | 3 mg/mL | | |
| Cough drops | Dextromethorphan HBr | | | |
| Robitussin | | | | |
| Chloroseptic Sore Throat spray | Phenol, Glycerin | 5% v/v | | |
| Emergen-C | Zinc, Magnesium, Riboflavin, Vitamin C | | | |
| Zinc (for pyrophosphate based LAMP assays) | Zinc | | | |
| Nyquil | Acetaminophen, Doxylamine succinate, Dextromethorphan HBr | | | |
| Mucin: bovine submaxillary gland, type I-S | | 2.5 mg/ml | | |
| Human Genomic DNA | | 10 ng/µl | | |
| Vaseline | Petroleum Jelly | | | |
| Nicotine | Nicotine | 0.03 mg/ml | | |
| Tobacco | Nicotine, Tar, Carbon Monoxide, Formaldehyde, Ammonia, Hydrogen Cyanide, Arsenic, and DDT | | | |
| Alcohol | Ethanol | 5% | | |
| White blood cells/Leukocytes | | 1 to 5x10^6 cells/mL | | |
| Whole Blood | | 2.5% | | |
||
### 5. External Controls:
FDA recommends that external positive control material is provided in a concentration that is adequately representative of a real clinical sample and that is challenging enough for the test system to detect potential reagent deterioration. Therefore, it is recommended that the positive control mimics a low positive sample (i.e., ≤ 5x LoD). However, the provided information in your EUA template indicates that you are providing the external positive controls with a concentration of 100,000 copies/mL equivalent to 8x LoD. Your control does not meet the recommended concentration and is therefore not an adequate control for the performance of your test with low positive samples. Please provide the validation data for the control material for FDA review.
### 6. RUO Reagents:
In your manufacturing information you indicate that your test ought to be used with recommended Research Use Only (RUO) reagents manufactured by a 3rd party. E.g., LGC Biosearch Technologies/Eurofins Genomics/Integrated DNA Technologies/Sigma LAMP primers, New England Biolabs Colorimetric LAMP Master Mix). As you are aware, RUO products are not subject to 21 CFR Part 820. Because of this, RUO reagents may vary across different manufacturers and lots in ways that may affect the performance of the test. Since continued quality and adequate performance of your test is not assured in this case, you may not recommend as components of an authorized test materials/components that are labeled RUO. Therefore, you have the following options:
a) Identify and recommend IVD labeled materials from a third-party manufacturer, or
b) Qualify specific lots of the recommended RUO labeled third party manufactured materials for adequate performance with your test and post the lot numbers e.g., on your product website, or
c) Bring the materials under your own quality system by supplying them as part of the kit. In this case the control material you purchase is considered a raw material that becomes a component of your kit for which quality and performance you are responsible.
Without the information outlined above, we are not able to determine that your test is adequately validated for its intended use. As a result, the performance of your device is unknown which may put patients at unreasonable risk of harm due to inaccurate results.
By October 15, 2021, 12 pm (eastern), please reply to this email with information sufficient to demonstrate that the device is adequately validated for its proposed intended use, including an explanation of why the new information is adequate to overcome our concerns about the health risks posed by your device’s unknown clinical and analytical performance as reported in your original submission.
If you do not yet have the information requested above, it may take significant time to generate it. You have the option to voluntarily withdraw your EUA request while you collect appropriate validation data and resubmit your request once you have adequately validated your device. If you choose to withdraw, please notify us of that in your response.
If you do not respond by October 15, 2021, 12 pm (eastern), or if the information you provide does not demonstrate that your device is adequately validated for its intended use, we may take steps as described in the guidance referenced above, including removing the test from the website listing of notifications, and likely would not be able to determine that the criteria for emergency use authorization have been met. If such steps are taken and we make that determination, we would expect you to suspend distribution of your test, and we may request that you take additional actions to protect the public health as appropriate.
# 4,121 2021-10-13_FloodLAMP FDA Correspondence and 10-14 Meeting Notes.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-10-13_FloodLAMP FDA Correspondence and 10-14 Meeting Notes.md
file_date: 2021-10-13
title: FloodLAMP FDA Correspondence and 10-14 Meeting Notes
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notes: attachments changed from gdoc version
summary_short: The email thread documents FDA’s October 2021 interactive review of FloodLAMP’s EUA210582 QuickColor COVID-19 Test, including an FDA request for additional information, a follow-up offer to meet by Zoom, and FloodLAMP’s written response arguing for an amended serial-screening intended use. It captures key feedback from FDA reviewers about open-protocol EUA/designation concerns, the need for acceptable clinical evidence for serial screening, and constraints around reference panels, followed by FDA’s deprioritization/closure letter and FloodLAMP’s appeal for reconsideration. The final exchange confirms FDA understood the intended-use amendment but deemed FloodLAMP’s clinical study inadequate for screening with serial testing, directing FloodLAMP to the updated molecular EUA template or a pre-EUA supplement for study-design feedback.
CONTENT
## 2021-10-13_Email from FDA lead reviewer - Request for Additional Information pdf
from: Li, Liang <Liang.Li1@fda.hhs.gov>
to: "randy@floodlamp.bio" <randy@floodlamp.bio>
cc: "Li, Li (CDRH)" <Li.Li2@fda.hhs.gov>,
"Schlottmann, Silke" <Silke.Schlottmann@fda.hhs.gov>,
"Roth, Kristian" <Kristian.Roth@fda.hhs.gov>,
"EUA210582@docs.fda.gov" <EUA210582@docs.fda.gov>,
"Post, Justin" <Justin.Post@fda.hhs.gov>
date: Oct 13, 2021, 8:25 AM
subject: EUA210582-Additional Information needed
signed-by: fda.hhs.gov
Dear Mr. True,
I’m Liang Li, the lead reviewer for your submission EUA210582 Flood LAMP QuickColor COVID-19 Test.
Attached, please find FDA’s letter with the request for additional information for your EUA submission.
Best Regards,
Liang
**Liang Li, Ph.D.**
*Scientific Reviewer*
General Bacteriology and Antimicrobial Susceptibility Branch
Office of In Vitro Diagnostics and Radiological Health
Office of Product Evaluation and Quality
Center for Devices and Radiological Health
U.S. Food and Drug Administration
Phone: (240)-402-8107
Liang.Li1@fda.hhs.gov
### Attachment 1
EMAIL ATTACHMENT ORIGINAL FILE NAME: EUA210582-Additional Information-Final.pdf
FLOODLAMP ARCHIVE FILE PATH FOR ATTACHMENT MARKDOWN FILE: regulatory/fl-fda-correspondence/2021-10-13_FDA Request for Additional Information.md
FLOODLAMP ARCHIVE FILE FOR ATTACHMENT - GDRIVE URL: [2021-10-13_FDA Request for Additional Information.pdf](https://drive.google.com/file/d/1fapKSzKCQz3mCpQfZveqabVI-A6ANSr8)
## 2021-10-13_Email Followup from FDA lead reviewer offering zoom meeting next day
from: **Li, Liang** <Liang.Li1@fda.hhs.gov>
to: "randy@floodlamp.bio" <randy@floodlamp.bio>
cc: "Li, Li (CDRH)" <Li.Li2@fda.hhs.gov>,
"Schlottmann, Silke" <Silke.Schlottmann@fda.hhs.gov>,
"Roth, Kristian" <Kristian.Roth@fda.hhs.gov>,
"Post, Justin" <Justin.Post@fda.hhs.gov>,
"EUA210582@docs.fda.gov" <EUA210582@docs.fda.gov>
date: Oct 13, 2021, 10:15 AM
subject: EUA210582-Setting up a meeting
signed-by: fda.hhs.gov
Dear Mr. True,
Just would like to follow up by email and offer that we could have a quick zoom meeting (30 minutes) tomorrow to discuss about your EUA210582 submission. Please let us know if you are available:
10:30 - 11:00 am EST or
12:30 -1:00 pm EST
Please let us know your availability and we will send out a zoom invite.
Thanks,
Liang
## 2021-10-14_Zoom Meeting Notes for FloodLAMP and FDA
FloodLAMP: Randy True (CEO), Anne Wyllie (Advisor)
FDA: Liang Li, Silke Schlottmann, Kris Roth
- Discussed open protocol EUA approach
- Silke asked about designation, said they would not want us to make IFU publicly available
- Randy relayed initially we'll deploy like Saliva direct but subsequently FloodLAMP will produce full reagent kit
- Randy communicated request to amend intended use to only serial screening (not persons suspected of COVID)
- Silke asked about showing data for intended population, Randy replied the clinical samples were remnant with no clinical info
- Kris mentioned there are 6 criteria for serial screening amendment, risk-benefit different for POC/at-home vs lab based tests
- Kris said we could consider the use bulb pipet to qualify for POC, calibrated pipet is "on edge" for POC
- Anne asked if we could validate with blinded ref panel
- Silke said ref panel is no longer available
- Agreed FloodLAMP would provide written response by Oct 20
## 2021-10-20_Email from FloodLAMP - Reply to FDA Additional Information Request
from: Randy True <randy@floodlamp.bio>
to: "Li, Liang" <Liang.Li1@fda.hhs.gov>
cc: "Schlottmann, Silke" <Silke.Schlottmann@fda.hhs.gov>,
"Roth, Kristian" <Kristian.Roth@fda.hhs.gov>,
"EUA210582@docs.fda.gov" <EUA210582@docs.fda.gov>
date: Oct 20, 2021, 8:06 AM
subject: Re: EUA210582-Additional Information needed
mailed-by: floodlamp.bio
Dear Liang, Silke, Kris,
Thank you for your patience in this response. Attached is a letter addressing your letter last week. We think this resolves some of the points, and we have follow up questions on others.
It seems that the central issue is that the current risk-benefit analysis does not allow us to utilize the streamlined screening with serial testing because our submission is for a lab rather than POC test. Did I understand that correctly from our call?
I would like to better understand the risk-benefit analysis and see if there is more information or data that we can share to support authorization. I would expect that a high complexity CLIA lab rather than POC setting would be a risk mitigating factor. I understood from our call that a lab rather than POC test reduces the benefit, however I would ask for consideration of the fact that our test being instrument-free with a visual readout does not have the usual scalability problems and high capital investment costs typically associated with molecular lab tests. Is that able to be factored into the risk-benefit analysis/calculation?
Kris, you mentioned there are 6 criteria for the serial screening claim. I cannot find those in the FDA statement from March or in the supplemental template. Can you please point me to those or share them?
Also attached is the letter to Tim Stenzel that I mentioned on our call. This letter provides more details on the potential for impact of the test and our company's work. SalivaDirect was developed and initially supported by a small but dedicated team of just 4 people. It has been very successful, in the U.S. and globally, due to the fact that it was FDA authorized as an open source protocol EUA test. In the assessment of a leading CEO, it has caused cost compression in the entire industry. As with SalivaDirect, we at FloodLAMP expect an outsized impact due to the open source protocol approach combined with the highly scalable configuration of our colorimetric LAMP test.
We have not received any communication back from Dr. Stenzel. If you have any feedback on engaging with CDRH leadership regarding prioritization and the potential for impact of our tests, please let me know.
On the submission, it would greatly expedite our ability to add significant screening in the coming winter months if we are granted authorization in the near term. If it's helpful, we are willing to consider conditions of authorization to minimize potential risks. It is much more difficult to make rapid progress on the dissemination and commercialization of this high impact, rapid molecular test and the screening programs it enables, prior to any FDA authorization.
Thank you for your constructive feedback and engagement. Please let me know the next step. I am generally available to meet and expect to be able to respond in writing quickly, typically within 24 hours, 2 days max.
Best Regards,
Randy
**3 Attachments**
### Attachment 1
EMAIL ATTACHMENT ORIGINAL FILE NAME: EUA210582 Response 10-20.pdf
FLOODLAMP ARCHIVE FILE PATH FOR ATTACHMENT MARKDOWN FILE: regulatory/fl-fda-correspondence/2021-10-20_Response to FDA re QuickColor - EUA210582 10-13.md
FLOODLAMP ARCHIVE FILE FOR ATTACHMENT - GDRIVE URL: [2021-10-20_Response to FDA re QuickColor - EUA210582 10-13](https://docs.google.com/document/d/1T1xco5NCe0F8GF84JqVZ0hDyBO0HsG-wbZ-66ezg14I)
### Attachment 2
EMAIL ATTACHMENT ORIGINAL FILE NAME: FloodLAMP Email to Tim Stenzel 10-04-21.pdf
FLOODLAMP ARCHIVE FILE PATH FOR ATTACHMENT XLSX FILE: regulatory/fl-fda-correspondence/2021-10-04_FloodLAMP Email to Tim Stenzel - 4 pages
FLOODLAMP ARCHIVE FILE FOR ATTACHMENT - GDRIVE URL: [2021-10-04_FloodLAMP Email to Tim Stenzel - 4 pages](https://docs.google.com/document/d/1z3zw4jLv5UmZaSFGxloNeBQmV46WWAa70BbfAbowX7A)
### Attachment 3
EMAIL ATTACHMENT ORIGINAL FILE NAME: Supporting Data - FloodLAMP EasyPCR COVID-19 Test.xlsx
FLOODLAMP ARCHIVE FILE PATH FOR ATTACHMENT MARKDOWN FILE: regulatory/fl-fda-submissions/2021-03-22_EUA Sub Supporting Data - FloodLAMP EasyPCR COVID-19 Test.xlsx
FLOODLAMP ARCHIVE FILE FOR ATTACHMENT - GDRIVE URL: [2021-03-22_EUA Sub Supporting Data - FloodLAMP EasyPCR COVID-19 Test](https://docs.google.com/spreadsheets/d/1kmo5uzHk0_XLr2USMpalTUCzatXR2brmBFam80uJ_5k)
## 2021-10-21_Email from FDA lead reviewer - Final Decision
from: Li, Liang <[Liang.Li1@fda.hhs.gov](mailto:Liang.Li1@fda.hhs.gov)>
to: "randy@floodlamp.bio" <randy@floodlamp.bio>
cc: "EUA210582@docs.fda.gov" <EUA210582@docs.fda.gov>,
"Post, Justin" <Justin.Post@fda.hhs.gov>,
"Li, Li (CDRH)" <Li.Li2@fda.hhs.gov>,
"St. Pierre, Don J." <don.st.pierre@fda.hhs.gov>,
"Roth, Kristian" <Kristian.Roth@fda.hhs.gov>,
oir-policy <CDRH-OIR-POPS@fda.hhs.gov>,
"Schlottmann, Silke" <Silke.Schlottmann@fda.hhs.gov>
date: Oct 21, 2021, 5:57 AM
subject: Final Decision for EUA210582 Request – letter attached
Dear Mr. True,
The additional information you provided does not demonstrate that your device is adequately validated for its intended use. Please see attached letter regarding your EUA request, EUA210582. This is the final decision on your EUA request, and your EUA is now closed. For additional information on FDA's priorities with respect to review of EUA requests for COVID-19 tests, see our website’s [FAQs on Testing for SARS-CoV-2](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2#5f9fefc60116f).
Please confirm receipt of this email and attached letter.
Thanks,
Liang
**Liang Li, Ph.D.**
*Scientific Reviewer*
Dear Mr. True:
This letter is in response to your request for an Emergency Use Authorization (EUA) for the
Flood LAMP QuickColor COVID-19 Test, intended for the following use(s): the qualitative
detection of SARS-CoV-2 in anterior nasal swabs from individuals suspected of COVID-19 by
their healthcare provider and from individuals without symptoms or other epidemiological
reasons to suspect COVID-19 infection, when tested at least once per week. Given the volume of
EUA requests the Agency has received, FDA is prioritizing review of EUA requests for tests,
taking into account a variety of factors such as the public health need for the product, availability of the product, extent to which the product would serve a significant unmet medical need, and availability and adequacy of the information concerning the likelihood that the product may be safe and effective in diagnosing the disease/condition. Based on these factors, our review of your submission thus far, and the anticipated resources needed to continue review of your EUA request, FDA has determined that further review of your EUA request is not a priority. FDA therefore declines to issue an EUA for the product at this time.
This test has not been authorized to be distributed or used as proposed. FDA is committed to
doing everything possible to help combat the COVID-19 outbreak and appreciates your efforts in
this matter.
Sincerely,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Donald J. St.Pierre
Deputy Director, New Product Evaluation
## 2021-10-28_Email from FloodLAMP - Reply to Final Decision
Randy True <randy@floodlamp.bio>
to: "Li, Liang" <Liang.Li1@fda.hhs.gov>
cc: "EUA210582@docs.fda.gov" <EUA210582@docs.fda.gov>,
"Post, Justin" <Justin.Post@fda.hhs.gov>,
"Li, Li (CDRH)" <Li.Li2@fda.hhs.gov>,
"St. Pierre, Don J." <don.st.pierre@fda.hhs.gov>,
"Roth, Kristian" <Kristian.Roth@fda.hhs.gov>,
oir-policy <CDRH-OIR-POPS@fda.hhs.gov>,
"Schlottmann, Silke" <Silke.Schlottmann@fda.hhs.gov>
date: Oct 28, 2021, 8:56 AM
subject: Re: Final Decision for EUA210582 Request – letter attached
Hi Liang,
Yes I did receive the letter and have been consulting with our advisors and regulatory experts on the next step.
The letter specifies that our intended use includes persons suspected of COVID-19 by their healthcare provider. We requested to amend our submission to be limited to screening with serial testing. The intention was for that to be a formal amendment, rather than a question.
Can you please confirm that the intended use amendment was understood by all prior to the decision to deprioritize and close our submission?
If it was not understood, I'd kindly ask the team to reconsider the closure and work with us in an efficient, focused manner to resolve whether our current clinical study is adequate for the screening with serial testing intended use. We believe that our clinical data along with our analytical LoD data shows superior performance to all antigen tests that have been authorized for this intended use.
If our current clinical study data is acceptable (completing items 1a,c and d), we will pull out all the stops to quickly complete the other items to demonstrate adequate performance. Updating the inclusivity study, variant analysis, cross reactivity, and interfering substances (items 2, 3, 4) are straightforward and low risk. This streamlined path to authorization, for which it seems the serial testing indication was created, would enable us to rapidly deploy the millions of tests we have ready in the coming months.
If our current clinical study is not acceptable, then we would request feedback on the new clinical study design for the general screening intended use. We've included that in a pre-EUA (PEUA210313) but did not receive feedback on the study design. That pre-EUA included several other complex components, so we would be happy to resubmit a focus pre-EUA or send a Qsub to the email box. We have an IRB in place already with an enrichment study design, so we think the feedback here could be very efficient as well. It's my understanding this study design is required as a condition of authorization for the screening with serial testing intended use as well. We will proceed with completing the other items in parallel as performing a new clinical study will take more time.
Best Regards,
Randy
## 2021-10-29_Email from FDA lead reviewer - Reply regarding Deprioritization
from: Li, Liang <Liang.Li1@fda.hhs.gov>
to: Randy True <randy@floodlamp.bio>
cc: "EUA210582@docs.fda.gov" <EUA210582@docs.fda.gov>,
"Post, Justin" <Justin.Post@fda.hhs.gov>,
"Li, Li (CDRH)" <Li.Li2@fda.hhs.gov>,
"St. Pierre, Don J." <don.st.pierre@fda.hhs.gov>,
"Roth, Kristian" <Kristian.Roth@fda.hhs.gov>,
oir-policy <CDRH-OIR-POPS@fda.hhs.gov>,
"Schlottmann, Silke" <Silke.Schlottmann@fda.hhs.gov>
date: Oct 29, 2021, 11:03 AM
subject: RE: \[EXTERNAL\] Re: Final Decision for EUA210582 Request – letter attached
Hi Mr. True,
Thanks for acknowledging the receipt of my email and the DTI letter.
We understood the intended use amendment when we sent the Deprioritization Letter. Your current clinical study is not acceptable to support testing a screening population with serial testing. Regarding PEUA210313, it appears it was reviewed and closed on 6/17/21. If you have additional questions regarding an appropriate study design, you can refer to the new molecular EUA template and/or send in an PEUA amendment/supplement for FDA feedback.
Thanks,
Liang
# 1,052 2021-10-20_Response to FDA re QuickColor - EUA210582 10-13.md
METADATA
last updated: 2025-12-16 BA updated metadata after BA fixed inconsistencies
file_name: 2021-10-20_Response to FDA re QuickColor - EUA210582 10-13.md
file_date: 2021-10-20
title: Response to FDA re QuickColor - EUA210582 10-13
category: regulatory
subcategory: fl-fda-correspondence
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summary_short: The Response to FDA re QuickColor (EUA210582) addresses FDA’s October 13 feedback by proposing updates to the intended use (removing “suspected of COVID” and focusing on serial screening), limiting sample type to nasal swabs only, and defending test performance with Stanford clinical evaluation data plus real-world pooled surveillance results. It also outlines planned updates or requests for FDA guidance on inclusivity/variant analysis, cross-reactivity and interference expectations for LAMP, endogenous interfering substances, external control concentration rationale, and qualification/lot tracking for RUO reagents.
CONTENT
In response to the letter on October 13 regarding our EUA submission EUA210582:
## 1.a. Intended Use Population
We request to ammend our submission to remove the persons suspected of COVID intended use. We propose to retain the screening with serial testing claim, and seek guidance on the appropriate frequency given the test performance data. We also seek guidance on the post authorization clinical study, for which we have submitted a pre-EUA (PEUA210313) and have a IRB approved study protocol (WIRB Tracking Number 20211472). The clinical study in our EUA submissions was performed with de-identified leftover samples selected by the Stanford Clinical Lab.
## 1.b. Sample Types
We request to ammend our submission to remove NP and OP specimen types. All of our validation and real world testing to date has been with nasal swabs and we intend to exclusively utilize nasal swabs.
## 1.c Low Performance and 1.d. Low Positive Samples
We understand the PPA threshold for the screening with serial testing claim to be 80%. The analytical and clinical performance of the test exceeds that of many other devices with the same intended use. To the best of our knowledge, the performance of our QuickColor LAMP test exceeds all authorized antigen tests.
During the Stanford clinical evaluation, a PCR test using the SalivaDirect version of the CDC primers, was also run on the same inactivated samples (data shown in columns J,K, and L in Supporting Data, tab "4 Clinical Evaluation" in EUA210582, also attached). Only 4 samples with Ct values higher than 36 were not detected by the QuickColor LAMP test. This viral load threshold is concordant with the LoD of 12,500 copies/mL, measured with contrived positives created by spiking gamma inactivated cell lysate from BEI into negative clinical matrix.
In addition to the Stanford clinical evaluation data, we include real world evidence of good test performance from surveillance our testing programs using the same test protocol and reagents, with pools of up to 4 AN swabs. Through the Sept. 28, this real world data comprises:
- approximately 800 pools run (reactions);
- approximately 2,300 people screened;
- 3 unknown positives detected and confirmed by reflex diagnostic test;
- 26 known positives confirmed;
- no known or suspected false negatives.
We understand that the FDA makes EUA decisions based upon data submitted for specific test systems. In consideration of the potential benefits and known and potential risks of our test, we would like to share that all components of the FloodLAMP QuickColor test, including the exact TCEP/EDTA inactivation solution chemistry, the same primer sequences (all 3 genes or a subset), and the same NEB Colorimetric LAMP Master Mix product (catalog M1804) have been independently validated in several EUA authroized tests and/or submissions (Yu/Rosbash from Brandeis, Kundrod/Richards-Kortum from Rice, Prime Diagnostics, Color Genomic's EUA, Detectachem's EUA). Additionally, a Gates/NEB/IGCEB collaboration has validated a RT-LAMP assay with the same NEB M1804 LAMP Master Mix and 2 of the 3 primers in our test, and published the results of this [large multicenter prospective observational study](https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00381-3/fulltext). They are undergoing the Prequalification process with the WHO.
## 2. Inclusivity Study and Variant Analysis
The inclusivity analysis will be updated and presented in the provided format.
## 3. Cross Reactivity / Microbial Interference
The provided feedback seems to assume PCR is the amplification technique. With LAMP, near perfect homology across B3, F3, FIP and BIP is necessary to support successful amplification. With the exception of SARS-CoV, which was included in the wet testing, no other organisms showed >80% homology with more than one primer.
## 4. Endogenous Interfering Substances
The current set of 5 interfering substances were selected based upon those included in authorized EUA tests. In light of the changes to the sample type and intended use, please advise on any updates to the required list.
## 5. External Controls
The concentration of 100,000 copies/mL was selected to be the same as the SalivaDirect(TM) test. Please advise on the suitability of mirroring this EUA.
The positive control material was validated with PCR, routinely measuring in the 31-32 Ct range. In our preliminary LoD Study for the EasyPCR(TM) test, the positive control Ct was 31.1 while the contrived positive with gamma inactivated virus at the same 100,000 copies/mL was 31.7.
## 6. RUO Reagents
We will qualify specific lots of RUO reagents and post the lot numbers.
METADATA
last updated: 2026-03-10_105731
file_name: _archive-combined-files_irb_18k.md
category: regulatory
subcategory: irb
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tokens:
CONTENT
# _archive-combined-files_irb_18k (4 files, 18,063 tokens)
# 6,018 _AI_digestion_irb_new-clinical-study-design.md
METADATA
last updated: 2026-02-28 RT initial creation
file_name: _AI_digestion_irb_new-clinical-study-design.md
file_date: 2026-02-28
title: FloodLAMP Integrated Clinical Study Design - Digestion
category: regulatory
subcategory: irb
tags: clinical-study, enrichment, surveillance, EUA, study-design, cascading-cohort
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license: CC BY 4.0 - https://creativecommons.org/licenses/by/4.0/
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notes: Created by Claude Opus 4.6 Max during archive preparation. **NOT HUMAN VERIFIED - MAY CONTAIN ERRORS** Digestion and analysis of FloodLAMP's integrated clinical study design (~May-August 2022), synthesized from planning notes with whiteboard diagram, associated slide deck/GDoc content, and the original IRB protocol (Protocol 20210401).
summary_short: Digestion of FloodLAMP's integrated clinical study design (~May-August 2022) that merged an active school-based surveillance program with a clinical trial for generating EUA submission data. Covers the enrichment strategy using school exposures and surveillance-detected positives, a cascading cohort structure for maximizing positive specimen yield, comparator testing efficiency, multi-assay validation design, and RNAseP cross-validation, with both internal and external-facing analyses.
CONTENT
## Prompt (Verbatim)
Review the following file and summarize the proposal and try to identify the key reasons for this. This was a new clinical study design that I was trying to figure out and I had an image of it. There, you know, it's not like a single, I don't think it's, I think it's a couple collected kind of associated ideas. But I feel like there's something really important here. I remember thinking this was important and like working on kind of writing it up. I even made a slide deck and it revolved around sort of an integrated, you know, integrating a, like a surveillance program with, doing a clinical study and I think there was like a more comprehensive version of it and a less comprehensive. I'm not really sure. So I want you to kind of summarize, digest, really kind of do a thorough job figuring out what the ideas were, both from the image and from the text and then create a digestion, create the digestion both for me and then also for an external audience, you know, and assume that the external audience is familiar with, you know, diagnostic testing, clinical study designs for testing, etc. So you don't really have to give a background there and just, you know, get to the meat and the key, the key design and ideas behind it. I'm including a project description and a tone here. And you know what? I'm also gonna go ahead and include our IRB. Because that can be some good background info. Okay, do it.
**Files included in context window:**
- _notes_irb_new-clinical-study-design.md
- [hand-drawn whiteboard diagram]
- project-description.md
- tone.md
- IRB - FloodLAMP COVID-19 Biobank and Test Validation Protocol 20210401 v01.md
## Prompt (Cleaned)
Review the following file and summarize the proposal, identifying the key reasons behind it. This was a new clinical study design that I was working on, and I had an image of it. It's not a single idea -- I think it's a collection of associated ideas. I feel like there's something really important here. I remember thinking this was important and working on writing it up. I even made a slide deck, and it revolved around integrating a surveillance program with a clinical study. I think there was a more comprehensive version and a less comprehensive one, but I'm not sure.
Summarize, digest, and do a thorough job figuring out what the ideas were, both from the image and from the text. Create the digestion both for me and for an external audience. Assume the external audience is familiar with diagnostic testing and clinical study designs for testing, so you don't need to provide background -- just get to the key design and ideas behind it.
I'm including a project description and a tone guide. I'm also including our IRB protocol for background context.
**Files included in context window:**
- _notes_irb_new-clinical-study-design.md
- [hand-drawn whiteboard diagram]
- project-description.md
- tone.md
- IRB - FloodLAMP COVID-19 Biobank and Test Validation Protocol 20210401 v01.md
## AI Response - Digestion: FloodLAMP Integrated Clinical Study Design (May 2022)
Done. I created the digestion at `data/floodlamp/regulatory/irb/_digestion_irb_new-clinical-study-design.md` with both an internal and external section.
Here's my read on what was really going on and why it felt important:
**The central idea** was not just a clinical study design but an operational architecture that merged a surveillance program with a clinical trial. Instead of treating these as separate activities (run surveillance over here, run a clinical study over there), the design recognized that a well-structured surveillance program *already contains* most of what you need for a clinical study: consented participants, collection logistics, ongoing testing, and a population with real exposure risk. The study just added the comparator testing, randomization, and formal follow-up protocols on top.
**The enrichment strategy** was the practical engine. Low prevalence was the killer problem for small companies trying to generate clinical data. Instead of brute-force enrolling thousands of people hoping for 20 positives, the design used school exposure events and surveillance-detected positives as triggers to activate intensive serial testing of households. This is much more efficient and avoids the bias concern of re-testing already-confirmed positives from other tests.
**The cascading cohort structure** was the really clever part. One positive pool in a household cascades into daily paired testing of the whole family, catching new infections at onset. Each new positive restarts the cycle. This multiplied the positive specimen yield from each initial detection event, all with properly paired comparator data.
**The RNAseP angle from the whiteboard** adds another layer: by running both FloodLAMP EasyPCR and the Eurofins comparator across large sample sets, you could cross-validate that FloodLAMP's internal sample adequacy control (RNAseP) was reliable. This would strengthen the home collection usability story (proving people collected their swabs properly) and the overall analytical validation.
**The bottom line**: this was a resource-efficient design for a small company that turned the constraint of limited resources into an advantage by making the surveillance program and the clinical study the same thing, with an enrichment strategy that solved the prevalence problem and a cascading cohort structure that maximized data yield per positive event.
### Internal Summary (For the Author)
#### What This Was
This was a clinical study design developed around May-August 2022 to solve several interrelated problems simultaneously. It represented an evolution from the broad, flexible original IRB protocol (which allowed up to 100,000 specimens across multiple collection modes) into a specific, operationally integrated plan. There was a slide deck and at least one detailed planning document associated with it.
#### The Core Insight
The central idea was to merge an active school-based surveillance testing program with a clinical study, so that the surveillance infrastructure (logistics, population, ongoing testing) would serve double duty as the apparatus for generating clinical performance data for EUA submission. Rather than running a standalone clinical trial that required building recruitment, collection, and testing from scratch, the study would ride on top of existing surveillance operations.
This had two major advantages:
1. It solved the recruitment and logistics problem by using an already-running program.
2. It provided direct value to study participants (testing that helped stop spread in classrooms and families), making this genuinely participant-beneficial rather than purely extractive research.
#### The Enrichment Strategy
Low prevalence was the fundamental obstacle to getting enough positive samples. The design addressed this through two enrichment approaches:
1. **Outbreak chasing**: When a school exposure event occurred, recruit the affected families for serial testing. Send collection kits home with the exposed student the same day if possible; collect swabs the next morning and courier them to the lab within hours.
2. **Surveillance-based enrichment**: Pre-recruit families into the study through the surveillance program. When a routine surveillance test came back positive, those families would be activated into the study's formal protocol arms. This was the more systematic, ongoing version.
Both approaches increased the effective positive rate without introducing the kind of bias that would come from, say, only enrolling people who already tested positive elsewhere (which the notes flagged as a concern: "Could/should we ignore how they tested positive? FDA might ding us for bias").
#### The Cascading Cohort Structure
This is where the design got particularly clever. Rather than a single - timepoint collection, it used a cascading structure that multiplied the data yield:
- **Initial Collection**: Pooled family swabs for FloodLAMP + individual comparator swabs. Run QuickColor immediately.
- **Pool Positive path**: Send individual comparator swabs to CLIA lab. Run EasyPCR. Move the family into the Positive Follow Up Cohort.
- **Positive Follow Up Cohort**: The family collects paired individual swabs daily (FloodLAMP + comparator). Also run rapid antigen tests. The logic: other family members were likely exposed and may be developing infections, so continued testing catches new positives as they emerge.
- **Serial Follow Up Cohort**: Willing participants continue daily paired testing. If a new FloodLAMP positive appears, restart the Positive Follow Up protocol for that person.
The net effect: a single initial positive in a household pool could cascade into multiple confirmed positives across family members, each with paired FloodLAMP/comparator data.
#### Cost Optimization
A key practical feature: the expensive comparator PCR did not need to be run on every negative sample. All FloodLAMP-positive pools needed comparator PCR run (to confirm/disconfirm), but for negatives, only a subset (at least 20) required comparator testing. This meant the surveillance testing could scale broadly while keeping comparator costs manageable. The notes mention this as funding-dependent: "Depending on funding we can run larger negative arms that include the comparator PCR, which give greater statistical power."
#### Diagram of Clinical Study Design Ideas
_made with Claude desktop from hand drawn image_
Interactive HTML diagram showing the four sample processing paths in the integrated clinical study design: (A) Elute in Saline, where pooled swabs are split, with half sent to Eurofins as comparator and half through 100x inactivation; (B) 1x ISS, where the inactivated half is combined with 1x ISS and run on both FloodLAMP QuickColor LAMP and EasyPCR; (C) Comparator, where multiple individual swabs are sent to Eurofins; and (D) Enrichment, where enriched individual swabs are run directly on FloodLAMP QC and EasyPCR. Both EasyPCR outputs feed into a cross-validation of RNAseP signal over large sample sets. Based on a hand-drawn whiteboard sketch from the original planning sessions.
#### The Whiteboard Sketch
The whiteboard image shows three tiers of the study:
**Top tier (Main pooled arm)**: Multiple swabs pooled in saline (1X ISS), then split. Half goes to Eurofins (external CLIA lab) as comparator. The other half goes through 100X inactivation, then runs on both FLQC (FloodLAMP QuickColor LAMP) and FLEPCR (FloodLAMP EasyPCR). A key annotation: the Eurofins comparator PCR "Validates RNAseP Signal from our PCR," meaning the external reference data could be used to validate FloodLAMP's internal sample adequacy control (RNAseP) across a large population.
**Middle tier (Individual comparator arm)**: Individual swabs sent to Eurofins, with the specific goal to "Compare RNAseP over big sample sets." This appears to be a dedicated arm for building a large dataset correlating FloodLAMP's RNAseP internal control with the external reference, a useful dataset for demonstrating sample collection and processing quality.
**Bottom tier (Enrichment arm)**: Individual swabs from the enrichment strategy run directly on FloodLAMP QC (QuickColor) and EP (EasyPCR). This is the streamlined path for enriched samples where the focus is on FloodLAMP performance data.
#### What It Was Simultaneously Validating
The study was designed to generate clinical data for multiple claims in a single integrated effort:
1. QuickColor (RT-LAMP) performance
2. EasyPCR (RT-qPCR) performance
3. Pooled vs. individual collection performance
4. Home collection kit usability (with and without the FloodLAMP Mobile App)
5. Asymptomatic testing claim (tests run under moderate complexity)
#### The RNAseP Angle
The whiteboard repeatedly emphasizes RNAseP validation. RNAseP is a human housekeeping gene used as an internal control to confirm that a collected swab actually contains sufficient human cellular material (i.e., the swab was properly collected and processed). By running both FloodLAMP EasyPCR (which detects RNAseP) and the Eurofins comparator across large sample sets, FloodLAMP could validate that its RNAseP signal was a reliable indicator of sample adequacy. This matters for both regulatory submissions and for the usability study (the mobile app arm), where RNAseP signal strength could be used to objectively assess whether participants collected their swabs correctly.
#### Practical Status and Constraints
The August 2022 planning notes show this was being scoped to a single Miami site (Embassy or Nova Southeastern), with one operator (FloodLAMP trained staff member who ran Combate program) running FloodLAMP tests and coordinating the PCR comparator. The comparator was the Abbott M2000 system ($85/test, same-day results but no Ct values). There were open questions about whether EasyPCR could be run at the same site or would need a collaborator (James Roach at Cleveland Clinic Ft. Lauderdale or Mayo). The design acknowledged it could expand to 3 sites for 510K requirements.
#### Why This Felt Important
Looking at it in hindsight, the design's significance was in recognizing that for a small company with limited resources, the path to clinical data did not have to be a traditional standalone trial. By structuring a surveillance program so that it inherently generated clinical-grade data, with proper consent, comparator testing, and enrichment, the company could build toward both EUA submission and a much larger publication-quality dataset using essentially the same operational apparatus. The cascading cohort structure was an efficient way to extract maximum clinical data from a low-prevalence environment. And the RNAseP cross-validation was a genuinely useful secondary dataset that could strengthen both the usability claim and the overall analytical validation story.
### External Digestion (For Audience Familiar with Diagnostic Clinical Study Design)
#### Overview
This document describes a clinical study design developed by FloodLAMP Biotechnologies in mid-2022 for generating clinical performance data for multiple molecular COVID-19 assays (an RT-LAMP test called QuickColor and an RT-qPCR test called EasyPCR), a pooled home collection kit, and an associated mobile application. The design aimed to satisfy EUA submission data requirements while simultaneously establishing infrastructure for a larger dataset suitable for publication and 510(k) submission.
#### Design Rationale
The fundamental challenge was generating sufficient positive clinical specimens during a period of variable and often low SARS-CoV-2 prevalence, using the resources of a small company. The design addressed this by integrating the clinical study into an existing school-based surveillance testing program rather than operating a standalone trial.
#### Integrated Surveillance-Clinical Study Model
The study operated within the framework of an active surveillance program providing serial screening to school populations and their families. This integration served three purposes:
1. **Recruitment pipeline**: Families already participating in surveillance were pre-consented for study participation, eliminating the need for separate recruitment infrastructure.
2. **Enrichment mechanism**: Surveillance testing identified positive individuals and exposure events in real time, enabling targeted activation of clinical study protocols for participants most likely to yield positive specimens.
3. **Participant benefit**: The study provided actionable testing results that helped interrupt transmission within classrooms and households, aligning participant and study interests.
#### Enrichment Strategy
Two enrichment approaches were employed:
- **Exposure-based**: Following a confirmed school exposure event, families of exposed students were recruited for serial testing. Collection kits were distributed same-day when possible, with morning collection and same-day courier to the lab.
- **Surveillance-based**: Families pre-enrolled in the study were activated into the formal clinical protocol when their routine surveillance test returned positive.
Both approaches increased the effective positive specimen rate without selecting for individuals with known positive results from external tests, which would risk introducing ascertainment bias.
#### Cascading Cohort Structure
The study used a multi-stage cohort design that maximized data yield from each positive finding:
1. **Initial Collection**: Participants collected paired specimens: pooled anterior nares swabs for FloodLAMP testing and individual swabs for comparator PCR (high-sensitivity EUA-authorized test at a CLIA lab). Collection order was randomized. QuickColor LAMP was run immediately on the pooled specimen.
2. **Pool Positive Pathway**: If QuickColor detected a positive pool, individual comparator swabs were sent to a CLIA lab (fulfilling the pooled test study arm). FloodLAMP EasyPCR was also run on the same specimen. The family was enrolled in the Positive Follow Up Cohort.
3. **Positive Follow Up Cohort**: All household members collected daily paired individual swabs (FloodLAMP + comparator) plus rapid antigen tests. The rationale: household contacts of newly identified positive individuals were at elevated risk of developing infection, and serial daily testing provided the opportunity to capture new infections at onset, generating additional paired positive specimens with both FloodLAMP and comparator data.
4. **Serial Follow Up Cohort**: Willing participants continued daily paired testing beyond the initial follow-up period. Any new FloodLAMP-positive result restarted the Positive Follow Up protocol for that individual.
This cascading structure meant a single initial positive pool could generate multiple confirmed positive specimens across household members, each with paired investigational and comparator test results.
#### Comparator Testing Efficiency
The design incorporated a cost-optimization: comparator PCR was run on all FloodLAMP-positive specimens but only a defined subset of negatives (minimum 20 for the primary analysis). This allowed surveillance-scale testing volumes without proportional comparator testing costs, while still generating sufficient negative agreement data.
#### Multi-Assay, Multi-Claim Validation
The integrated design simultaneously generated clinical performance data for:
- QuickColor (RT-LAMP) sensitivity and specificity, pooled and individual specimens
- EasyPCR (RT-qPCR) sensitivity and specificity
- Pooled vs. individual collection concordance
- Home collection kit usability (two arms: with and without FloodLAMP Mobile App, assessed via survey, video-recorded collection, and RNAseP-based sample adequacy analysis)
- Asymptomatic screening claim (tests performed under moderate complexity)
#### RNAseP Cross-Validation
A secondary objective involved correlating the RNAseP (human internal control) signal from FloodLAMP EasyPCR against the external comparator across large sample sets. This served dual purposes: validating FloodLAMP's internal sample adequacy metric and providing objective data on self-collection quality, relevant to both the usability study arm and the home collection kit submission.
#### Operational Parameters
The study was planned for a single initial site in the Miami area, with the possibility of expanding to three sites for 510(k) geographic diversity requirements. The comparator assay was the Abbott M2000 real-time PCR system run through a local CLIA lab. The minimum target was 20 prospectively collected positive and 20 negative specimens for the primary EUA analysis, with the surveillance infrastructure positioned to generate a substantially larger dataset over time.
#### Relationship to Prior Protocol
This design operationalized a broader IRB-approved protocol (Protocol 20210401, April 2021) that permitted collection of up to 100,000 specimens across multiple collection modalities. The earlier protocol established the regulatory framework; this design specified how that framework would be executed in practice through integration with surveillance operations.
## Slides - FloodLAMP Clinical Study Design - May 2022
https://docs.google.com/presentation/d/1U6NCayI6slDDV36jrq98A4ScT3X0KzNlIy0CIp348KM
### FloodLAMP Integrated Clinical Study
1) Pooled self collection with the FloodLAMP Pooled Home Collection Kit DTC
2) Tests run under moderate complexity for asymptomatic claim
- QuickColor
- EasyPCR
- Pooled and individual test
3) Usability study of the FloodLAMP Mobile App
The goals of this clinical study are both to obtain the minimum necessary clinical data for EUA submission, as well as put in place the apparatus to obtain a much larger clinical data set, both for publication and for 510K. An enrichment strategy utilizes 1) school exposures, and 2) routine surveillance testing. In both, the clinical study offers value to the participants in providing testing to stop spread within classrooms and families.
### Recruitment
Recruit families for serial testing after school exposure.
Distribute collection materials for FL (pooled and indiv) and comp PCR (likely wet AN swab, pref saline).
if possible send collection kits home with student same day
next morning collection, likely send courier same day (within a few hours)
Also run surveillance serial screening program, where families are pre-recruited into the study. For this arm, we use an enrichment strategy where we place families into the study if their surveillance test is positive.
### Initial Collection
Have participants collect 2 swabs shortly after notification of exposure
FloodLAMP is pooled AN swabs (our collection kit)
Comparator PCR is individual AN swab (their collection kit, saline/PBS)
Run FloodLAMP QuickColor immediately
## GDoc - Clinical Study Plan May22 - NEEDS REVIEW AND CLEANUP FOR PUB
https://docs.google.com/document/d/1M9jC0gBEOC1kFlfOWMVSeSfbl2J66zeuLksfuI3MkG4
### 8-2-22
#### Baseline Assumptions:
* Miami only site (Embassy or Nova)
* could extend for 510K req of 3 sites
* ND running FL and coordinating the PCR comparator
* QuickColor and EasyPCR tests not the
* 20 positives and negatives (asymptomatic)
* Indiv samples (not pooled)
* Enrichment strategy
* Options for recruitment
* outbreak chase
* outreach to positives from testing programs
* them if they are asymp
* their contacts
* For both Pos and Neg
* how to do negs? ads in same venue
* Comparator must be high sensitivity PCR EUA test not non-EUA LDT
#### Questions
How to run EasyPCR also?
1) freeze inactivated samples and batch up to run all at once? still where??
2) collaborator such as James Roach at Mayo in FTL
Collection: self collection or HCW collected?
If/how to include antigen tests?
If/how to include Combate or other surveillance participants?
Could/should we ignore how they tested positive? FDA might ding us for bias
- exposure testing serially by antigen tests
Can we run at Embassy?
Do we want to limit it to Florida and ND running?
Abbott M2000 system \- what ND uses ($85 per test, same day by 9:30pm if submitted by 5:30pm) \- Abbott system does not provide Ct values
United Clinical Laboratories
Look for other CLIA labs around Ft Lauderdale
#### Info for Plan
Budget
Timeframe
Challenges or Roadblocks
#### To Do's for various people
- [ ] get better understanding of ND's schedule
- [ ] get info on options for the PCR test, what lab, what assay?
### FloodLAMP Integrated Clinical Study for:
1) Pooled self collection with the FloodLAMP Pooled Home Collection Kit DTC
2) Tests run under moderate complexity for asymptomatic claim
1) QuickColor
2) EasyPCR
3) Pooled and individual test
3) Usability study of the FloodLAMP Mobile App
The goals of this clinical study are both to obtain the minimum necessary clinical data for EUA submission, as well as put in place the apparatus to obtain a much larger clinical data set, both for publication and for 510K. An enrichment strategy utilizes 1\) school exposures, and 2\) routine surveillance testing. In both, the clinical study offers value to the participants in providing testing to stop spread within classrooms and families.
### Consider including:
* POC for 1XISS in dispenser and reaction mix provided
* arm for asym people with positive result
* arm with just our test on repeat swabs and arm with their swab/tube and our test
* get ND involved when we need another site \- James Roach at Ft. L Cleveland Clinic
### Key Outstanding Questions
- [ ] Do we need a clinical lab to run our QuickColor LAMP test? Or can we run that ourselves in a research lab?
### Recruitment
Recruit families for serial testing after school exposure
Distribute collection materials for FL (pooled and indiv) and comp PCR (likely wet AN swab, pref saline)
* if possible send home with student same day
* next morning collection, likely send courier same day (within a few hours)
Also run surveillance serial screening program, where families are pre-recruited into the study. For this arm, we use an enrichment strategy where we place families into the study if their surveillance test is positive.
### Initial Collection
Have participants collect 2 swabs shortly after notification of exposure
Randomize which swab is done first
- [ ] How to randomize?
- [ ] Should we consider FloodLAMP first, then 2nd swab for comparator?
- [ ] Do we need to specify at least 10min and no more than 30min as in our Pre-EUA
FloodLAMP is pooled AN swabs (our collection kit)
- [ ] Is QuickColor & EasyPCR assayed only using pooled AN swabs, or are there multiple arms \- pooled and individual swabs?
- [ ] Are we comparing pooled AN swabs vs all individual swab comparators in the pool?
- [ ] In the case of enriched positive samples in the pooled case, are we controlling it so that there is only one positive swab per pool? If so, how are we sampling the negative swabs?
Comparator PCR is individual AN swab (their collection kit, saline/PBS)
Run FloodLAMP QuickColor immediately
#### Pool Positive
If FloodLAMP QuickColor is positive:
* Send indiv comparator PCR swabs to CLIA lab to run. These fulfill the **Pooled Test Study Arm**.
* If possible, get frozen aliquot of saline eluted swab (fresh would be difficult, maybe friendly lab).
* Run fresh FloodLAMP EasyPCR
* Add family to **Positive Follow Up Cohort** (looking to catch other exposed family members at onset of infection).
* Individual swabs for follow up cohort?
* QuickColor and EasyPCR?
* Comparator swab collected & randomized in the same way?
#### Pool Negative
Select 20 negative pools:
* Send indiv comparator PCR swabs to CLIA lab to run
* Run fresh FloodLAMP EasyPCR
If any individual comparator PCR results are positive, move family to Positive Follow Up Cohort
#### Positive Follow Up Cohort
Same day as detecting the positive pool \- have the family collect pairs of individual swabs for FloodLAMP tests and comparator PCR.
Testing follows the same protocol as initial collection except FloodLAMP swabs are individual instead of pooled.
Family also collect and each run antigen tests at least 10min after other swabs (document results with photo and time of collection).
All FloodLAMP QuickColor negatives do not have to be run for the comparator PCR, only a subset (at least 20). Depending on funding we can run larger negative arms that include the comparator PCR, which give greater statistical power to the sensitivity and specificity.
#### Serial Follow Up Cohort
For willing study participants from the Positive Follow Up Cohort, offer to continue serial testing daily per the paired individual swab protocol. The rationale here is that some or all of the family may have been exposed to the likely infected family member(s). By continuing to test them daily in the study, there's the opportunity to pick up a new infection early. Again, the collected PCR swabs only need to be run with the associated cost, if the FloodLAMP QuickColor LAMP test is positive (restart the Positive Follow Up Cohort). Also running rapid antigen daily as above?
#### Collection Kit Usability Study
See Pre-EUA submitted 5-18-2021, Section H.3
Includes:
* 12 question survey
* video recording collection
* incoming inspection
* sample adequacy analysis
2 arms, Arm1 without FloodLAMP Mobile App, and Arm2 with the FloodLAMP Mobile App.
Since all collections for the entire study will be done with the FloodLAMP Mobile App excluding this Arm1, all participants in the study can be given the survey, and their inactivated samples frozen and run on FloodLAMP EasyPCR where the RNAseP signal can be used to assess the sample adequacy. The FDA replied that they did not approve of this but it appears they misunderstood.
### Need to Do/Find
- [ ] Symptom tracker \- maybe rolled into overall daily survey/form, include vaccination/booster status, infection history
### Ideas
- [ ] Get feedback from Dave and others
# 1,560 _context-commentary_regulatory-irb.md
METADATA
last updated: 2026-02-28 RT
file_name: _context-commentary_regulatory-irb.md
category: regulatory
subcategory: irb
words: 1167
tokens: 1560
CONTENT
## Context
An Institutional Review Board (IRB) is an independent ethics committee that reviews and approves research involving human subjects. Any clinical study collecting specimens from human participants, including the clinical performance studies needed for FDA Emergency Use Authorization (EUA) submissions, requires IRB approval before it can begin. The IRB evaluates whether the study design adequately protects participants' rights, safety, and welfare.
This subcategory contains two files from FloodLAMP's IRB process: a clinical study protocol and an informed consent form, both dated April 2021 (Protocol 20210401). The protocol, titled "FloodLAMP COVID-19 Biobank and Test Validation Protocol," outlined a study to collect up to 100,000 consented clinical specimens across multiple U.S. sites to evaluate FloodLAMP's molecular COVID-19 assays (QuickColor RT-LAMP, QuickFluor RT-LAMP, and EasyPCR RT-qPCR) and a home collection kit. The informed consent form documented voluntary participation, specimen handling, de-identification procedures, and participant rights.
The relationship between the IRB and FDA EUA submissions is sequential rather than direct: IRB approval is a prerequisite for conducting a clinical study, and the clinical study generates the performance data that gets submitted to the FDA as part of an EUA application. The IRB itself does not appear in the EUA submission. Rather, it serves as the regulatory gatekeeper that must approve the study before clinical specimens can be collected from human participants. FloodLAMP needed clinical performance data — positive and negative percent agreement against an EUA-authorized high-sensitivity PCR comparator — to support its 2nd round of EUA submissions for pooling, asymptomatic, and the new serial screening claims. Generating that data required running a clinical study on human specimens, and running that study required IRB approval.
Note that this IRB is not related to FloodLAMP's first round of EUA submissions in March of 2021. The Stanford Clinical Lab performed the clinical study for those submissions, using banked samples.
FloodLAMP obtained IRB approval through WCG (formerly Western Institutional Review Board), a well-known commercial IRB. The protocol was broad and flexible, designed to cover three collection modalities: co-located sites adjacent to existing testing programs (such as Stanford or San Francisco city testing sites), independently operated FloodLAMP collection sites, and distributed home collection kits. The study also included provisions for the FloodLAMP Mobile App, pooled specimen collection, and multiple swab types.
Despite obtaining IRB approval and preparing a detailed protocol, FloodLAMP never executed the clinical study, due to the FDA's decision to decline further review of the FloodLAMP EUA and Pre-EUA submissions. The company later developed a more operationally integrated study design in mid-2022 that would have merged clinical data collection with an active school-based surveillance testing program (documented in the companion file `_AI_digestion_irb_new-clinical-study-design.md`), but this design also was not executed before the company ceased operations.
Other parts of the archive document the FDA submission process itself. The fl-fda-submissions and fl-fda-correspondence subcategories in the Regulatory collection contain the EUA applications and related correspondence that these IRB documents were intended to support.
The archive also includes additional IRBs, consent forms, and clinical study designs from other organizations, located in the `IRBs and Consents from Others` subfolder:
- American Cancer Society event LIABILITY WAIVER AND RELEASE OF CLAIMS.pdf
- Arizona Dept of Health Services informed consent.pdf
- Color Genomics IRB.docx
- EmpowerDX (Eurofins) consent form.docx
- Lucira Screenshot_2021-02-17 COVID-19 Test Study.png
- NextEraEnergy PCR Testing Patient Consent Form.pdf
- Stanford Catch Consent.docx
Technical note: These files are not considered primary archive files, and therefore were not converted to markdown and included in the AI-ready combined md files.
## Commentary
The IRB process was handled through WCG (Western Institutional Review Board), with a total cost of approximately $11,360 over two years including a renewal. This was a considerable expense for a small company, made more notable by the fact that the clinical study was never actually conducted. The IRB approval and the detailed protocol it covered remained unused.
The experience highlighted what appeared to be a cumbersome and inefficient process. The IRB pathway felt siloed, with limited templates, examples, or structured support available for small organizations navigating it for the first time, particularly during a public health emergency when speed should have been a priority. For a small company attempting to bring a new diagnostic test through the regulatory pathway during an active pandemic, the combination of IRB costs, the time required to prepare the protocol, and the separate expense of actually running a clinical study created significant barriers to generating the clinical data that the FDA required.
To illustrate the broader cost picture: FloodLAMP received a quote of approximately $100,000 from a clinical research organization to manage participant recruitment and sourcing alone, targeting roughly 40 positive specimens. This did not include running the tests themselves; a separate CLIA laboratory was needed for that. These costs reflected the broader pandemic dynamic, where demand for clinical services far outstripped supply and pricing reflected that imbalance.
The IRB and clinical study process, as experienced, suggests an area where standardization and streamlining could benefit the field, both in routine times and especially during public health emergencies. The barriers to generating clinical performance data disproportionately affect small companies and organizations that lack established clinical trial infrastructure, institutional IRB relationships, or the budgets to absorb six-figure study costs. If decentralized and low-cost diagnostic testing is to play a meaningful role in future pandemic response, the regulatory pathway for generating the required clinical data may need to be correspondingly accessible.
The FDA did recognize elements of this problem. Through a collaboration with the NIH, the Rapid Acceleration of Diagnostics (RADx) program established the Independent Test Assessment Program (ITAP), which provided standardized evaluation protocols, data reporting mechanisms, and targeted outreach to test developers to accelerate regulatory review and authorization. ITAP facilitated the authorization of a number of at-home and point-of-care COVID-19 tests, and the model has since been extended to other diagnostics including multiplex respiratory panels, mpox, and hepatitis. However, ITAP's COVID-19 focus was primarily on rapid antigen tests, and the program's resources and outreach were oriented toward developers with tests already authorized in other markets or at a relatively advanced stage. While ITAP likely accelerated some authorizations, it did not address the more fundamental barriers and inefficiencies of the overall EUA clinical study and IRB process, and it was not readily accessible to smaller, earlier-stage companies and organizations developing novel testing approaches. For more on FloodLAMP's engagement with RADx-related programs, see the archive files in various/fl-proposals subcategory.
Later in FloodLAMP's trajectory, around mid-2022, a new clinical study design was developed that attempted to address some of these constraints. The design integrated clinical data collection into an active school-based surveillance testing program, using an enrichment strategy to solve the low-prevalence problem and a cascading cohort structure to maximize data yield per positive event. This approach would have generated clinical performance data at a fraction of the cost of a standalone trial. The design is documented in a companion file (`_AI_digestion_irb_new-clinical-study-design.md`) and may be of interest to researchers or organizations facing similar challenges in generating clinical data for novel diagnostics during periods of variable disease prevalence.
# 5,914 IRB - FloodLAMP COVID-19 Biobank and Test Validation Protocol 20210401 v01.md
METADATA
last updated: 2026-03-05 by BA
file_name: IRB - FloodLAMP COVID-19 Biobank and Test Validation Protocol 20210401 v01.md
file_date: 2021-04-01
title: IRB - FloodLAMP COVID-19 Biobank and Test Validation Protocol 20210401 v01
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notes:
summary_short: The FloodLAMP COVID-19 Biobank and Test Validation Protocol (Protocol 20210401) lays out an IRB-governed study to collect up to 100,000 consented clinical specimens across multiple U.S. sites to evaluate FloodLAMP’s QuickColor/QuickFluor RT-LAMP assays, EasyPCR RT-qPCR assay, and a home collection kit (including pooled collection and optional mobile app use). It specifies intended use, inclusion/exclusion criteria, collection variations (co-located sites, independent/mobile sites, and distributed “home” kits), specimen handling requirements (e.g., dry swabs within 56 hours or frozen ≤-70°C), QC/control expectations, and comparison to an EUA-authorized high-sensitivity PCR reference method. It describes de-identification and bias-minimization procedures, data collection and statistical analysis plans (PPA/NPA with confidence intervals and call-rate handling), plus monitoring, record retention, deviations, and ethics/safety oversight aligned to GCP and 21 CFR Part 812.
CONTENT
***INTERNAL TITLE:*** FloodLAMP COVID-19 Biobank and Test Validation Protocol
**FloodLAMP COVID-19 Biobank and Test Validation Protocol**
**Protocol Number: 20210401**
## REVISION HISTORY
| **ECR** | **Version Number** | **Date issued** | **Author(s) of changes** | **Details of changes made** |
|-----------|-----------|-----------|-----------------|----------------------|
| N/A | 01 | | | Original release ||
||
## KEY STUDY CONTACTS
| **Field** | **Value** |
| :---- | :---- |
| Sponsor | FloodLAMP Biotechnologies, PBC 930 Brittan Ave San Carlos, CA 94070 ||
| Primary Study Contact | Randy True Chief Scientific Officer randy@floodlamp.bio xxx-xxx-xxxx ||
||
## INVESTIGATOR SIGNATURE PAGE
**Protocol Title: FloodLAMP COVID-19 Biobank and Test Validation Protocol**
**Protocol Number: 20210401**
The undersigned confirms that the following protocol has been agreed and accepted. I agree to conduct the trial in compliance with this protocol. I agree to ensure that the confidential information contained in this document will not be used for any other purpose other than the evaluation or conduct of the clinical investigation without the prior written consent of the Sponsor.
I agree to conduct the clinical trial in compliance with the approved protocol and will adhere to the principles outlined in the Declaration of Helsinki, 21 CRF 812.100 General responsibilities of investigators, and the current ICH GCP regulations (ICH E6 (R1) Section 4, the Sponsor’s SOPs (if applicable), National Laws and Regulations, and other regulatory requirements as required.
I certify that I have not been terminated from an investigation due to compliance failure (debarment).
I agree to conduct the investigation(s) in accordance with the investigator agreement, investigational plan, current protocol, applicable regulatory requirements and regulations and conditions of approval imposed by the reviewing IRB.
I agree to personally conduct or supervise the described investigation.
I agree to ensure that all requirements of informed consent are met (if applicable).
I agree to submit sufficient accurate financial disclosure information and to promptly update this information if any relevant changes occur during the course of the investigation and for 1 year following completion of the study.
I agree not to use the device or permit it to be used for any purpose other than the investigational testing specified in the protocol.
I agree not to permit the device to be used before proper training has been given by myself, my study staff members, or sponsor.
I agree to maintain adequate and accurate records and to make those records available for inspection by the sponsor, its representatives, applicable regulatory authorities and the IRB.
I agree to comply with all other requirements regarding the obligations and responsibilities of investigators (21CFR 812.100 General responsibilities of investigators).
| | | |
|-------------------------------|---------------|----------|
| **Investigator Printed Name** | **Signature** | **Date** |
||
## PROTOCOL SYNOPSIS
| | |
| :---- | :---- |
| Clinical Study Protocol Title | FloodLAMP COVID-19 Test Development Study ||
| Protocol Number | 20210401 ||
| Sponsor | FloodLAMP Biotechnologies, PBC 930 Brittan Ave San Carlos, CA 94070 ||
| Investigational Products | FloodLAMP QuickColor TM Test, FloodLAMP QuickFluor TM Test, FloodLAMP EasyPCR TM Test, FloodLAMP Home Collection Kit ||
| Instruments and Software | RT-PCR Instruments, FloodLAMP Mobile App ||
| Controls | Not Provided but necessary: external positive control for the detection of SARS-CoV-2 and to monitor functioning of reagents along with a negative control, to monitor for contamination during sample processing. ||
| Proposed Intended Use | The FloodLAMP COVID-19 Tests comprise several molecular assays that utilize a streamlined sample preparation protocol. The assays include polymerase chain reaction (PCR) and reverse transcriptase loop-mediated isothermal amplification (RT-LAMP). The tests are intended for the qualitative detection of RNA from SARS-CoV-2 in anterior nares (nasal) swab specimens from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories. Sample pooling is at a baseline level of 4, with on-site and at-home modalities. Pooling of pools to levels greater than 20 will be investigated pending LoD determination and validation studies. Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities. Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information. The assay is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of real-time PCR and in vitro diagnostic procedures. The assay is only for use under the Food and Drug Administration’s Emergency Use Authorization. Use of the FloodLAMP QuickColor TM Test in a general, asymptomatic screening population is intended to be used as part of an infection control plan that may include additional preventative measures, such as a predefined serial testing plan or directed testing of high-risk individuals. Negative results do not preclude current or future infection obtained through community transmission or other exposures. Negative results must be considered in the context of an individual’s recent exposures, history, and presence of clinical signs and symptoms consistent with COVID-19. ||
| Study Overview | The study will include up to 100,000 unique clinical specimens (will depend on prevalence in the intended population) from across at least 3 geographically diverse testing in the United States. Additional sample collection sites may be brought on to ensure sufficient enrollment for the study. ||
| Clinical Specimen Categories | Fresh Prospective Frozen Prospective ||
| Inclusion/Exclusion Criteria | Inclusion: The specimen is an anterior nasal swab and QR code labeled tube included with the FloodLAMP Home Collection Kit. The swab specimen can be tested within 56 hours or less after collection. If frozen, specimens are to be stored at ≤-70℃ until tested. Subjects with any of the following: Suspected of COVID-19, whether or not symptomatic Not experiencing symptoms and/or who have not notified a physician that they suspect they have COVID-19 Had a positive COVID-19 test within the last 10 days The specimen is from a consenting male or female subject of any age Exclusion: The specimen was not properly collected, identified, transported, processed, or stored according to the instructions provided by the sponsor. The specimen was not collected under informed consent. ||
| Enrollment Dates | Approximately April 1, 2021 through April 1, 2022 ||
| Device Class | Class II, Nonsignificant Risk ||
| Primary Objective | The objective of this study is to generate clinical performance and usability data for the FloodLAMP QuickColor TM , QuickFluor TM , and EasyPCR TM Tests and FloodLAMP Home Collection Kit. ||
| Analysis Method | Upon completion of the clinical validation studies, Positive and Negative Percent Agreement for each target will be calculated and presented in 2x2 tables with the reference vs. subject device including 95% two-sided confidence intervals. ||
||
## 1. INTRODUCTION
### 1.1. BACKGROUND
The COVID-19 pandemic has revealed the value for new modalities of public health focused testing and screening. FloodLAMP's molecular tests and home collection kit combine streamlined extractionless, ultra-low cost, supply chain robust assay protocols with highly scalable at-home and on-site sample collection. Together these enable the new type of mass screening of interacting populations, such as schools and workplaces, to safely reopen society. Furthering this capability is needed (along with vaccines) to ultimately overcome the COVID-19 crisis, first in the U.S., then globally.
The populations most susceptible include the elderly over 65 years old and individuals who have preexisting comorbidities, including diabetes, obesity, and cardiovascular disease.
### 1.2. STUDY RATIONALE
The scope of the study is to validate the FloodLAMP COVID-19 Tests and Home Collection Kit with up to 100,000 unique clinical specimens from across three geographically diverse testing sites in the United States. Number of enrolled patients should be sufficient to ensure at least 20 positive samples are prospectively collected in the intended use populations. The results will be analyzed and compared against results from a CLIA lab that can run an EUA comparator test on dry swabs.
### 1.3. SAMPLE SIZE DETERMINATION
Will depend on the prevalence of SARS-CoV-2 in the intended use populations.
## 2. INVESTIGATIONAL DEVICE PROPOSED INTENDED USE STATEMENT
FloodLAMP QuickColor(TM) COVID-19 Test and FloodLAMP QuickFluor(TM) COVID-19 Test are reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assay. The FloodLAMP EasyPCR(TM) COVID-19 Test is a real-time reverse transcriptase polymerase chain reaction (RT-qPCR) assay. The tests are intended for the qualitative detection of RNA from SARS-CoV-2 in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs from individuals suspected of COVID-19 by their healthcare provider and from individuals without symptoms or other epidemiological reasons to suspect COVID-19 infection, when tested at a weekly interval with no more than 9 days between tests. Testing is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, to perform high complexity tests, or by similarly qualified non-U.S. laboratories.
Results are for the identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in upper respiratory specimens including nasopharyngeal swabs, anterior nasal and mid-turbinate nasal swabs during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA; clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all test results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
The FloodLAMP COVID-19 Tests are intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of *in vitro* diagnostic procedures. The FloodLAMP COVID-19 Tests are only for use under the Food and Drug Administration’s Emergency Use Authorization.
## 3. STUDY OBJECTIVE
The objective of this study is to generate clinical performance data for the FloodLAMP QuickColor(TM) COVID-19 Test, FloodLAMP QuickFluor(TM) COVID-19 Test, FloodLAMP EasyPCR(TM) COVID-19 Test, and the FloodLAMP Home Collection Kit.
## 4. STUDY DESIGN OVERVIEW
### 4.1. PROTOCOL SUMMARY
The purpose of this study is to determine the accuracy and usability of the FloodLAMP COVID-19 Tests and Home Collection Kit in the intended populations compared to a CLIA lab that can run an EUA comparator test on dry swabs. The primary outcome of the study will be to determine the sensitivity and specificity of the FloodLAMP COVID-19 Tests and usability of the Home Collection Kit.
Three modes of sample collection will be stratified:
**Variation 1**: The collection site is co-located with a current testing program for Persons Suspected of COVID that is utilizing a high sensitivity EUA PCR test, e.g., adjacent to Stanford or San Francisco city testing site. After completion of the EUA test specimen collection, the participant would be asked if they would like to participate in the FloodLAMP research study. If the participant accepts, a self-collection kit would be offered, and participants would collect according to printed instructions. Optionally, they may be asked if they would like to download the FloodLAMP app and follow collection instructions through the app. Participants would place the collected specimen tube in a biobag and deposit the biobag in a collection bin.
**Variation 2**: FloodLAMP would independently run a physical or mobile site (e.g., at tent outside the FloodLAMP lab in a parking lot), in the form of a drive thru. A self-collection kit would be picked up by participants or be handed through a car window. Specimens would be collected in the car according to instructions (printed or through app), specimen tubes placed in a biobag, and deposited into a collection bin.
**Variation 3**: Self-collection kits will be distributed, either at the sites described above, other physical locations or through delivery by mail or courier. These are termed "home" collection kits though they may be utilized in a workplace setting, in a car, or at other locations. The home kits will include variations for self-collection of both pooled specimens and individual collected samples. The home collection may include testing of the FloodLAMP app and involve user factors testing with surveys and other interactions with participants.
In all three variations, initial studies will comprise collection of two anterior nares swabs whereby the order of collection is randomized. In Variations 2 & 3, one swab would be sent to a CLIA lab to run an EUA approved Comparator test. The other swab would be used to run the FloodLAMP COVID-19 Tests. Subsequent studies may include collection of other specimen types, including saliva.
Recruitment would be performed online or through other standard means. Optionally, self-collection kits for multiple collections may be provided. Specimens may be pooled for validation studies.
Variations in the self-collection kits will include both supervised and unsupervised versions. Supervision may be provided in person at physical sites or remotely through video for collection in a participant's home or car.
### 4.2. PRIMARY MEASURE OF PERFORMANCE
The results of the FloodLAMP COVID-19 Tests will be compared against results from a reference test for the same set of patient specimens.
***Examination and Interpretation of Patient Specimen Results:***
Assessment of the FloodLAMP COVID-19 Tests of clinical specimen test results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted. Results will be interpreted according to the Instructions for Use.
### 4.3. ACCEPTANCE CRITERIA
Upon completion of the clinical validation studies, Positive and Negative Agreement for each target will be calculated and data stratified as previously described.
Figure 1: Study Workflow
```mermaid
flowchart TD
A["Sample Collection
Meet inclusion/exclusion
criteria"] --> B{"N<=100,000"}
B --> C["Specimen processing
Take two of nasal
swabs from anterior
nares"]
C --> D["Subject device testing
Nasal swabs"]
C --> E["Comparator device testing
NP swabs"]
D --> F["Analysis performed and results
documented on case report
form CRF"]
E --> F
```
Dry swabs should be processed within 56 hours from collection.
If frozen, specimens are to be stored at ≤-70°C until tested.
## 5. DEVICE DESCRIPTION
See Instructions for Use: Principles of Procedure
### 5.1. INVESTIGATIONAL USE ONLY KIT CONFIGURATION
See Instructions for Use: Materials Provided but Not Required
### 5.2. REAGENTS, CONSUMABLES AND EQUIPMENT REQUIRED BUT NOT PROVIDED
See Instructions for Use: Standard Lab Equipment and Consumables
### 5.3. REAGENT HANDLING AND STORAGE
See Instructions for Use: Materials Provided but Not Required
### 5.4. CONTROLS
See Instructions for Use: Running Tests - Controls Preparation, Results Interpretation - Test Controls
### 5.5. INSTRUMENTS AND SOFTWARE
See Instructions for Use: Running Tests
## 6. STUDY SPECIMENS
### 6.1. SPECIMEN SELECTION
The enrollment period will span from the date of first specimen is enrolled to the date of last specimen is enrolled at a site as determined by the Sponsor. Valid specimens are those that meet the criteria outlined in sections 7.2 and 7.3. Patient informed consent (documented using forms provided by the site, provided online, or within the FloodLAMP Mobile App) will be required for this study. No results derived from the investigational device will be included as part of any subject patient management diagnostic algorithm.
### 6.2. INCLUSION CRITERIA
Specimens must meet **all** the below criteria to be considered for study enrollment.
1. The specimen is an anterior nasal swab using the swab and QR code labeled tubes included with the FloodLAMP Home Collection Kit.
2. The swab specimen can be tested within 56 hours of collection. If frozen, specimens are to be stored at ≤-70℃ until tested.
3. Subjects with any of the following:
- Suspected of COVID, whether or not symptomatic
- Not experiencing symptoms and/or who have not notified a physician that they suspect they have COVID-19
- Had a positive COVID test within the last 10 days
4. The specimen is from a consenting male or female subject of any age.
### 6.3. EXCLUSION CRITERIA
Specimens that meet **any** of the below criteria may not be considered for study enrollment.
1. The specimen was not properly collected, identified, transported, processed, or stored according to the instructions provided by the sponsor.
2. The specimen was collected at a site which is not covered under the study IRB.
## 7. STUDY PROCEDURE
### 7.1. BLINDING OF THE STUDY AND PROCEDURES TO MINIMIZE BIAS
In order to preserve the confidentiality of subjects, the following procedures will be implemented:
1. Clinical data will be de-identified.
2. Available clinical information will be provided in such a way that it does not make the subject identifiable.
3. No personal identifiers or protected health information (PHI) will be collected or included as part of any study data so the confidentiality of each subject is protected.
4. Patient specimens will be assigned a unique study number by an individual with no direct involvement in the study (Honest Broker).
5. Testing personnel will not have access to any prior clinical data or reference method (comparator) results.
### 7.2. SAMPLE TYPES, SAMPLE COLLECTION, PROCESSING AND STORAGE
#### 7.2.1. Specimen Types
**Fresh Prospective**
Best efforts will be made to enroll and test at least 20 fresh, prospectively (FDA guidance for asymptomatic testing) collected, confirmed SARS-CoV-2 positive subjects. A combination of fresh and frozen specimens may be tested to reach the 20 asymptomatic subjects required.
#### 7.2.2. Specimen Collection and Processing
**Refer to the Instructions for Use**
FloodLAMP COVID-19 Test swab samples should preferably not be frozen or refrigerated prior to elution and should be tested within 56 hours from collection. If frozen, specimens are to be stored at ≤-70℃ until tested.
### 7.3. QUALITY CONTROL
***Procedural Control:***
Prior to testing patient specimens, QC for each test system should be run according to local, state and federal regulations and the Instructions for Use.
***External Positive and Negative Controls:***
One positive and one negative control will be included on every 96-well plate with up to 94 samples, or with every batch of strip tubes on each heater. All test controls should be examined prior to interpretation of patient specimen results. If the controls are not valid and the expected result, the specimen results cannot be interpreted. Refer to the Instructions for Use.
### 7.4. REFERENCE METHOD
Results from the subject device will be compared to a high sensitivity purified PCR EUA Authorized test. Reference testing may be performed at one or more of the clinical trial sites or a centralized testing laboratory. If a site is also conducting testing of the subject device, different personnel will be assigned to oversee and perform reference testing.
## 8. RESULTS
### 8.1. RESULTS INTERPRETATION
Refer to the Instructions for Use.
Assessment of the results of FloodLAMP Tests should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted.
### 8.2. DATA COLLECTION
**Demographic Data**
Age/age range, gender and ethnicity will be collected on each subject enrolled in the study.
**Missing Data**
If required data are missing for any subject, then the results of any testing may be excluded from the final data analysis set. An explanation will be provided in the EUA submission.
**Determination of Sample Size**
The total number of subjects that will be included in the study will depend on the prevalence of specimens that meet the inclusion criteria.
## 9. REGULATORY AND ADMINISTRATIVE REQUIREMENTS
### 9.1. PROTOCOL AMENDMENTS
Any modification to the protocol, which may impact on the conduct of the study, including changes of study objectives, study design, patient population, study procedures, and significant administrative aspects, will require a formal amendment to the protocol.
The approval letter, signed/approved by the IRB chairman, must refer specifically to the Investigator, the Sponsor protocol number, the protocol title, the protocol amendment number and the date of the protocol amendment.
Administrative changes to the protocol are minor corrections and/or clarifications that have no impact on the way the study is to be conducted and may not indicate an IRB formal review. These administrative changes will be agreed upon by the Sponsor and the Investigator. The IRB may be notified of administrative changes at the discretion of the Investigator.
### 9.2. DOCUMENTING AND HANDLING OF DEVIATIONS FROM THE PROTOCOL
Deviations to the protocol will be noted in the EUA Submission.
### 9.3. RECORD RETENTION
All records and documents pertaining to the conduct of the study, including but not limited to Electronic Data Record Form for a period of at least two years after the last approval of a marketing application in an ICH region and until there are no pending or contemplated marketing applications in and ICH region or at least two years have elapsed since the formal discontinuation of clinical development of the investigational product. These documents should be retained for a longer period, however, if required by the regulatory requirements or by an agreement with the Sponsor (Good Clinical Practice: Consolidated Guidance (ICH-E6 section 4.9.5)).
### 9.4. CASE REPORT FORMS (CRF)
Individual subject’s data will be recorded. No personal identifiers will be recorded on this form and at no point during the study (including the sample retention period) will the Investigator, study personnel, or the Sponsor, have access to patient identifiers.
### 9.5. MONITORING OF STUDY SITES
The clinical study shall be monitored by the trained clinical study personnel or designated representative via remote communications and/or on-site visits throughout the duration of the study. The study staff member or designated representative shall discuss any issues or problems concerning the conduct of the study with the Investigator and/or Sponsor.
### 9.6. QUALITY ASSURANCE AUDITS
During the study, representatives from the Sponsor may visit the site to carry out an audit of the study. Such an audit will require access to records that are relevant to the study. Sufficient prior notice will be provided to allow the investigator to prepare properly for the audit. Similar auditing procedures may also be conducted by agents of applicable regulatory agencies reviewing the results of the study. Participation in this study implies acceptance of potential inspections by the Sponsor or applicable regulatory authorities.
### 9.7. STUDY COMPLETION AND CLOSE OUT
Upon completion of the study, the Investigator shall notify the IRB of the conclusion of the study. The final report will be sent to the IRB.
## 10. STATISTICAL ANALYSES
Upon completion of the clinical validation studies, Positive and Negative Percent Agreement for each reportable target will be calculated and presented in 2x2 tables with the reference vs. subject device. Data will be combined across sites.
Initial call rates will be calculated. For specimens with invalid results, regardless of the reason, one repeat per specimen will be permitted. Final call rates will then be calculated using the results from the repeat analyses.
**Exclusion of Specimens from Analysis**
Any specimens that do not meet the Inclusion/Exclusion criteria will be removed from the final data set with a rationale provided in the EUA submission.
## 11. RISK ANALYSIS
### 11.1. CLINICAL STUDY SITES AND INFORMED CONSENT
This study has been determined by the Sponsor to be a Nonsignificant Risk. Each site will be responsible for submitting the Clinical Study Protocol and associated templates for institutional/third party IRB review and approval prior to study initiation. Subject recruitment will be performed, and informed consent will be required for this study. The testing personnel and sites will represent the environment for which the device is intended.
## 12. SAFETY
**DEFINITIONS**
Adverse Event
An adverse event (AE) is any untoward medical occurrence, unintended disease or injury or any untoward clinical signs (including any abnormal medical finding) in subjects, users, or other persons whether or not related to the investigational medical device.
Serious Adverse Device Effect
Adverse device effect that has resulted in any of the consequences characteristic of a serious adverse event.
Unanticipated Serious Adverse Device Effect (USADE)
Serious adverse device effect which by its nature, incidence, severity or outcome has not been identified in the current version of the risk analysis report.
NOTE: Anticipated: an effect which by its nature, incidence, severity or outcome has been previously identified
## 13. ETHICS
Use of human subjects in this evaluation will be subject to approval by an Institutional Review Board (IRB). Written statements of the IRB approvals of this protocol will be documented in the study file. The current investigation is in accordance with 21 CFR Part 812 (c)(3) and the FDA Information Sheet Guidance for IRBs, Clinical Investigators, and Sponsors (January 2006).
## 14. ASSOCIATED DOCUMENTS
14.1. Instructions for Use FloodLAMP QuickColor(TM) COVID-19 Test v1.0
14.2. Instructions for Use FloodLAMP QuickFluor(TM) COVID-19 Test v1.0
14.3. Instructions for Use FloodLAMP EasyPCR(TM) COVID-19 Test v1.0
14.4. Instructions for Use FloodLAMP Home Collection Kit
14.5. Research Subject Information and Consent Form
14.6. Case Report Form
# 2,965 IRB - FloodLAMP Informed Consent 20210401 v01.md
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last updated: 2025-12-18 RT
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summary_short: The FloodLAMP COVID-19 Biobank and Test Validation Protocol informed consent form explains voluntary participation in donating biospecimens (e.g., blood, saliva, and various swabs) and optional surveys for research and test development. It outlines what participants should expect (no individual results, minimal risks, possible re-contact), how samples/data are coded and de-identified under HIPAA, and who may access or receive shared de-identified data. It also discloses ownership and potential commercialization of specimens/data, participant rights to withdraw, and oversight by an independent IRB.
CONTENT
***INTERNAL TITLE:*** RESEARCH SUBJECT INFORMATION AND CONSENT FORM
**TITLE:** FloodLAMP COVID-19 Biobank and Test Validation Protocol
**PROTOCOL NO.:** 20210401
**SPONSOR:** FloodLAMP Biotechnologies, Public Benefit Corporation
**INVESTIGATOR:** Randall True
FloodLAMP Biotechnologies, PBC
930 Brittan Ave
San Carlos, CA 94070
USA
**STUDY-RELATED**
**PHONE NUMBER(S):** xxx-xxx-xxxx between 9:00 AM \- 5:00 PM PST
## Part 1: Information and Consent Form
**Why is this research being done?**
The purpose of this study is to collect biological samples (also called specimens) for research use in FloodLAMP's laboratory. Examples of biological samples include blood, saliva, nasal swabs, throat swabs, nostril swabs, and cheek swabs. These samples may be used to develop new tests and/or evaluate and improve existing tests such as tests to detect viruses such as SARS-CoV-2.
The researchers in this study are employees of and own equity interest in the sponsor company,
FloodLAMP Biotechnologies, PBC. Please feel free to ask any further questions you might have about this matter.
**How many people will be in this study?**
We may enroll up to 100,000 people in this research study.
**What will happen if I join this study?**
We will ask you to sign this Consent Form prior to collection of your biological specimens, and we may ask you to complete a short survey. Your participation in this study is voluntary. You are not required to answer any additional questions and can always say "No". If you choose to participate in this study, we will ask you to affirm that you have read and agree to the study consent form by signing your name.
We will then ask you to provide one or more biological samples including blood, saliva, sputum,
nasal (nasopharyngeal), throat (oropharyngeal), nostril (anterior nares), and check (buccal).
Samples will be self-collected and/or collected by trained personnel.
* **Blood Draw:** To donate a blood sample, you will have your blood drawn (about 1
tablespoon). It will take you about 10-15 minutes to donate a blood sample.
* **Saliva Spit:** To donate a saliva sample, you will spit (about 2 teaspoons) directly into a collection container. It will take you about 5 minutes to donate each saliva sample.
* **Sputum Cough:** To donate a sputum sample, you will first rinse your mouth with water and then produce a deep cough that produces mucus, which you will spit directly into a collection container. It will take you about 5 minutes to donate each sputum sample.
* **Nasopharyngeal (NP) Swab:** To donate a nasopharyngeal sample you will tilt your head back, and a swab will be inserted in your nostril. The swab will be left in place for several seconds to absorb secretions before removing. This procedure may be performed in both nostrils. It will take you about 5 minutes to donate each nasopharyngeal sample.
* **Oropharyngeal (Throat) Swab:** To donate an oropharyngeal sample, a swab will be inserted into your mouth and the back and sides of your throat will be swabbed (posterior pharynx and tonsillar areas). It will take you about 5 minutes to donate each oropharyngeal sample
* **Anterior Nares (AN, Nasal) Swab:** To donate an anterior nares sample, you will insert a swab into your nostril and swab the inside of your nostril. Repeat for the other nostril. It will take you about 5 minutes to donate each anterior nares sample.
* **Buccal (Cheek) Swab:** To donate a buccal sample, you will insert a swab into your mouth between the cheek and upper gum and swab the inner cheek. It will take you about 5 minutes to donate each buccal swab sample.
At the time of donation, we will also describe the collection method for each sample type in-person. You are not required to provide any or all of the requested sample types, and you can always say "No".
All samples will be collected on an as-needed and volunteer basis. Your sample will not be labeled with any of your identifiable information but will be assigned a unique code for re-contacting purposes. We may re-contact you by phone or email sometime in the future to collect another set of samples. You are not required to provide another set of samples, and you can always say "No".
Your participation in this study involves you giving broad consent. This means that you allow your information and samples to be used for a variety of future research which will be reviewed by an Independent Review Board (IRS), but which cannot be specified at this present time.
**Will I receive results?**
No, you will not receive any results as part of this research study.
**What are my other options?**
This is not a treatment trial. You may choose not to participate in this study.
**What are the benefits of participating in the study?**
There is no direct benefit to you for participating in this research study. However, by participating in this research study, you are contributing to scientific knowledge that may lead to new discoveries that could indirectly benefit you or your family members.
**What are the risks or discomforts of the study?**
The risk of participating in this study is minimal. For blood draws, you may experience bruising and swelling around the puncture site, dizziness or fainting, or infection (rare) during the blood draw.
For nasal swabs and throat swabs, you may experience some mild pain or feel a little discomfort
during the collection process. You may gag a little or experience a minor nosebleed after some of the swab collection processes. You can stop or withdraw from providing a sample at any time.
There is a potential risk of breach of confidentiality.
There may be other risks to you that are unknown.
**Will it cost me anything to be in this study?**
No, there is no cost to you to participate in this research study.
**Will I be paid if I join this study?**
Participation in this study is voluntary and you are not guaranteed payment. However, some sample collection visits and/or surveys may be eligible for monetary or cash equivalents in the form of gift cards, as compensation for your time, travel, and/or any other inconveniences related to your participation. If you are eligible for a sample collection visit and/or survey that offers compensation, you will be provided additional information about compensation prior to your visit.
**How long is the study?**
The study does not currently have a set end date, but your active participation ends after completion of specimen collection and the survey. We may re-contact you by phone or email sometime in the future to request another set of samples
**Can I leave the study early?**
Yes. Your participation in this research study is voluntary. You may choose not to participate or
change your mind at any time and for any reason without penalty or loss of benefits to which you are otherwise entitled. If you decide to leave the research study, contact FloodLAMP at
650- 394-5233 between 9:00 AM \- 5:00 PM PST or email support@FloodLAMP.bio. If you withdraw from this study, your samples and the data derived from your samples and other information will be destroyed if possible. Data that are already being used for research cannot be destroyed or removed.
**How will my privacy be protected?**
The information we gather from you for this study will be kept confidential and managed according to the requirements of HIPAA. These include the right to know who will be able to get your information and why they may be able to get it. Our lab will assign an anonymous identifier to each sample, which will be used in our research. For FloodLAMP research purposes, all individually identifiable information will be de-identified using the HIPAA Safe Harbor method for de-identification of protected health information (see 45 CFR 164.514).
**Who will have access to my information?**
FloodLAMP will have access to your information. All information will be stored in a secure password protected database or, in the case of paper documents, in a secure location at FloodLAMP. Your sample and information will be de-identified, meaning certain identifying information that associates such samples and information with you will be removed. Samples will be coded with a number which can only be linked to your identifying information by FloodLAMP. FloodLAMP will use information collected through this study for research purposes, including product development and/or improvement.
At FloodLAMP, we believe that sharing scientific data will help accelerate the pace of discoveries. Your deidentified sample and information may be accessed by third-party research institutions. Any identifying information that associates such samples and information with you will be removed.
Your private information and your medical record will be shared with individuals and organizations that conduct or watch over this research, including:
* The research sponsor
* People who work with the research sponsor
* The Institutional Review Board (IRB) that reviewed this research
We may publish the results of this research. However, we will keep your name and other identifying information confidential.
We protect your information from disclosure to others to the extent required by law. We cannot promise complete secrecy.
**Potential Commercial Interest**
By signing this consent, you agree that your specimen and any data associated with such specimen will be owned by FloodLAMP. If a commercial product or service is developed from this study, the commercial product will be owned by FloodLAMP or its designee. By taking part in this study, you agree that FloodLAMP (and other research groups or organizations) are free to apply for and use intellectual property (including patents) relating to any inventions arising from this research.
There are no plans to provide any financial compensation (money) or financial benefit or other benefit to you for such commercialization, and you will not profit financially from any products or services developed from your participation in this study.
**What do I do if I have any questions, concerns, complaints or feel I have a research-related problem about the study?**
If you have questions, concerns, or complaints, or think this research has hurt you or made you sick, talk to the research team at the phone number listed above on the first page.
FloodLAMP does not expect that any injury will result from your participation in this study. However, if you are injured as a direct result of study procedures, you will receive medical treatment. You and/or your health plan/insurance will be billed for this treatment. FloodLAMP has no plans to pay for this treatment. There are no plans to offer any type of payment for injury. However, by signing this form, you have not given up any of your legal rights. In the unlikely event that an injury does result from your participation in this study, you can contact FloodLAMP at xxx-xxx-xxxx between 9:00 AM \- 5:00 PM PST or email support@FloodLAMP.bio.
**What other things should I know about this research study?**
This study is approved by Western Institutional Review Board (WIRB). WIRB's objective is to protect the rights and welfare of the people taking part in human research studies. You may contact WIRB if you have questions about your rights as a participant, if you have questions, concerns, or complaints, or if you think you have not been treated fairly, at 360-252-2500 or Help@wirb.com.
## Part II. Certificate of Paper Consent or Signed Electronic Consent
I have read this Consent Form describing how my information will be stored, used, and disclosed for the FloodLAMP COVID-19 Biobank and Validation Protocol. My sample will be de-identified at the time of collection. I will not receive any results as part of this study. This study is voluntary; I am not required to provide any or all specimens and/or specimen types as part of this study. I have had a chance to ask questions about the storage, use, and disclosure of my information. My questions have been answered to my satisfaction, and I agree to participate in the FloodLAMP COVID-19 Biobank and Validation Protocol Study.
Name of participant: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Email: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Home address: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Signature of participant: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Signature of witness: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Signature of person obtaining consent: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\[Agree and Complete Enrollment\]
METADATA
last updated: 2026-03-10_105731
file_name: _archive-combined-files_ldts_242k.md
category: regulatory
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gfile_url: **FLAGGED - TBD user-facing Google-hosted public file URL**
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CONTENT
# _archive-combined-files_ldts_242k (13 files, 241,605 tokens)
# 7,034 _AI_COVID19_LDTs_FDA_Policy_Report.md
METADATA
last updated: 2026-03-01 AI
file_name: _AI_COVID19_LDTs_FDA_Policy_Report.md
file_date: 2026-03-01
title: FDA, LDTs, and COVID-19: Interactions, Policy Shifts, and Key Issues (2020-2023)
category: regulatory
subcategory: ldts
tags: ldts, fda, covid-19, eua, laboratory-developed-tests, enforcement-discretion
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notes: Created by ChatGPT Pro 5.2 Extended during archive preparation. **NOT HUMAN VERIFIED - MAY CONTAIN ERRORS** Detailed analysis of FDA policy actions, enforcement discretion shifts, and LDT oversight during COVID-19 (2020-2023), synthesizing GAO-22-104266, FDA COVID test policy guidance (7th edition), HHS rescission statements, and CDC LOCS alerts. Prompt not included.
summary_short: FDA, LDTs, and COVID-19 policy analysis covering three phases of LDT oversight during the pandemic: initial EUA-based enforcement discretion (early 2020), HHS blocking mandatory premarket review (Aug 2020-Nov 2021), and FDA's restoration of EUA-first posture (Nov 2021-2023). Includes detailed timeline, document index, and quantitative markers drawn primarily from GAO-22-104266 and FDA policy guidance.
CONTENT
***INTERNAL TITLE:*** FDA, LDTs, and COVID-19: Interactions, Policy Shifts, and Key Issues (2020-2023)
**Time window covered:** January 2020 - May 2023 (plus key transition guidance issued during the PHE through March 2023)
**Scope note:**
This report is narrowly focused on **COVID-19-era** interactions, guidance, enforcement policies, and disputes involving **laboratory-developed tests (LDTs)** and **FDA oversight**. It intentionally **does not repeat** (1) pre-pandemic LDT regulatory history or (2) the post-pandemic 2024 LDT Final Rule and later litigation that is covered in separate archive documents.
---
## Table of contents
1. What changed during COVID (executive overview)
2. Key terms and why “LDT vs FDA-authorized” mattered in practice
3. COVID-era policy mechanisms that shaped LDT oversight
4. Detailed timeline of policy actions (with “what changed” and “why it mattered”)
5. The major issues and disputes (quality, access, liability, payer acceptance, federal–state roles)
6. COVID-era document index (date, issuer, action, link)
7. Appendix: structured timeline table + key quantitative markers
---
## 1. What changed during COVID (executive overview)
Across the COVID-19 period, the LDT/FDA relationship moved through three distinct phases—each with a different answer to “*Does a COVID LDT need FDA authorization?*”
### Phase A — Early pandemic expansion with guardrails (Feb–Mar 2020)
- **FDA’s operational posture:** FDA expected COVID-19 diagnostic LDTs to pursue **EUA authorization**, but used **enforcement discretion** to let certain labs start testing **before** authorization if they validated, notified FDA, and submitted an EUA request on a defined timeline.
- **Key artifact:** FDA created **notification lists** to track tests being used while EUA review was pending.
### Phase B — HHS blocks mandatory FDA premarket review; FDA declines LDT EUA reviews (Aug–Oct 2020 → late 2021)
- **HHS action (Aug 19, 2020):** HHS stated FDA **“will not require premarket review”** of LDTs without notice-and-comment rulemaking, even during COVID-19.
- **FDA follow-on (Oct 2020):** FDA posted an FAQ indicating it was **declining to review** EUA requests for LDTs “at this time,” and CDC communicated this shift to laboratories.
### Phase C — HHS reverses; FDA rebuilds EUA-first posture and unwinds notification-list model (Nov 2021 → 2023)
- **HHS action (Nov 15, 2021):** HHS withdrew the 2020 policy, restoring FDA’s prior authority/approach.
- **FDA action (Nov 15, 2021 and later editions):** FDA issued revised COVID test policy guidance, generally expecting tests (including LDTs) to have EUA authorization before being offered, and took steps to **reduce unauthorized tests** remaining on notification lists.
**High-level impact:**
COVID forced repeated changes in what “LDT vs FDA-authorized test” meant in real-world terms—affecting **validation expectations, use environments (CLIA constraints), liability and PREP Act coverage messaging, payer/contracting acceptance, and FDA’s ability to intervene** when tests performed poorly.
---
## 2. Key terms (COVID-era operational definitions)
### 2.1 What the government meant by “LDT” during COVID
Across federal documents summarized below, an LDT is generally treated as an in vitro diagnostic test that is:
- **designed, manufactured, and used within a single laboratory**, and
- performed within a lab certified under **CLIA** that meets **high-complexity** testing requirements.
FDA and GAO also highlight boundary issues:
- FDA does **not** consider a test an LDT if it is designed/manufactured wholly or partly outside the lab that offers it.
- FDA officials told GAO that tests developed by **large multistate lab networks** can be treated as **commercial** tests if distributed to multiple labs in a network.
### 2.2 EUA-authorized vs “unauthorized but tolerated”
- **EUA-authorized test:** FDA has issued an EUA; the product is subject to conditions of authorization and becomes an official “authorized” countermeasure.
- **Unauthorized but tolerated test:** Offered under FDA’s enforcement discretion policies (early pandemic), under state/territory authorization (early pandemic), or as an LDT offered without EUA during the Aug 2020–Nov 2021 HHS policy period.
---
## 3. Policy mechanisms that shaped COVID-19 LDT oversight
### 3.1 EUA declaration: the legal trigger tying policy to emergency powers
FDA’s COVID test policy documents explicitly tie their duration and framework to the HHS Secretary’s **February 4, 2020** declaration under FD&C Act §564 for IVDs related to COVID-19. (FDA policy guidance cites 85 FR 7316 for the declaration.)
### 3.2 Enforcement discretion “lanes” to scale testing quickly
To expand capacity rapidly, FDA used enforcement discretion so that certain tests could be distributed/offered **before** EUA issuance. For LDTs, early discretion applied to **high-complexity CLIA labs** developing tests for use in their own lab.
### 3.3 Notification lists: a COVID-era operational bridge between “unauthorized” and “authorized”
GAO reports FDA maintained **four notification lists**: diagnostic LDTs, antibody LDTs, diagnostic commercial tests, and antibody commercial tests. Tests could remain on these lists while FDA reviewed EUA requests.
### 3.4 State/territory authorization option (March 2020 policy)
FDA created a policy for states/territories to authorize labs within their borders to develop and use COVID tests without EUA submission to FDA. GAO reports eight states and Puerto Rico notified FDA of intent to do this; six states authorized labs and used FDA guidance as they built review processes.
### 3.5 Continuous interaction channels: pre‑EUA, templates, and Town Halls
GAO documents several mechanisms that functioned as “interaction infrastructure” between FDA and test developers:
- **EUA templates** (available by request in January 2020; posted Feb 29, 2020; eight templates on website by Nov 2021).
- **Pre‑EUA process** (GAO reports 1,275 pre‑EUA requests for COVID tests Jan 2020–Sep 2021).
- **Weekly/biweekly public Town Hall calls** (beginning March 25, 2020; GAO reports 70 town halls held by Sept 30, 2021).
---
## 4. Detailed timeline of LDT–FDA policy actions during COVID-19
### Legend
Each timeline entry is presented as:
- **Date**
- **Actor / venue**
- **Action / document**
- **What changed for LDTs vs FDA-authorized tests**
- **Why it mattered (issues / controversy)**
---
### 4.1 January–February 2020: emergency declarations and EUA authority
#### Jan 31, 2020 — HHS public health emergency (PHS Act §319)
- **Actor:** HHS
- **Action:** Declared a public health emergency related to COVID-19; mobilized HHS operating divisions.
- **Why it mattered:** Establishes the emergency context referenced in later FDA policy background.
#### Feb 4, 2020 — HHS EUA declaration for COVID IVDs (FD&C Act §564)
- **Actor:** HHS
- **Action:** Declared circumstances exist justifying EUA issuance for COVID-related in vitro diagnostics.
- **Why it mattered for LDTs:** During declared emergencies, FDA historically did **not** apply broad LDT enforcement discretion; this set up the later tension between “normal LDT discretion” and emergency oversight.
**Primary anchor:** FDA COVID test policy guidance (7th edition, Jan 12, 2023) + referenced Federal Register citation.
---
### 4.2 Feb 29, 2020: FDA opens a rapid diagnostic LDT pathway (validate → notify → file EUA)
#### Feb 29, 2020 — FDA enforcement discretion policy for diagnostic LDTs
- **Actor:** FDA
- **Action (as summarized by GAO):** FDA said it did not intend to object to high‑complexity CLIA labs using validated diagnostic LDTs **prior to authorization**, as long as labs (1) validated, (2) notified FDA, and (3) submitted an EUA request within **15 business days** after notification.
- **LDT vs FDA-authorized distinction at this point:** LDTs could be used *temporarily* without EUA, but EUA submission remained the expected endpoint.
- **Operational detail:** After notification, FDA placed tests on a “notification list.”
**Why it mattered:**
This policy was meant to increase testing capacity rapidly while still channeling tests toward EUA authorization as the durability/credibility step.
**Source:** GAO narrative and Appendix II.
---
### 4.3 March 16, 2020: FDA expands the model (commercial tests), adds serology flexibility, and decentralizes via states
#### March 16, 2020 — Commercial diagnostic test enforcement discretion lane
- **Actor:** FDA
- **Action (GAO):** Similar “validate → notify → submit EUA within 15 business days” lane extended to commercial diagnostic tests; FDA later clarified use was limited to high‑complexity CLIA labs unless an EUA expanded environments.
- **Why it mattered:** Enlarged the pool of tests available quickly, but increased the volume of “unauthorized but tolerated” tests awaiting review.
#### March 16, 2020 — Antibody/serology policy (initially no EUA expected)
- **Actor:** FDA
- **Action (GAO):** FDA initially did not expect antibody test developers (including laboratories) to seek EUA if they validated, notified FDA, and included specific disclaimers in reports.
- **Why it mattered:** This permissive approach led to the “serology flood” problem—an important cautionary example used in later policy debates about whether LDT oversight should be loosened or tightened during emergencies.
#### March 16, 2020 — State/territory authorization policy for LDTs
- **Actor:** FDA
- **Action (GAO):** FDA said it did not intend to object to states/territories authorizing laboratories within their jurisdiction to develop and use COVID-19 LDTs without EUA submission to FDA.
- **Documented uptake:** GAO reports **eight states and Puerto Rico** notified FDA; six states authorized laboratories; and those states used FDA guidance in building review processes. GAO reports that as of April 2021 those six states had authorized **91 laboratories** that developed **121 molecular tests**, and **19 laboratories** that developed **23 antibody tests**.
**Why it mattered:**
Created a meaningful alternative to FDA EUA review, but with the tradeoff of unevenness and questions about standardization and accountability.
**Source:** GAO narrative.
---
### 4.4 April–May 2020: serology quality concerns drive tightening
#### April 2020 — Interagency serology evaluation collaborations
- **Actor:** FDA + NCI + NIAID + CDC + BARDA
- **Action (GAO):** Partnered to evaluate antibody test performance to inform authorization decisions and address market quality concerns.
#### May 4, 2020 — FDA tightens antibody test pathway
- **Actor:** FDA
- **Action (GAO):** FDA revised policy to expect commercial manufacturers of antibody tests to submit EUA requests within **10 business days** (labs encouraged but not required).
- **Market cleanup:** GAO reports FDA removed **268** commercially developed antibody tests from its notification list as of July 30, 2021 when manufacturers did not submit an EUA within the deadline or did not address significant problems in time.
**Why it mattered:**
This is a core “policy learning” moment: loosening premarket oversight can expand availability fast, but can also flood the market with weak tests—inviting later tightening.
**Source:** GAO narrative and Appendix II.
---
### 4.5 Aug–Oct 2020: HHS blocks mandatory FDA premarket review; FDA declines to review LDT EUA submissions
#### Aug 19, 2020 — HHS web statement limiting FDA premarket review of LDTs
- **Actor:** HHS
- **Document:** “Rescission of Guidances and Other Informal Issuances Concerning Premarket Review of Laboratory Developed Tests” (HHS web statement; archived copy).
- **Key language (short excerpt, <25 words):** HHS determined FDA “**will not require premarket review**” of LDTs absent “**notice-and-comment rulemaking**.”
- **Additional HHS points (paraphrased):**
- EUA/510(k)/PMA submissions for LDTs could be made **voluntarily**, and FDA would adjudicate.
- LDTs used without FDA review would not be eligible for **PREP Act coverage** absent approval/clearance/authorization, and would remain regulated under **CLIA/CMS**.
- Active EUAs for COVID-19 LDTs were unaffected.
**Why it mattered:**
This reversed the early COVID posture that treated EUA as the expected requirement for COVID LDTs and created a period where “LDT without EUA” was legally permissible under the federal executive branch’s stated position.
**Primary source:** archived HHS statement PDF.
#### Oct 7, 2020 — FDA posts FAQ: “declining to review EUA requests for LDTs”
- **Actor:** FDA
- **Action:** FDA posted an FAQ clarifying review priorities and stating it was “declining to review EUA requests for LDTs at this time.”
#### Oct 9, 2020 — CDC LOCS lab alert: communicates the shift
- **Actor:** CDC (LOCS)
- **Document:** “Lab Alert: FDA Suspends Review of EUA Requests for Laboratory-Developed Tests for SARS-CoV-2”
- **Key point:** In alignment with the HHS announcement, FDA “will not review EUA requests for any LDTs at this time,” and CDC directs labs to FDA FAQs and HHS FAQs resources.
**Why it mattered / issues flagged:**
GAO reports lab associations described confusion and uncertainty—particularly around payer expectations and PREP Act liability protection for LDTs without EUA authorization.
**Sources:** CDC LOCS alert; GAO text box on LDT EUA policy changes.
---
### 4.6 2021: FDA review prioritization, screening focus, and the lead-up to reversal
#### March 16, 2021 — FDA streamlining path for serial screening tools (including at-home/OTC)
- **Actor:** FDA
- **Action (GAO Appendix II):** FDA announced steps to streamline authorization for serial screening of asymptomatic individuals, including at-home and OTC tests.
- **Why it matters for LDT policy:** Shows FDA’s emphasis on resource allocation and public-health impact in deciding what to prioritize for EUA review.
#### 2020–Sep 2021: “decline to review” as an operational lever
- **Actor:** FDA
- **Action (GAO):** FDA prioritized EUA review for tests that increased accessibility (POC, home collection, at-home) or capacity (high throughput, supply-sparing). GAO reports that as of Sept 30, 2021 FDA had declined to review **558** EUA requests, including **230 LDTs**.
- **Why it mattered:** Even where EUA submission could be “voluntary” (Aug 2020–Nov 2021), FDA’s decision to decline review functionally shaped the market.
**Source:** GAO narrative.
---
### 4.7 Nov 15, 2021: HHS withdraws the 2020 policy; FDA issues revised COVID tests policy and begins unwinding notification lists
#### Nov 15, 2021 — HHS withdrawal of the Aug 2020 policy
- **Actor:** HHS
- **Action (GAO Appendix II):** Withdrew the August 2020 policy, thereby reinstating FDA’s approach to regulating COVID-19 LDTs.
- **Stated rationale (as widely reported):** The 2020 policy “limited FDA’s ability to address certain problematic COVID-19 tests.”
**Sources:** GAO Appendix II; JAMA commentary discussing the withdrawal rationale.
#### Nov 15, 2021 — FDA revised COVID tests policy (key LDT-relevant elements, per GAO)
GAO summarizes that FDA’s updated guidance:
- generally expected COVID tests to have EUA authorization before being offered;
- would no longer add commercial or LDT tests to notification lists;
- would no longer apply the March 2020 state authorization policy to **additional** states/territories; and
- expected labs offering LDTs without EUA submissions to submit an EUA request within **60 calendar days** or cease marketing/offering (GAO summary).
**Why it mattered:**
This was a decisive move away from the early-pandemic “notify and list” model, driven by concerns that tests remained available for months without full review.
**Source:** GAO Appendix II; GAO discussion of notification list durations and risks.
---
### 4.8 2022–Jan 2023: continued EUA-first posture, with clarifications for legacy pathways
#### Notification list persistence and the November 2021 “phase down”
GAO quantifies why FDA intervened:
- In June 2021, the longest commercial antibody test stayed on a notification list **359 days** before FDA declined authorization.
- GAO found 65% of commercial diagnostic tests on notification lists in Nov 2021 had been listed for **at least a year**.
- As of April 8, 2022, GAO reports **68 tests remained** on notification lists, including **26** lab-developed diagnostic tests and **25** lab-developed antibody tests.
FDA’s Nov 2021 policy sought to reduce this backlog and phase the lists out.
**Source:** GAO narrative.
#### Jan 12, 2023 — FDA issues 7th edition COVID test policy (within the EUA declaration period)
- **Actor:** FDA
- **Document:** “Policy for Coronavirus Disease-2019 Tests (Revised)” (7th edition; supersedes Sep 27, 2022 edition)
- **Notable LDT-specific clarifications:**
1) **State/territory authorization narrowed:**
FDA reiterates it no longer intends to extend the state policy to new states/territories. For states/territories already listed before Nov 15, 2021 and continuing to authorize labs, FDA does not intend to object where the state/territory takes responsibility—limited to single-site high-complexity CLIA labs and excluding at-home/home collection tests.
2) **Handling of certain “legacy” LDTs tied to the Aug 2020–Nov 2021 period:**
FDA does not intend to object to continued distribution while FDA reviews EUA requests for (a) tests on notification lists and (b) certain LDTs offered during the Aug 2020–Nov 2021 window where an EUA request was later submitted per the Nov 2021 approach. If FDA declines to review/authorize, it generally expects cessation within **15 calendar days**.
**Why it mattered:**
This edition shows how FDA operationalized the “reasserted authority” phase: keeping limited accommodation for tests already in motion, while reinforcing EUA-first expectations.
**Source:** FDA policy guidance (Jan 12, 2023).
---
### 4.9 March–May 2023: transition planning as the PHE ended
#### March 27, 2023 — FDA EUA transition plan (final guidance)
- **Actor:** FDA
- **Document:** “Transition Plan for Medical Devices Issued EUAs Related to COVID-19”
- **LDT-specific statement (paraphrased):** FDA generally exercises enforcement discretion for LDTs, but did not apply that discretion to LDTs used for declared emergencies under §564; **after termination of the EUA declaration for COVID IVDs, FDA intends to treat COVID-19 LDTs like other LDTs**.
**Why it mattered:**
Signals that COVID-era heightened oversight of LDTs was tied to the EUA declaration; once EUA authority ends, the default LDT enforcement approach returns.
**Source:** FDA transition plan guidance (Mar 27, 2023).
#### May 11, 2023 — COVID-19 PHE expires (PHS Act §319)
- **Actor:** HHS (PHE expiration) + FDA communications
- **FDA summary (as of Nov 8, 2023 update):** Enforcement policy guidances tied to the PHE (within scope of FDA’s transition plan for enforcement policies) are no longer in effect; **existing EUAs remain in effect** under FD&C Act §564 until EUA declarations terminate.
**Source:** FDA SARS-CoV-2 testing FAQs page.
---
## 5. The major issues and disputes during COVID (as reflected in government reporting and policy pivots)
### 5.1 Access vs oversight: the “speed–quality” balancing act
- **Access pressure:** Early in the pandemic, stakeholders told GAO that EUA processes may have stymied scaling when testing capacity was limited; some would have preferred FDA not object to LDT use without EUA sooner.
- **Oversight pressure:** FDA officials emphasized that poorly performing tests could undermine emergency response; the serology episode became a vivid case for tightening.
### 5.2 Serology: a cautionary example that shaped broader policy attitudes
GAO highlights that poorly performing or fraudulent antibody tests flooded the market under early permissive policy, prompting:
- May 4, 2020 tightening,
- interagency performance evaluations, and
- large-scale removals from notification lists.
This event became a reference point for arguments that “flexibility without robust validation” has real downstream harms.
### 5.3 Policy whiplash and market confusion (Aug 2020–Nov 2021)
This period created unusual uncertainty because:
- HHS said FDA could not require premarket review of LDTs (including EUA),
- FDA later declined to review LDT EUA submissions, and
- market actors (payers, employers, institutions) could still insist on “FDA-authorized” status.
GAO reports lab associations flagged confusion particularly around **insurance coverage and PREP Act liability protections** for LDTs without EUA.
### 5.4 Notification lists: the risk of “unauthorized tests” remaining in use for long durations
GAO documents that tests sometimes remained on notification lists for months (or a year+), meaning:
- tests could be used widely before FDA completed full EUA review, and
- some flaws might not be uncovered until full review (e.g., use of contrived samples vs live viral samples).
This motivated the Nov 2021 policy to phase down notification lists and force reconfirmation for pending EUA submissions.
### 5.5 Federal–state role tension: state authorization as capacity tool vs standardization challenge
The state authorization pathway was intended to accelerate capacity; GAO reports uptake and significant numbers of state-authorized tests.
But FDA later limited expansion, reflecting a shift toward standardization and FDA-centered review as the pandemic evolved.
---
## 6. Document index: key COVID-era primary sources and where they fit
| Date | Issuer | Document / venue | Type | Direct relevance to LDT vs EUA issues |
|---|---|---|---|---|
| Jan 31, 2020 | HHS | §319 public health emergency declaration (referenced in FDA policy background) | Declaration | Emergency context |
| Feb 4, 2020 | HHS | §564 EUA declaration for COVID IVDs (85 FR 7316 ref in FDA policy) | Declaration | Legal trigger for COVID IVD EUAs |
| Feb 29, 2020 | FDA | COVID test policy (1st edition) | Guidance | Diagnostic LDTs: validate/notify + EUA within 15 business days |
| Mar 16, 2020 | FDA | COVID test policy revision | Guidance | Expands to commercial tests; creates state authorization; permissive serology policy |
| May 4, 2020 | FDA | COVID test policy revision | Guidance | Tightens serology; EUA expected for commercial antibody tests |
| Aug 19, 2020 | HHS | “Rescission of Guidances…” | Web statement | FDA cannot require premarket review of LDTs absent rulemaking; PREP Act messaging |
| Oct 7–9, 2020 | FDA / CDC | FDA FAQ language + CDC LOCS lab alert | FAQ / Lab alert | FDA declines to review EUA requests for LDTs “at this time” |
| Mar 16, 2021 | FDA | FDA press statement on screening tools | Press statement | Streamlining EUA path for serial screening (including at-home/OTC) |
| Nov 15, 2021 | HHS / FDA | HHS withdrawal + FDA revised policy | Statement + Guidance | Restores FDA approach; unwinds notification lists; deadlines for EUA submissions |
| Jan 12, 2023 | FDA | “Policy for Coronavirus Disease‑2019 Tests (Revised)” | Guidance | Clarifies state policy (only existing states); legacy tests; cease within 15 days if declined |
| Mar 27, 2023 | FDA | EUA transition plan guidance | Guidance | COVID LDTs revert to general LDT enforcement approach after EUA declaration ends |
| May 11, 2023 | HHS / FDA | PHE expiration + transition communications | Milestone | Ends PHE-era enforcement policies; EUAs remain until EUA declarations end |
| | | | | |
---
## 7. Appendix A — Structured timeline table (condensed)
> This table is designed for quick scanning. The detailed narrative above is the “full text” record.
| Date | Action | Key LDT vs EUA implication |
|---|---|---|
| Jan 31, 2020 | HHS §319 PHE declared | Emergency conditions established |
| Feb 4, 2020 | HHS §564 EUA declaration for COVID IVDs | EUA pathway activated for diagnostics |
| Feb 29, 2020 | FDA enforcement discretion for diagnostic LDTs | LDTs may be used before EUA if validated/notified; EUA expected soon |
| Mar 16, 2020 | FDA expands to commercial tests + serology + state authorization | Multiple “pre‑EUA” lanes; states can authorize LDTs |
| May 4, 2020 | FDA tightens serology oversight | EUA expected for commercial serology; market cleanup begins |
| Aug 19, 2020 | HHS blocks mandatory FDA premarket review of LDTs | LDTs not required to submit EUA absent rulemaking; PREP Act messaging |
| Oct 7–9, 2020 | FDA declines LDT EUA reviews; CDC alerts labs | “Voluntary EUA” becomes uncertain; LDT authorization signal weakened |
| Mar 16, 2021 | FDA focuses on screening/serial testing authorizations | Review prioritization becomes central |
| Nov 15, 2021 | HHS withdraws Aug 2020 policy; FDA revises guidance | EUA-first posture restored; notification lists phased down |
| Jan 12, 2023 | FDA clarifies state policy and legacy tests | Existing state pathway only; “stop within 15 days” if declined |
| Mar 27, 2023 | FDA issues EUA transition plan | COVID LDTs revert to general LDT approach after EUA declaration ends |
| May 11, 2023 | PHE ends | PHE-related enforcement guidances end; EUAs continue |
| | | |
---
## 8. Appendix B — Quantitative markers and documented operational facts
These data points are useful “anchor facts” when describing the scale and operational impact of policies.
- **State authorization uptake:** Eight states + Puerto Rico notified FDA; six states authorized labs; by April 2021 those six states authorized 91 labs with 121 molecular tests and 19 labs with 23 antibody tests. *(GAO)*
- **Pre‑EUA engagement:** 1,275 pre‑EUA requests (Jan 2020–Sep 2021). *(GAO)*
- **Town Halls:** 70 town halls for test developers held by Sept 30, 2021 (began March 25, 2020). *(GAO)*
- **“Decline to review” scale:** As of Sept 30, 2021, FDA declined to review 558 EUA requests, including 230 LDTs. *(GAO)*
- **Notification list persistence:** In June 2021, the longest commercial antibody test was on a notification list 359 days; 65% of commercial diagnostic tests on notification list in Nov 2021 had been listed for at least a year. *(GAO)*
- **Notification list size after phase-down:** As of April 8, 2022, 68 tests remained on notification lists, including 26 lab-developed diagnostic tests and 25 lab-developed antibody tests. *(GAO)*
- **Serology removals:** As of July 30, 2021, FDA had removed 268 commercial antibody tests from the notification list. *(GAO)*
---
## 9. Source list and direct links
### Primary / authoritative sources (recommended for citation)
1. **GAO (May 2022):** *COVID‑19: FDA Took Steps to Help Make Tests Available; Policy for Future Public Health Emergencies Needed (GAO‑22‑104266)*
PDF: https://www.gao.gov/assets/gao-22-104266.pdf
2. **FDA (Jan 12, 2023):** *Policy for Coronavirus Disease‑2019 Tests (Revised) — Guidance for Developers and FDA Staff*
PDF: https://www.fda.gov/media/135659/download
3. **HHS (Aug 19, 2020; archived copy):** *Rescission of Guidances and Other Informal Issuances Concerning Premarket Review of Laboratory Developed Tests*
Archived PDF copy: https://www.thefdalawblog.com/wp-content/uploads/2021/11/HHS-Statement.pdf
4. **CDC LOCS (Oct 9, 2020):** *Lab Alert: FDA Suspends Review of EUA Requests for Laboratory‑Developed Tests for SARS‑CoV‑2*
https://www.cdc.gov/locs/2020/fda_suspends_review_of_eua_requests_for_lab_developed_tests_for_SARS-CoV-2.html
5. **FDA (Mar 27, 2023):** *Transition Plan for Medical Devices Issued EUAs Related to COVID‑19*
PDF: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/FDA/COVID-Transition-EUA-Guidance.pdf
6. **FDA (FAQs updated Nov 8, 2023):** *FAQs on Testing for SARS‑CoV‑2*
https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2
### High-quality secondary synthesis (useful for interpreting controversies)
7. **JAMA (Mar 4, 2022):** *SARS‑CoV‑2 Laboratory‑Developed Tests: Integrity Restored*
https://jamanetwork.com/journals/jama/fullarticle/2789917
8. **Ropes & Gray (Aug 24, 2020):** *HHS Prohibits FDA from Requiring Premarket Review of LDTs, Including During the COVID‑19 Emergency*
https://www.ropesgray.com/en/insights/alerts/2020/08/hhs-prohibits-fda-from-requiring-premarket-review-of-ldts-including-during-the-covid-19-emergency
---
## 10. Notes on how this report fits the FloodLAMP archive
- **Pre-pandemic background:** See the JD Supra / Skadden overview article (included in this archive subcategory).
- **Post-pandemic rule/litigation:** See the separate document on the 2024 LDT Final Rule and subsequent legal history.
---
*This report is an evidence-oriented synthesis of dated policy actions and is not legal advice.*
# 775 _AI_FDA 2024 LDT Rule - Status and Legal History.md
METADATA
last updated: 2026-02-28 AI
file_name: _AI_FDA 2024 LDT Rule - Status and Legal History.md
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title: FloodLAMP FDA 2024 LDT Rule - Status and Legal History
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notes: Created by ChatGPT 5.2 thinking during archive preparation. **NOT HUMAN VERIFIED - MAY CONTAIN ERRORS** Overview of the FDA's 2024 final rule on laboratory-developed tests, the phaseout timeline, legal challenges, court vacatur, and current regulatory status as of February 2026.
summary_short: FDA 2024 LDT final rule overview and legal history, covering the phased enforcement-discretion rollback (2025--2028 milestones), the March 2025 Eastern District of Texas vacatur, FDA's decision not to appeal, and the September 2025 regulatory text reversion--returning LDT oversight to the pre-2024 status quo.
CONTENT
## What the FDA's 2024 LDT Rule Was
Laboratory-developed tests (LDTs) are in vitro diagnostic (IVD) tests that are designed, manufactured, and used within a single laboratory (as opposed to test kits sold broadly to many labs).
For decades, FDA generally took the position that many LDTs could fall within medical device/IVD authorities, but mostly exercised "enforcement discretion" (i.e., did not generally enforce device requirements like premarket review) for most LDTs.
In May 2024, FDA issued a final rule ("Medical Devices; Laboratory Developed Tests," 89 Fed. Reg. 37286) that aimed to end that broad enforcement discretion over time by:
- Amending the definition of "in vitro diagnostic products" in 21 C.F.R. Section 809.3(a) to explicitly include IVDs "including when the manufacturer ... is a laboratory."
- Creating a ~4-year, staged phaseout of enforcement discretion, gradually expecting labs offering LDTs to comply with device requirements. FDA's FAQ described the milestones like this:
- May 6, 2025: adverse event reporting (MDR), corrections/removals reporting, and complaint files
- May 6, 2026: registration/listing, labeling, and investigational use requirements
- May 6, 2027: additional quality system requirements (with specific QS elements emphasized for LDTs)
- Nov 6, 2027: premarket review for high-risk LDTs
- May 6, 2028: premarket review for moderate-risk (and the subset of low-risk) LDTs that require it
## What Happened Legally (and the Current Status)
### 1) The Rule Was Struck Down (Vacated) in Federal Court
On March 31, 2025, the U.S. District Court for the Eastern District of Texas vacated the 2024 final rule in consolidated cases brought by laboratory groups (including ACLA and AMP), holding FDA lacked statutory authority under the FD&C Act to regulate LDTs as "devices" in the way the rule attempted--characterizing LDTs as medical test services rather than devices.
### 2) FDA Did Not Appeal
Multiple sources report the government declined to appeal within the deadline, leaving the district court decision in place.
### 3) FDA Formally Reverted the Regulation Text (Rescinded the 2024 Change)
After the vacatur, FDA issued a final rule on September 19, 2025 reverting 21 C.F.R. Section 809.3(a) back to its pre-2024 wording (i.e., removing the "including when the manufacturer...is a laboratory" language). FDA's own LDT page summarizes this sequence (final rule -> vacated -> reverted).
Reporting on the rollback likewise describes FDA rescinding the rule following the court decision.
## Where Things Stand Now (as of Feb 9, 2026)
- The FDA's 2024 LDT final rule is not in effect: it was vacated by the court and FDA did not appeal, and FDA then reverted the regulatory text to the pre-2024 version.
- Practically, that means the phaseout schedule (2025--2028 milestones) is no longer operative, and the regulatory landscape largely returns to the pre-2024 status quo (LDTs primarily overseen via CLIA laboratory regulation, with FDA continuing its traditional device oversight of commercial test kits/IVDs and certain other categories).
- The larger policy question (whether Congress gives FDA explicit LDT authority via new legislation) remains a live debate, but that is separate from the now-vacated 2024 rule.
# 947 _context-commentary_regulatory-ldts.md
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last updated: 2026-03-01 RT
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CONTENT
## Context
The FloodLAMP test was never used as an LDT. Our pilots operated under surveillance (see archive folder regulatory/surveillance), and we submitted to the FDA for IVD EUA. We had discussions with UnitedHealth Group about a clinical lab network adopting our direct LAMP test as an LDT, shared all of our information (data, FDA submissions, cost model, etc.), but they did not move forward with the project.
As a background explainer, Laboratory-developed tests (LDTs) are in vitro diagnostic tests that are designed, manufactured, and used within a single clinical laboratory, as opposed to commercial IVD test kits produced by diagnostic manufacturers and sold to laboratories across the country. Commercial IVDs are subject to FDA premarket review under the medical device classification system, while LDTs have historically operated under FDA "enforcement discretion," meaning the agency asserted jurisdiction but generally chose not to enforce device requirements. This distinction created a bifurcated market: commercial diagnostic products held to rigorous FDA analytical and clinical validation standards, and laboratory-developed tests for the same purposes that were primarily overseen through CMS under the Clinical Laboratory Improvement Amendments (CLIA). The tension between these two regulatory tracks became a central issue during the COVID-19 pandemic and in the years that followed.
The JD Supra article by Skadden Arps attorneys (October 2020) provides a useful overview of the decades-long history of LDT regulation, tracing FDA's evolving posture from initial enforcement discretion through the 2010 public workshop, the 2014 draft guidance, the 2017 retreat to Congress, and the COVID-era policy reversals. It remains a good starting point for understanding the regulatory backdrop against which COVID-era LDT policy played out.
Two AI-generated reports in this subcategory provide more detailed analysis. The first, "FDA, LDTs, and COVID-19: Interactions, Policy Shifts, and Key Issues (2020-2023)," is a detailed synthesis of how FDA oversight of COVID-19 LDTs moved through three distinct phases: initial EUA-based enforcement discretion, the August 2020 HHS policy blocking mandatory premarket review, and FDA's restoration of an EUA-first posture after November 2021. The second, "FDA 2024 LDT Rule - Status and Legal History," covers the post-pandemic attempt by FDA to formally end broad enforcement discretion for LDTs through rulemaking, the subsequent legal challenge, the March 2025 court vacatur, and FDA's decision not to appeal, which returned LDT oversight to the pre-2024 status quo.
Related regulatory subcategories in this archive include: FDA Policy (`regulatory/fda-policy/`), which covers broader FDA regulatory actions and user fee frameworks; FDA Town Halls (`regulatory/fda-townhalls/`), which documents the weekly public calls FDA held with COVID-19 test developers; Surveillance (`regulatory/surveillance/`), which covers the surveillance testing framework under which many LDT-based programs operated; and Open EUAs (`regulatory/open-euas/`), which addresses the question of whether FDA should have made EUA pathways more accessible to LDT developers and smaller laboratories.
## Commentary
LDT regulation is deeply interconnected with FDA testing policy. As the AI report on COVID-era LDT oversight documents in detail, the FDA went back and forth during the pandemic on whether LDTs needed EUA authorization, with HHS at one point blocking mandatory premarket review entirely and FDA later restoring an EUA-first posture. Underlying these policy swings is a structural gap in the regulatory framework: there is no middle ground between laboratory-developed tests, where a single lab has broad authority to develop and use a test internally, and commercial IVDs produced by manufacturers who contract with reagent companies to produce kits sold to laboratories nationwide (or direct to consumers for at-home devices). This gap became acutely problematic during the pandemic, when the need to rapidly scale testing demanded something between the two models. A promising solution emerged in the form of the Open EUA, pioneered and authorized during the pandemic by the SalivaDirect program under Dr. Anne Wyllie, which allowed multiple laboratories to adopt and run a validated protocol under a shared authorization, overseen and managed by a responsible party (which became a nonprofit). Unfortunately, the Open EUA concept was not further developed by FDA or the field, and it remains an underexplored pathway.
For fuller commentary on LDTs, FDA policy, and Open EUAs, see `regulatory/open-euas/_context-commentary_regulatory-open-euas.md`.
# 2,661 2020-10-03_JD Supra Article - FDA Oversight of Laboratory-Developed Tests Continues To Evolve.md
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summary_short: The JD Supra article “FDA Oversight of Laboratory-Developed Tests Continues To Evolve” reviews how FDA regulation of LDTs has shifted over decades and highlights the August 19, 2020 policy change stating LDTs would not face FDA premarket review absent formal rulemaking. It summarizes COVID-era FDA policies and the emerging role of Congress (including the VALID Act) in shaping a longer-term regulatory framework, underscoring ongoing uncertainty for laboratories and diagnostic developers.
CONTENT
***INTERNAL TITLE:*** FDA Oversight of Laboratory-Developed Tests Continues To Evolve \| JD Supra
[https://www.jdsupra.com/legalnews/fda-oversight-of-laboratory-developed-27221/](https://www.jdsupra.com/legalnews/fda-oversight-of-laboratory-developed-27221/)
October 3, 2020
[By William (Bill) McConagha, Amanda H. Chan (Skadden Arps LLP)](https://www.skadden.com/insights/publications/2020/09/quarterly-insights/fda-oversight-of-laboratory-developed-tests)
On August 19, 2020, the Trump administration made a major announcement that marks the latest development in the ever-evolving saga of the Food and Drug Administration’s (FDA) oversight of laboratory-developed tests (LDTs). The administration declared that LDTs, which are a subset of in vitro diagnostic tests (IVDs) developed and used in-house by clinical laboratories, would not be subject to premarket review by the FDA absent formal agency rulemaking. This announcement reversed the position that the FDA staked out in late February 2020, when it issued a guidance document for the industry on the development of IVDs to diagnose COVID-19.
The February guidance set expectations regarding the analytical and clinical validation of IVDs used to address the pandemic and included most complex LDTs intended to diagnose the disease. The FDA published a second policy in March allowing for independent authorization of LDTs by states and expounded on these policies again in May.
The FDA’s oversight of LDTs in the context of COVID-19 — promulgated with little fanfare given the exigencies of the pandemic — represented yet another turn in the agency’s mercurial relationship with these controversial diagnostics that dates back more than four decades. Because the administration and the Department of Health and Human Services has now rescinded the FDA’s prior guidance, laboratories must decide whether to voluntarily seek an emergency use authorization from the FDA for their LDTs, which would provide the tort protections associated with all such authorized countermeasures, or to proceed without it. Longer term, the future and degree of FDA oversight of LDTs will remain uncertain until either the FDA undertakes a formal rulemaking process or Congress takes legislative action.
## History of LDT Regulation
IVDs are “those reagents, instruments, and systems intended for use in diagnosis of disease or other conditions, including a determination of the state of health, in order to cure, mitigate, treat, or prevent disease or its sequelae,” according to the FDA. “Such products are intended for use in the collection, preparation, and examination of specimens taken from the human body.” The FDA began regulating them as medical devices when Congress amended the Food, Drug and Cosmetic Act in 1976 to create the comprehensive regulatory scheme providing for the risk-based medical device classification system and premarket review process that exists today. Components of IVDs, such as antibodies, specific receptor proteins, ligands, nucleic acid sequences and other analyte-specific reagents, are also subject to FDA oversight as medical devices. Most of the hundreds of IVDs on the market today have been cleared by the FDA as Class II medical devices, which are sold to laboratories across the country.
The disconnect in this area is that, at the same time the FDA developed a robust regulatory process for premarket review of IVDs, it adopted a decidedly laissez faire approach to regulation of LDTs, a subset of IVDs that are designed, manufactured and used within a single laboratory for clinical use. The FDA perceived LDTs as low risk due to their limited number and primary use in rare disease contexts. Accordingly, LDTs were not subject to the agency’s robust premarket evaluations of analytical and clinical validity. Analytical validity focuses on “whether a test can accurately and reliably measure what it claims to measure,” whereas clinical validity focuses on “whether the measurement is predictive of a certain state of health.” The result is a bifurcated market, in which IVDs developed for commercial sale are held to rigorous FDA standards while homegrown tests developed for the same uses inside the developer’s lab are not.
**The FDA’s oversight of laboratory-developed tests in the context of COVID-19 represented yet another turn in the agency’s mercurial relationship with these controversial diagnostics that dates back more than four decades.**
Medical and technological advances over the past four decades have driven the development of LDTs to cover a wide range of conditions, including human papillomavirus, Lyme disease, whooping cough, certain cancers and heart disease. The growth of the LDT industry has led to concerns among stakeholders about whether current regulatory oversight of LDTs, led primarily by the Centers for Medicare and Medicaid Services (CMS), is sufficient to ensure their safety and effectiveness. Reports of inaccuracies in cervical cancer testing led to the enactment of the Clinical Laboratory Improvement Amendments of 1988 (CLIA), which extended federal regulations to all laboratories performing testing on human specimens for the purpose of diagnosis or treatment. Under the CLIA, CMS evaluates the analytical but not clinical validity of LDTs during accreditation surveys of laboratories. These surveys are conducted on a biennial basis, so it may take up to two years after an LDT has been offered for clinical use before its analytical validity is confirmed by regulators.
In July 2010, the FDA announced its intent to reconsider its long-standing policy of enforcement discretion with respect to LDTs after identifying issues with several high-risk LDTs and hosted a public workshop to gather feedback from industry stakeholders. Four years later, the FDA issued draft guidance proposing a regulatory framework for LDTs. It followed up a year later with a report on 20 case studies of potential and actual patient harm arising from inaccurate or unreliable LDTs that supported the need for increased LDT oversight. Members of the lab and diagnostic industry pushed back against the FDA’s new position, asserting the FDA had no right to regulate LDTs in the first place. They argued LDTs were clinical rather than medical devices and that regulation would constitute an intrusion into the practice of medicine. Industry stakeholders were also concerned that FDA oversight would stifle innovation, raise costs for laboratories and limit patient access to LDTs they deemed vital to public health.
In January 2017, the FDA announced it would not finalize the guidance and invited Congress to address the issue. To advance the discussion, however, the FDA published a position paper synthesizing feedback it received from stakeholders as well as its own views on appropriate oversight that would balance the need for innovation with the need for assuring the safety and effectiveness of LDTs. The FDA proposed an approach in which agency oversight would be phased in over several years based on risk. The proposal would grandfather tests already on the market and exempt from most oversight LDTs that are low risk or intended for rare diseases, forensic use, public health surveillance and so-called “traditional” tests that “use components that are legally marketed for clinical use and whose output is the result of manual interpretation by a qualified laboratory professional, without the use of automated instrumentation or software for intermediate or final interpretation.” All other tests, including modified versions of grandfathered tests, would be subject over time to adverse event and malfunction reporting, premarket clearance and approval, and CLIA-based quality requirements. The FDA reserved the right to take action against any LDT, even those exempted from the phased-in requirements, in the event of deceptive promotion or inadequate validation.
Many stakeholders interpreted the FDA’s announcement as a retreat to the long-standing position of enforcement discretion while it turned the issue over to Congress to resolve. The reality was less clear, however, as the agency continued to assert its jurisdiction over LDTs in certain circumstances. In October 2018, FDA issued a guidance warning that many genetic tests on the market that claim to predict a patient’s response to specific medications had not been reviewed by the agency and might not be supported by requisite scientific or clinical evidence. In April 2019, the FDA issued a warning letter to Inova Genomics Laboratory alleging that its genetic tests, which were offered for the same purpose, were adulterated and misbranded, and posed a significant public health concern because they had not been adequately validated. Notably, the FDA rejected Inova’s assertions that the company was operating within an “LDT Exemption” by explaining that no exemption existed and that the agency never created a “legal carve out” from its premarket review processes for LDTs. The agency also asserted that it retained the discretion to take action against LDTs “when appropriate” despite its long-standing policy of exercising enforcement discretion. The FDA’s unpredictable approach toward LDTs left members of the lab and diagnostic industry unsettled and anxious about federal challenges to the legality of their tests.
## Considerations for COVID-19
Facing the COVID-19 pandemic, the FDA took another step toward more complete oversight when it included LDTs in its polices for other IVDs intended to diagnose the disease. The position was no doubt fueled by the FDA’s desire to ensure a measure of analytical and clinical validity for all complex tests used to diagnose the disease, given the obvious exigencies and public health equities at issue. However, the Trump administration’s August 19 announcement formally rescinds guidance and other informal statements from the agency concerning premarket review of LDTs. The move frees developers of LDTs to act without FDA pre-review, which offers a measure of clarity for the market but also triggers concern from public health experts who believe now is the time for more oversight, not less.
## Congressional Action
Against this backdrop, there may be greater pressure than ever on Congress to take up the issue. Lawmakers have made several attempts at determining the future of LDT regulation. A draft bipartisan bill released in March 2017 outlined a regulatory framework for LDTs based in part on a proposal by the Diagnostic Test Working Group, a coalition of industry stakeholders. After feedback from the FDA, lawmakers unveiled a new bill, the Verifying Accurate, Leading-Edge IVCT Development (VALID) Act, in December 2018. On March 5, 2020, lawmakers introduced a revised VALID Act with bipartisan sponsorship.
The VALID Act would create a new regulatory framework to govern the development and use of all in vitro clinical tests (IVCTs), which would include both IVDs and LDTs. The proposal would replace the three-tiered system used to regulate other medical devices with a two-tiered system consisting of low- and high-risk tests (although the legislation would allow the FDA to develop special controls for certain high-risk tests, which could evolve into a third tier of moderate-risk devices). The legislation would require premarket evaluation and compliance with quality system regulations unless an exemption applied. Like the FDA’s 2017 proposal, the act would exempt low-risk tests such as those intended to treat rare diseases and some LDTs that are already in use. Current LDTs not eligible for grandfathering under the act would be handled under special transitional provisions. The legislation also includes a precertification program intended to reduce regulatory burdens and provide priority review/breakthrough concepts. The program is modeled after those that exist today for other medical products to support expedited development and review of novel tests or tests intended to treat a life-threatening or irreversibly debilitating human disease or condition.
## Conclusion
Whether and when Congress will act on the legislation is unclear. The current controversy surrounding COVID-19 testing is sure to put a spotlight on this issue, and the VALID Act has bipartisan support in committees of jurisdiction in both chambers. But the United States is heading toward another presidential election, and the current Congress has been notably partisan. The Medical Device User Fee Amendments must be renewed in September 2022, and that must-pass legislation is a likely vehicle for enactment of the VALID Act if it is not taken up beforehand. Some form of the legislation certainly could move in the next year, but the window is tight given the election and the other pandemic-related causes, which will take priority.
In the meantime, industry stakeholders should closely monitor developments in the LDT space. LDTs and related genetic tests play a significant role in health care decision-making, and a new regulatory framework will have major implications for the future of these products. But critical questions remain, including whether Congress will take action and whether the FDA will eventually act if Congress does not. Whether the FDA intends to respond to the August 19 announcement by initiating a rulemaking or formally modifying its 2017 position is unclear. The FDA likely will wait for the outcome of the election and take stock of its options then. Regardless of how, if at all, a more defined regulatory framework for LDTs ultimately crystallizes, the latest announcement makes clear that lasting guidance is necessary for all parties to navigate the world of LDTs with some measure of certainty, both during COVID-19 and beyond.
# 67,421 2023-12-04_ACLA - Letter to FDA - Comments on FDAs Proposed Regulation of LDTs as Medical Devices.md
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summary_short: The American Clinical Laboratory Association’s December 4, 2023 letter submits formal comments opposing FDA’s proposed rule to regulate laboratory developed tests (LDTs) as medical devices. It argues that LDTs are professional laboratory services already subject to robust oversight under CLIA and state law, and that applying device regulation would reduce patient access, stifle diagnostic innovation, and exceed FDA’s legal authority.
CONTENT
December 4, 2023
U.S. Food and Drug Administration
Dockets Management Staff (HFA-305)
5630 Fishers Lane, Room 1061
Rockville, MD 20852
**Re: ACLA Comments on Proposed Rule, “Medical Devices; Laboratory Developed Tests” (Docket No. FDA-2023-N-2177)**
The American Clinical Laboratory Association (ACLA) submits the attached comments on FDA’s Proposed Rule, “Medical Devices; Laboratory Developed Tests” (Docket No. FDA-2023-N-2177) (“Proposed Rule”) which, if finalized, would subject laboratory developed tests (LDTs) to regulation as medical devices.
ACLA is the national trade association representing leading laboratories that deliver essential diagnostic health information to patients and providers by advocating for policies that expand access to the highest quality clinical laboratory services, improve patient outcomes, and advance the next generation of personalized care. ACLA member laboratories are at the forefront of developing tests to respond to emerging health issues, and they frequently innovate new areas of science. LDTs offered by ACLA members play an indispensable role in delivering healthcare to patients.
As detailed in the attached, ACLA has grave concerns with FDA’s Proposed Rule, both as a matter of public policy and as a matter of law, and urges FDA to withdraw it. If implemented, the imposition of the ill-suited and rigid medical device authorities on LDTs would reduce patient access to widely used tests and dampen diagnostic innovations that improve and save lives. Over the past several years, ACLA worked collaboratively with FDA, Congress, and patient, provider, and diagnostic manufacturer stakeholders on legislation that could have established a role for FDA in an appropriate regulatory system for all diagnostics, complimentary to the already robust oversight of LDTs. ACLA’s goal throughout that process was to develop a regulatory approach that would account for the unique attributes of laboratory diagnostics and which would strike the right balance between encouraging diagnostic innovation, maintaining access to important tests, and regulatory oversight. ACLA steadfastly maintains that legislation is the right – and only – approach for FDA to have a role in the regulation of LDTs. FDA’s unilateral imposition of device law is misguided.
We would be pleased to further engage with FDA on any of the topics discussed in the attached comments.
Sincerely,
Susan Van Meter
President
## COMMENTS OF THE AMERICAN CLINICAL LABORATORY ASSOCIATION
Contents
Executive Summary .......................................................................................................................... 1
Discussion ........................................................................................................................................ 5
I. Device Regulation is Wrong for LDTs and Would Undermine Innovation and Access to Diagnostic Testing .......................................................................................................................... 5
A. LDTs are professional services, not devices. ......................................................................... 5
B. Applying device law would undermine innovation in diagnostics and access to critical testing services. ......................................................................................................................... 7
II. LDTs Are Subject to Robust Regulation and Review. ............................................................... 18
A. FDA’s history of inconsistent positions on LDTs. ................................................................. 18
B. CLIA applies to all clinical laboratories and LDTs. .............................................................. 20
C. State laws impose additional requirements on laboratory testing services. ......................... 23
D. Payers scrutinize LDTs for coverage decisions. ..................................................................... 24
III. FDA’s Proposed Rule Fails to Recognize the Significant Contributions of LDTs to the Public Health. ........................................................................................................................................ 25
A. LDTs drive advances in the public health by innovating at the pace of science. ................. 25
B. LDTs are essential for meeting current clinical care needs. .................................................. 31
IV. FDA’s Characterization of LDTs is Inaccurate. ........................................................................ 36
A. FDA’s methodology for critiquing LDTs is flawed. .............................................................. 36
B. FDA’s specific critiques are inaccurate. ................................................................................. 38
V. FDA’s Cost-Benefit Analysis is Flawed in Numerous Ways and Cannot Support Finalizing the Proposed Rule. ............................................................................................................................. 46
A. FDA underestimates the costs of the Proposed Rule. ............................................................ 46
B. The claimed benefits of the Proposed Rule are dramatically overstated. ............................. 54
VI. The Proposed Rule Raises Significant Legal Concerns. ........................................................... 59
A. LDTs are not “devices” under the FDCA. .............................................................................. 59
B. Had Congress provided FDA with authority over LDTs, it would have done so expressly. 64
C. LDTs cannot be subject to any FDCA authorities that require devices to be introduced or delivered into interstate commerce for commercial distribution. ............................................. 65
D. LDTs are not “held for sale” as required under FDCA Section 301(k). ................................ 67
E. Imposing device law on LDTs would violate the First Amendment. .................................... 68
F. FDA regulation would interfere with the practice of medicine. ............................................ 70
G. The NPRM Fails to Comply with Section 553(b) of the Administrative Procedure Act. ....... 70
VII. The Agency Could Revise the Rule to Reduce, but not Eliminate, the Net Negative Impact of the Rule to Public Health. ............................................................................................................. 71
A. Grandfathering for existing tests. .......................................................................................... 71
B. Extended implementation timeline. ....................................................................................... 72
C. New York State and MolDX programs. .................................................................................. 73
D. Flexible modifications policy. ............................................................................................... 74
E. Enforcement discretion for low-volume tests. ....................................................................... 75
F. Classification panels. .............................................................................................................. 75
G. CLIA regulation. ..................................................................................................................... 75
H. Request for information (RFI). ............................................................................................... 76
I. Equal treatment of LDT developers. ...................................................................................... 76
Conclusion ....................................................................................................................................... 77
Exhibit 1: Chris Carrigan, Global Economics Group, Review of the Food and Drug Administration’s Preliminary Regulatory Impact Analysis for its Medical Devices; Laboratory Developed Tests Proposed Rule
## EXECUTIVE SUMMARY
Laboratory developed tests (LDTs) are an indispensable pillar of our health care system, providing patients and physicians with diagnostic information to inform clinical care, power precision medicine, contribute to the discovery of novel therapeutics, and lead the fight against emerging pathogens. FDA’s Proposed Rule — which would subject virtually all LDTs to medical device regulation — would significantly undermine the ongoing ability of laboratories to develop and offer innovative LDTs. If finalized, the rule would reduce patient access to LDTs, including those for which there are no FDA-cleared or -approved tests. It would also markedly diminish innovation in the next generation of diagnostics, including because device authorities are rigid and would not allow LDTs to keep pace with scientific advances. The Proposed Rule is also illegal: LDTs are not devices, and FDA lacks authority to regulate them as such. Accordingly, the Proposed Rule represents a regulatory overreach, and it should be withdrawn for multiple policy and legal reasons.
First, and most importantly, FDA’s Proposed Rule would have significant adverse consequences for patients because it would undermine diagnostic and medical innovation and limit or eliminate access to critical tests. As described in Section I of these comments, the Proposed Rule would require laboratories to divert resources currently dedicated to research and development to focus on backward-looking activities in support of FDA approval for tests that have long been offered by laboratories and relied upon by physicians. Laboratories would be forced to examine test menus and make difficult decisions about which tests could support FDA submissions, likely resulting in the removal of low-volume tests, including for rare diseases, from test menus. That would also mean diverting resources away from the development of the next generation of diagnostics for cancer, infectious disease, cardiovascular disease, neurology, and numerous other diseases and conditions, including rare diseases and diagnostics for underserved communities, as well as diagnostics specifically developed for pediatric patients. The development of novel biopharmaceuticals would likewise slow. It would also mean reduced testing capacity, including for performance of IVDs, harming patient access to testing services, likely with disparate impacts for already underserved populations.
These added administrative burdens would be imposed at the very time when reimbursement for testing is being cut. While Congress recently enacted a one-year delay to Medicare payment cuts for clinical laboratory services, that is not a permanent solution. Year-over-year cuts are scheduled to be implemented starting January 1, 2025. At the same time, the costs of labor, equipment, and supplies are escalating, and a systemic workforce shortage for laboratory personnel persists.
The drain on innovation would be driven not just by the direct costs of FDA regulation (which would be significant), but also because the device framework is ill-suited and was never intended for LDTs. LDTs are services that rely on the expertise and judgment of trained medical and scientific professionals. Numerous aspects of device law — from the basic approval standards, to labeling and quality system requirements — do not fit LDTs. Moreover, the device regulatory system is rigid. The device premarket review system cannot account for the rapid evolution in diagnostic services occurring in oncology, neurology, infectious disease, and numerous other areas. Physicians and patients deserve testing services that incorporate the latest findings, including information reflected in clinical practice guidelines. Unlike FDA-regulated diagnostics, LDTs are able to accommodate the pace of change necessary to meet physician needs.
Consider oncology tests. In the oncology space, treating physicians rely on the professional services provided by laboratories because LDTs incorporate the latest scientific developments to inform the judgment of trained professionals, including diagnostic markers or combinations of markers. Often these developments are reflected in the clinical literature or in well-accepted guidelines from professional organizations. In fact, several ACLA member laboratories that have obtained FDA approval for oncology tests have found that physicians turn to LDTs (sometimes offered by the same laboratories) because the FDA-approved versions might not include the latest advances in patient care. But device law would fundamentally change this paradigm by requiring lengthy premarket review for all or most such updates. Medical device authorities do not allow for the rapid innovation required to meet recognized scientific advancements and the standard of care. These barriers to innovation would add months or years to the development lifecycle for new LDTs — months and years that can make a life-or-death difference to a patient.
Innovation and access to testing services would also suffer because of the FDA-review bottleneck that device regulation would create, which would be orders of magnitude greater than what the Agency experienced during the COVID pandemic. FDA is not prepared — and would not be prepared — to regulate LDTs. Even using FDA’s own estimates (which are based on assumptions and extrapolations, and are almost certainly low), the number of applications flooding into FDA would be staggering. FDA’s estimates suggest that the initial number of premarket approval applications (PMAs) for LDTs would be greater than the cumulative number of original PMAs processed by FDA in the entire history — going back to 1976 — of medical device premarket review. Similarly, the annual number of PMA submissions would increase FDA’s annual workload for diagnostics by over 500% (and that does not take into account other application types or other regulatory responsibilities). As we saw during the COVID pandemic, despite dedicated staff who strove to meet the challenge of a global pandemic, FDA lacks the resources to deal effectively with such surges in regulatory responsibilities. During the pandemic, resources had to be diverted from other parts of the Agency, and applications and interactions with FDA related to non-COVID diagnostics were placed on hold. FDA’s promises that it can scale up resources ring hollow. Not only are FDA’s resources limited, there simply are not enough trained scientists and regulatory professionals to go around, and FDA would be competing with laboratories that would also need to dramatically increase hiring of the same professionals (who are already in shortage) to deal with the new regulatory system. The impact of this rule, if finalized, would reverberate throughout the health care system, drawing away resources needed to advance medical product development.
Second, FDA’s Proposed Rule paints a profoundly inaccurate picture of the essential testing services provided by laboratories. As explained in Sections II and III of these comments, FDA fails to consider the robust oversight that currently applies to laboratory testing services or the important public health contributions of LDTs. As explained in Section IV of these comments, FDA also uses unreliable and cherry-picked sources to mischaracterize laboratory testing services. In fact, laboratories and the LDTs they offer are subject to robust regulation under federal and state statutes, supplemented by rigorous accreditation standards and review by payers. Under that system, laboratories offering LDTs have delivered groundbreaking innovations that shifted the standard of care for diagnosis (and treatment) of important diseases; have been the first to respond to emerging public health threats; have played pivotal roles in the development of FDA-approved drugs, biologics, and other therapeutic products; and have offered critical tests for unmet needs in clinical care.
Rather than credit laboratories and their highly trained staff with these exceptional contributions to the public health, FDA’s Proposed Rule paints a profoundly inaccurate picture. Even though FDA claims to be a data-driven agency, it did not systematically collect evidence to support the Proposed Rule. The “evidence” used to disparage LDTs is anecdotal and in many cases unverified, including selectively cherry-picked studies, unconfirmed allegations in lawsuits, complaints in the media and news stories, and claimed deficiencies in submissions. It is disappointing that FDA took this approach, which it would never allow the regulated industry to use and which may undermine patient faith in laboratory testing.
Third, FDA’s reliance on flawed data leads directly to the Agency’s failure to appropriately assess the costs and benefits of the Proposed Rule, which is addressed in Section V of our comments. As FDA’s Preliminary Regulatory Impact Analysis (RIA) acknowledges, FDA lacks data to properly consider the costs and benefits of the Proposed Rule. But it did not have to be this way: FDA has the regulatory tools to gather appropriate data to permit a more accurate assessment. FDA could have issued a Request for Information (RFI) to gather data on the number of laboratories that develop LDTs, the number of LDTs, the costs associated with research, development, and validation, as well as other categories of information. It also could have relied on the Centers for Medicare and Medicaid Services (CMS) to gather such data as CMS actively regulates clinical laboratories and LDTs. Instead of taking that approach, FDA assessed the costs and benefits of its proposed action using a series of unsupported assumptions and extrapolations.
To the extent that FDA has cited studies, those studies are flawed and/or misconstrued, leading FDA to underestimate the costs and overstate the claimed benefits of device regulation. As just one example, to estimate the claimed benefits of the proposed rule, FDA relies on a single study evaluating 19 oncology LDTs against FDA-approved companion diagnostics to broadly claim that 47% of all LDTs are “problematic.” Then, FDA uses that 47% figure to extrapolate claimed benefits based on eliminating misdiagnoses from such problematic LDTs due to FDA regulation of all LDTs. There are many problems with this approach, not least of which is that the study FDA relies upon in the study performed as well as FDA-approved tests, undercutting FDA’s argument that such tests are “problematic” and that FDA regulation would confer any benefits.
Likewise, FDA’s cost estimates are significantly understated and do not take into account many of the most impactful costs associated with the rule. As discussed above, if finalized, the Proposed Rule would likely cause many important LDTs to be withdrawn — not because those testing services are “problematic,” but because laboratories would lack the resources and time needed to develop and pursue FDA clearance or approval, and the very rigid and ill-suited nature of the medical device authorities would preclude many innovations from reaching patients. In fact, for the majority of LDTs, the burdens imposed by device regulation would significantly outweigh the value of FDA approval. Tests that serve small patient populations, such as for rare diseases, and those with modest reimbursement or revenue, may well be dropped from testing menus. Patients would suffer if these LDTs are no longer available. Failure to obtain a timely diagnosis would lead to increased morbidity and mortality, along with associated costs to our health care system and society more broadly. FDA’s cost-benefit analysis fails to take these and other costs into account. An appropriate cost-benefit analysis, supported by accurate data, would demonstrate that the costs of imposing device law on LDTs would greatly exceed the benefits.
Furthermore, an assessment of FDA’s RIA, drafted by Chris Carrigan, Global Economics Group, is attached as Exhibit 1 to these comments. As described in that analysis, the RIA fails to adhere to the standards in the Office of Management and Budget’s (OMB) Circular A-4, which describes the standards for producing RIAs for rulemaking that would have a significant economic impact. This results in an economic assessment that fails on several dimensions. Among other problems, the RIA significantly understates costs by failing to quantify a key effect of the Proposed Rule and substantially inflates benefits by misusing benefit transfer methods. Furthermore, FDA fails to evaluate reasonable alternative regulatory approaches and offers minimal discussion of the distributional effects, including those on marginalized and underserved communities.
Ultimately, the record compiled by FDA does not support that LDTs are a significant public health problem to be fixed. Moreover, the proposed “solution” (device law) would cause numerous negative consequences for patients and our health care system. Unilateral imposition of device regulation on LDTs is the wrong solution in search of a problem.
Fourth, FDA’s Proposed Rule is not just a bad public policy choice; it is illegal. As discussed in Section VI of these comments, FDA does not have legal authority to regulate LDTs as devices. The statutory authority to regulate devices delegated to FDA in the Food, Drug, and Cosmetic Act (FDCA), originally in 1938 and amended many times since, extends to physical products that are sold and distributed by manufacturers. But LDTs are services offered by trained laboratory professionals, not physical products. An LDT is a protocol or process by which a laboratory uses various tools—some of which are individually regulated as devices—to derive a test result for a patient. FDA’s assertion that an LDT is a device is no less misguided than calling a surgery—performed by a physician using various tools (scalpels, sutures, etc.)—a device.
The development and performance of LDTs is regulated under a separate statutory and regulatory framework—the Clinical Laboratory Improvement Amendments of 1988 (CLIA)—and complementary state laws that interact with CLIA. The text of the FDCA, together with the legislative history and broader statutory framework of the FDCA and CLIA, make clear that LDTs are not devices and that Congress did not grant FDA authority to regulate LDTs. FDA’s claim that it has authority over LDTs rests on an implausible assumption that an entire industry has been operating in violation of the FDCA for decades, and only now, after 85 years of device authority, has FDA decided to take action. FDA regulation of LDTs as devices would also raise significant concerns under the “major questions” doctrine and the First Amendment.
Finally, in Section VII of these comments, ACLA addresses the alternative approaches for which FDA solicited input, including (but not limited to) grandfathering, implementation timelines, recognizing existing programs such as that in New York State, and whether special treatment should be afforded to some test developers. While adopting some of these approaches could lessen the harm that would be created if the Proposed Rule were finalized, none would fix the fundamental legal and policy problems with imposing device law on testing services. The Proposed Rule would still exceed FDA’s legal authority and would have significant negative consequences for the public health, as outlined in these comments. Furthermore, affording special treatment to only certain laboratories would raise additional legal concerns.
For all of these reasons, which are discussed in detail in the pages that follow, the Proposed Rule should be withdrawn. Rather than expending resources to finalize the Proposed Rule, if FDA seeks to establish additional oversight of LDTs, the Agency should engage with stakeholders, other HHS agencies, and Congress in a renewed effort to develop legislation that would establish appropriate regulatory authority for such additional oversight.
## DISCUSSION
### I. Device Regulation is Wrong for LDTs and Would Undermine Innovation and Access to Diagnostic Testing.
In the Proposed Rule, FDA claims that it is “clarifying” that LDTs qualify as devices by adding ten words to the definition of an “in vitro diagnostic product” in 21 C.F.R. § 809.3 to state that such products “include[e] when the manufacturer of these products is a laboratory.” ACLA disagrees that the revised definition of “in vitro diagnostic product” in the Proposed Rule captures LDTs or that LDTs could qualify as devices.
Most fundamentally, the Proposed Rule reflects a misunderstanding of LDTs and the associated professional services provided by clinical laboratories. When understood that LDTs are services and not devices, it becomes abundantly clear that medical device regulation is the wrong fit for LDTs and applying such regulation would undermine diagnostic innovation and access to diagnostic testing for patients. Rather, LDTs have long been regulated under federal and state laws and subject to scrutiny by payers.
#### A. LDTs are professional services, not devices.
LDTs are unique assays designed, developed, and performed by clinical laboratories certified under CLIA to perform high-complexity testing (hereinafter “high-complexity laboratories”) to yield important clinical information about a patient that can be used to inform or guide patient care. Laboratories that develop and perform LDTs are providing professional health care services; they are not acting as “manufacturers” and are not distributing devices. In short, LDTs are professional services; they are not devices.
As an example, consider the workflow associated with a mass spectrometry test offered by an ACLA member laboratory. After the test is ordered by a physician, a blood specimen is obtained by a phlebotomist and sent to the laboratory, and then laboratory staff complete the following tasks:
**Pre-analytical steps**
- Laboratory receives the blood sample and enters it into the laboratory information system (LIS)
- Laboratory staff completes pre-analytical steps per the relevant standard operating procedures (SOPs). This may include centrifuging the sample or aliquoting the sample into a separate tube for testing
**Analytical steps**
- Laboratory scientist prepares reagents, standards, quality control materials, and retrieves patient sample for testing
- Laboratory scientist performs daily maintenance on the instrument system to be used for sample preparation and testing
- Laboratory scientist pipettes applicable samples and reagents into 96-well plate
- Laboratory scientist performs extraction of the analyte(s) of interest using an automated liquid handling instrument
- Laboratory scientist builds the test run into the instrument software, such as specimen information, and loads samples onto testing system, which includes an automated sampler, liquid chromatography instrumentation, and high-resolution mass spectrometer
- When testing is complete, the laboratory scientist reviews the run qualitatively and quantitatively (e.g., chromatography and signal-to-noise ratios), including reviewing quality control to ensure results are within parameters for acceptable performance
- Laboratory scientist reviews patient results and utilizes software to determine concentration of the analyte(s) being measured and enters results into LIS
**Post-analytical steps**
- A second laboratory scientist or lead scientist reviews the results to confirm they were accurately interpreted, quantitated, and entered into the LIS
- The reviewing scientist approves results in the LIS, sending them electronically to the patient’s electronic medical record
- The ordering clinician reviews the laboratory result produced by the test and uses it to inform clinician care decisions
This is an LDT: a series of tasks undertaken by trained laboratory professionals using instruments and other tools to derive information that may be useful to a treating physician. Under any reasonable interpretation, this is a service, not a device.
In contrast to LDTs, IVDs are manufactured products—instruments, reagents, materials, or any combination thereof—that are packaged, labeled and released by the manufacturer for use by a third party. IVDs are accompanied by instructions for use that inform the user how to use the device, and for IVD test kits, how to perform the test and what the results mean. They can be used by the persons identified in their label, whether that is the patient, a point-of-care provider, or a CLIA laboratory certified to perform the appropriate level of testing. Unlike LDTs, IVDs are products/articles that are commercially distributed to third parties. Because of this broad distribution, IVDs test kits present a greater potential for user error or other associated risks than LDTs. In contrast to IVDs, LDTs are developed specifically for use by the laboratory that created them, or laboratories under the same ownership/control, thereby promoting greater consistency in performance.
#### B. Applying device law would undermine innovation in diagnostics and access to critical testing services.
Imposing device law would limit the availability of breakthrough and high-quality LDTs that advance patient care. As elaborated upon further below in these comments, LDTs drive medical innovation and advance patient care – they are often the best available testing option for patients and satisfy unmet needs in the absence of cleared and approved IVDs. However, as explained below, device regulation would harm patients by limiting diagnostic innovation, causing important tests to be removed from test menus, reducing access to testing services, and creating an untenable bottleneck at FDA that would prevent needed diagnostics from reaching patients.
##### 1. Device regulation would slow innovation.
Device law would impose rigid requirements that are incompatible with LDTs and continued diagnostic innovation. Currently, laboratories can identify the need for a new clinical test, develop and validate that test, and introduce it within a matter of months. Then, because LDTs are services, trained laboratory professionals can fine-tune and adjust the performance of LDTs to meet patient and physician needs. However, the rigid requirements of device law directly conflict with the flexibility under existing law that supports laboratories’ ability to ensure that patients and providers receive the important diagnostic information they need. Several ACLA member laboratories that have obtained FDA approval for oncology tests have found that physicians prefer LDTs (sometimes offered by the same laboratories) because the FDA-approved versions might not include the latest advances in patient care. Medical device authorities do not allow for the rapid innovation required to meet recognized scientific advancements and the standard of care. The time to bring a new or modified test through FDA’s clearance and approval process could delay patient access to otherwise validated tests by a matter of years. The end result is that patient care would lag behind scientific and medical advancements, which is not in the interest of public health.
a) Device regulation would divert limited laboratory resources.
As an initial matter, application of device regulation under the Proposed Rule would require laboratories to divert their already-limited resources away from research and development activities and toward FDA compliance activities, including re-validation of existing tests to support premarket submissions during the phaseout period. As discussed in detail further below, the cost of compliance with the Proposed Rule is significant – and significantly underestimated by FDA. During the phaseout period, laboratories would have to devote significant resources to developing and implementing policies and procedures to comply with Stages 1 through 3 of the phaseout policy and to the backward-looking exercise of re-validating existing tests and preparing premarket submissions. Even after the phaseout period, there are significant costs associated with ongoing compliance with device regulation. To satisfy these requirements, laboratory personnel and resources that are otherwise typically devoted to test development and innovation would be diverted to these FDA compliance activities. If existing resources are not diverted, then laboratories would need to hire additional personnel and purchase more resources.
Putting monetary cost aside, it is extremely unlikely that laboratories would be able to hire sufficient additional personnel. For the past several years, the laboratory industry has suffered from a devastating workforce shortage. At the April 2023 meeting of the Clinical Laboratory Improvement Advisory Committee (CLIAC), FDA acknowledged that laboratories desire tests with automation, “especially high-throughput automation, because of workforce issues in your lab.” At the same meeting, a CLIAC member repeated that “workforce is the single most threat [sic] that we are experiencing right now in health care, not only with burnout, but with the pipeline is a key component to this.” And at the most recent CLIAC meeting in November 2023, the College of American Pathologists (CAP), an approved accreditation organization under CLIA, explained there are currently about 24,000 unfilled positions in laboratories across the country. Staffing for existing needs has been a challenge for years, and increasing staffing requirements to satisfy FDA regulatory expectations is not likely to be feasible. The result is that laboratory innovation in diagnostics would grind to a halt during the phaseout period while resources are diverted to focus on device compliance activities and revalidation of existing tests.
b) Rigid and burdensome device requirements would slow diagnostic innovation.
Device law also would add rigid and burdensome validation and testing requirements that are not deemed necessary by existing regulatory frameworks, and this would lead to less innovation and slower development timelines, often without corresponding benefit to patients. Partly because the standard under device law is based on safety and effectiveness, which is not an appropriate standard for laboratory diagnostics, and partly due to overly rigid approaches used by FDA, device law will add significant and unnecessary burdens to the development of new laboratory testing services using LDTs. Even assuming laboratories had the needed resources (which they do not, as explained above), and even assuming laboratories could shoulder the burdens of pursuing marketing submissions for all the new tests they develop (which they cannot, as explained further below), performing validation studies according to certain device special controls to support FDA clearance or approval can be prohibitively complex for LDTs. The end result is that important and innovative LDTs could not make their way through FDA’s cumbersome device regulatory framework, and patients and providers would not receive important diagnostic information.
As an example of device special controls that are prohibitively complex for LDTs, consider genetic health screening tests. Genetic health screening tests require accuracy studies that include, per variant and per sample-type: 20 unique wild-type samples plus between 3 and 20 unique positive samples depending on whether the variant is heterozygous or homozygous, and its frequency in the population (as low as less than 0.1% to as high as greater than 2%). While this might be manageable for a test for a single variant of a single gene using a single sample type, these requirements quickly become unmanageable for LDTs that analyze multiple genes representing tens of thousands of variants, and which accept multiple sample types. Moreover, these are the requirements for the accuracy study alone, and additional studies are still required for precision, determination of limit of detection, identification of interfering substances, and more. Simply locating the needed samples to perform these studies can be prohibitive, independent of the costs to perform the studies. Further, limiting FDA clearance to fewer variants is not an acceptable solution as this does not benefit the public health. For example, the first authorized cancer predisposition risk assessment system was cleared to identify only three variants on two BRCA genes. However, a study comparing this test to an LDT found that the cleared test missed over 90% of BRCA mutations in persons who are not of Ashkenazi-Jewish descent and even 10% of BRCA mutations among persons who are.
FDA often requires additional validation data that laboratories and other reviewing entities (e.g., CLIA, CAP, New York State) have not determined to be necessary. For example, in the context of emergency use authorizations (EUAs) for MPOX diagnostics, a published report details how FDA’s requests for additional validation studies or data did not meaningfully affect test performance and offered minimal benefits. Laboratories have reported similar experiences with rigid FDA requirements in the context of COVID-19 EUAs. For example, one ACLA member recalled submitting stability data for the use of a particular swab in its EUA submission for a COVID-19 specimen collection kit for use with its laboratory test. Despite providing more stability data than the swab manufacturer ever provided to support clearance of the swab, FDA rejected the EUA request because the swab’s stability data was not in the appropriate format. This rigid application of device standards slowed the availability of desperately needed testing.
FDA’s approach to device regulation presents other serious barriers to innovation. To support companion diagnostic (CDx) approvals, FDA requires clinical concordance studies to other PMA-approved devices or clinical trials in partnership with drug companies. When a CDx has already been approved for a specific biomarker, there is no incentive for a drug company to conduct additional clinical trials to support diagnostic approvals. If the original CDx claim is held by a single-site LDI, there is no incentive for the laboratory with the approval to conduct clinical concordance studies with additional laboratories to support other diagnostics approvals. Broad regulation of LDTs is likely to put significant constraints on CDx availability, where doctors and patients would be forced to send samples to specific laboratories. A similar situation would occur for single-site LDTs that have 510(k) clearance. In many cases, validation studies would simply not be possible for additional laboratories who wish to offer tests that are substantially equivalent to a predicate LDT.
And even if validation studies were feasible, laboratories simply cannot afford to pursue marketing submissions for all LDTs. As explained further below in these comments, the costs of compliance with device regulation under the Proposed Rule would be significant, despite the fact that in many cases they would not improve the accuracy or reliability of LDTs. Additionally, because the device framework is rigid and defaults any “new” test to class 3—the highest risk classification—a greater number of LDTs would require PMA and De Novo submissions than have been estimated by FDA. A greater number also would require 510(k) submissions. The costs associated with these submissions also would be higher than FDA has estimated.
Given the high costs and challenges with adapting LDT services to comply with device regulation, laboratories may abandon efforts to develop novel tests if they cannot be demonstrated to be profitable. This is likely to have disparate impacts on vulnerable communities, including rare disease communities, that depend on the development and availability of LDTs. For example, genomic and other -omic technologies and applications as validated LDTs have been instrumental to identifying disease etiologies and encouraging research aimed at therapies. Such LDTs have led to the discovery of novel disease etiologies and improved diagnostic workups. Laboratories may not pursue such LDTs for clinical use, however, given the onerous validation requirements that would make offering such tests unprofitable. Instead, laboratories would have to prioritize pursuing development and marketing authorization for those tests and modifications that would be the most profitable and not necessarily those that would have the greatest clinical impact, particularly for small patient populations.
c) Device regulation would delay needed updates to cleared and approved tests.
Additionally, device regulation would limit laboratories’ ability to offer modifications to cleared and approved tests, which are an important part of the clinical care services that laboratories offer to treating physicians. Currently, laboratories validate modifications to cleared/approved tests under CLIA and then make those modifications available to ordering providers. This has been important for adapting tests in unique circumstances, such as where a hospital laboratory may face practical challenges performing a test exactly according to its cleared/approved instructions for use, when there is a product or reagent shortage (or manufacturer recall) and different products or reagents must be validated for use, when the hospital needs to store specimens for longer periods prior to testing due to limited laboratory resources, or when the laboratory has upgraded to a higher throughput platform. Validating extended specimen stability specifications also has been critical for expanding access to tests for patients in underserved communities. It has also been of crucial importance to oncologists who expect to receive the most up-to-date information about genetic variants as relevant to treating cancer patients.
Most or all of these modifications would require, at minimum, a PMA supplement or new 510(k). In some cases, they may require entirely new PMAs or De Novo classification requests. This is supported by FDA’s current guidance on 510(k) modifications. Under that guidance, a wide range of modifications to cleared tests would require new 510(k) notifications. FDA’s guidance provides:
Examples of changes in technology, engineering, or materials that likely alter the operating principle of the IVD and for which a new 510(k) is likely required include:
- changes from radioimmunoassays ... to non-[radioimmunoassays];
- changes in the antibody;
- changes in detection reagents;
- changes in critical reactions components; and
- changes in conjugates.
Examples of changes in technology, engineering, performance, or materials that might alter the operating principle of the IVD include:
- changes from liquid to solid reagent;
- changes in calibration materials and quality control materials;
- changes in substrates;
- changes in specimen type;
- changes in specimen processing; and
- changes in incubation times.
The only modifications that the guidance identifies as not ordinarily affecting operating principles of the IVD are extremely limited, and include only:
- changes to external packaging;
- changes to use a new lot or batch for the same antibody or enzyme;
- changes to a new vendor for the same reagent; and
- changes in concentrations of packaged reagents provided the same diluted concentration was used in the assay.
Clearly, FDA expects 510(k)s for any meaningful modification to a cleared or approved IVD, and the same would apply to modifications to cleared LDTs. Indeed, FDA has issued warning letters to IVD kit manufacturers who failed to submit 510(k)s for incremental improvements. For example, in November 2022, FDA issued a warning letter to an IVD manufacturer who made a reagent change to reduce interference in its assay to measure cardiac troponin I. The standard for PMA supplements is even more stringent. A PMA supplement is required for any change that affects the safety or effectiveness of the device, including minor process changes that improve the performance of a test, or changes to a specimen tube in response to a supply chain shortage. Accordingly, modifications to approved LDTs would require frequent PMA supplements.
Predetermined change control plans (PCCPs) under new FDCA section 515C would not alleviate the need to submit 510(k)s and PMA supplements for modifications to cleared and approved IVDs. First, PCCPs only apply to changes that a manufacturer makes to its own device. It would not allow laboratories to adapt cleared/approved IVDs from other manufacturers to meet evolving clinical needs. Second, PCCPs only apply to those changes that the manufacturer can anticipate at the time of submission, and they do not afford a laboratory the ability to modify a cleared/approved test to meet evolving circumstances, such as product/reagent shortages or unique patient needs. Finally, PCCPs are a novel concept for FDA and industry, and it is unreasonable to expect laboratories not previously regulated by FDA to leverage tools that seasoned manufacturers are still grappling to understand. Ultimately, device regulation of LDTs would limit availability, slow innovation, and undermine incentives to improve existing tests.
d) Slowed innovation caused by applying device law would result in patient care lagging behind scientific and medical advances.
As demonstrated above, applying device law to LDTs would slow innovation. The detrimental impact to patients cannot be underestimated. This slowed innovation would cause patient care to lag behind established scientific and medical advances, many of which are recognized in clinical practice guidelines that represent the standard of care. Currently, high-complexity laboratories can validate methods under CLIA to measure biomarkers recommended under clinical practice guidelines or other peer-reviewed literature, and then report truthful and non-misleading information in test reports. In other words, laboratories can provide information that clinicians are requesting to inform patient care. However, device law limits the potential claims for a diagnostic intended to aid in therapy selection to those claims approved in drug labeling or a very limited subset of FDA-recognized sources, which will restrict laboratories from sharing this information until an FDA clearance or approval catches up with the recognized practice guideline or published literature. This would significantly slow innovation in the field of precision medicine, where the most up-to-date information on potential therapeutic options based on a patient’s test results is often found in clinical practice guidelines.
Precision medicine in oncology would be hit particularly hard. Oncologists rely on LDTs to deliver diagnostic information consistent with emerging science, and new scientific discoveries are being made, and new clinical care guidelines are being published, faster than FDA can review and approve marketing submissions for diagnostics. For example, the National Comprehensive Cancer Network (NCCN) updates their guidelines on a continual basis, and is currently on its fifth version in 2023 for its guideline on non-small cell lung cancer. By the time an oncology assay obtains approval or clearance, its clinical claims may not reflect the latest advances in patient care.
Moreover, as the sensitivity of instruments improves, and artificial intelligence/machine learning algorithms become more powerful, the pace of innovation in oncology is only expected to accelerate. Indeed, just last month (November 2023), a large diagnostic study of 43,524 individuals demonstrated that performing germline RNA sequencing (for which there are no approved or cleared IVDs) concurrently with DNA sequencing improves detection of novel variants and classification of existing variants. And innovative LDTs are catching more high-risk genetic variants missed by cleared/approved tests. Imposing device regulation on these assays would limit and slow patient and provider access to important diagnostic information based on the most current scientific knowledge.
evidence. That would be clearly at odds with the White House’s Cancer Moonshot, a primary goal of which is to expand access to cancer screenings.17 Time is of the essence to guide clinical care for oncology patients.
The bottom line is clear: applying ill-fitting device regulation to LDTs would slow diagnostic innovation to the detriment of patients.
##### 2. Medical device regulation would cause important tests to be removed from testing menus.
Under device regulation, laboratories may not be able to continue offering important, currently available LDTs—not because such tests are not analytically or clinically valid, but because the device framework is overly rigid and the cost of compliance and premarket review could not be justified. As discussed above, device law imposes burdensome validation requirements that are not required under existing regulatory frameworks, and as explained further below in these comments, the costs of compliance with device regulation and pursuing premarket authorization is high—higher than FDA estimates. In some cases, laboratories may not be able to justify the cost of compliance and/or pursuit of marketing authorization for tests, and those tests would simply be removed from test menus and become unavailable to patients.
Most LDTs offered by laboratories do not generate significant revenues. Based on an informal survey of ACLA members, the majority of LDTs have annual revenues of less than $5 million. This is consistent with studies showing that while there are a significant number of LDTs that have been developed and are offered to patients, the rate at which LDTs are performed in the clinical setting is far lower than the rate at which approved and cleared IVDs are performed.18 Accordingly, laboratories may not be able to financially justify pursuing marketing approval for all the LDTs they have developed. Indeed, a substantial portion of LDTs bring in less revenue than the user fee submission cost alone for the test.
Tests that are able to generate only modest revenue, such as those for which there is a small patient population, are likely to be culled from test menus first. Many microbiology tests would be expected to fall into this category, as the combination of organisms and tests exponentially compounds what could reasonably be achieved in a marketing submission. These LDTs would be abandoned based on the high cost of pursuing premarket submissions and the minimal profit margin associated with such tests—not due to a lack of analytical or clinical validity. Many of the other tests that would be abandoned are rare disease tests and tests for pediatric populations.
Removing these tests from the market would have dire impacts for patients who rely on these LDTs. Absence of lower cost LDTs would limit access, thereby prolonging the diagnostic journey for many patients and depriving others of critical information that can guide efficient and effective care. The impact would be particularly pronounced for patients with rare diseases who rely on innovative LDTs where there is no cleared/approved alternative. A September 2023 study by EveryLife Foundation concluded that, on average, rare disease patients spend more than 6 years searching for a diagnosis, but an earlier diagnosis can avoid costs between $86,000 and $517,000 per patient cumulatively, in terms of medical costs and productivity loss in the pre-diagnosis years, during such period.19 That earlier diagnosis is often available only with LDTs, but those LDTs may not be available under device regulation.20
In another study by Geno, et al., a hospital laboratory assessed the impact on its healthcare system when it was forced to discontinue its LDTs for immunosuppressant and definitive opioid testing (tests that are typically only available as LDTs) based on staffing constraints during the COVID-19 pandemic.21 The study concluded that, although referral testing was available for some immunosuppressant testing, the extended turnaround times during the pandemic led to complications in the initial dosing of transplant patients. And discontinuing in-house opioid testing cost the health system over half a million dollars in the year since testing was discontinued.22
We note that FDA has acknowledged that application of device regulation under the Proposed Rule would result in some tests being removed from the market.23 However, we think this is an unacceptable position for a public health agency. The public health is not protected by depriving patients of important tests. And indeed, FDA completely fails to consider the welfare costs to our healthcare system of having these tests become suddenly unavailable.
##### 3. Device regulation would cause laboratory testing services, including for IVDs, to become more limited.
Diverting laboratory resources to compliance with medical device regulation under the Proposed Rule—both during the phaseout period and on an ongoing basis—also would harm patient access to diagnostic testing because fewer resources and personnel would be available to perform clinical testing services. As explained further above in these comments, there is a dire workforce shortage in the laboratory industry. In addition to diverting resources away from current innovation practices, resources would be diverted away from clinical testing services for patients, including clinical testing services for both LDTs and IVDs performed in that laboratory. Accordingly, patient access to clinical testing services—both for LDTs and cleared/approved IVDs—would suffer. Ongoing compliance costs would have a similar effect. Under FDA regulation, laboratories would be subject to dual inspections by FDA as well as CLIA/CAP/state regulators, further diluting existing resources.
Because laboratory resources are so limited, if/when laboratories identify tests that are worth the cost of pursuing FDA marketing authorization, they may be forced to divert resources typically used for clinical testing back toward research and development. Those personnel and facility spaces cannot be simultaneously used to perform tests for patients. For example, laboratories that modify existing test systems may need to dedicate instrumentation typically devoted to clinical testing to be used for clinical development. The laboratory may even have to cease testing using the cleared or approved version of the test while awaiting FDA review of its proposed modification.
Moreover, some laboratories may not be able to justify the cost of complying with the Proposed Rule and may close completely, depriving patients access to all testing that was offered by that facility. This is likely to have a disparate impact on already vulnerable and underserved communities whose access to testing services is already limited. It could also lead to consolidation in the testing market, reducing competition, driving prices upward, and making testing services less accessible to patients.
Finally, we must stress that laboratories are already stretched exceedingly thin in terms of resources, including personnel. As discussed earlier, there is an ongoing shortage of laboratory professionals available to support testing services and development of new assays. Moreover, laboratories are facing significant cuts to payment for their services under the Protecting Access to Medicare Act (PAMA) of 2014.24 All of these factors, together with application of ill-fitting device regulation to LDTs, converge to threaten the continued existence of many laboratories, which is not in the interest of public health, particularly when, as FDA noted in the Proposed Rule, 70% of medical decisions are based on laboratory test results. FDA failed to consider these costs to our healthcare system.
##### 4. FDA is not prepared to regulate LDTs as devices, which would cause innovation to slow across the industry.
Under the Proposed Rule, FDA anticipates receiving all PMAs 3-5 years after the phaseout period is finalized, and all De Novo classification requests and 510(k)s 4 years after the phaseout period is finalized. These initial premarket submissions, as well as ongoing submissions expected on an ongoing basis thereafter would slow patient access to innovative tests as FDA deals with an overwhelming increase in workload, leading to extended review times and fewer FDA resources to engage with applicants and developers. Moreover, FDA is likely to face the same or similar staffing challenges as both the Agency and laboratories compete for limited specialized talent amidst an existing workforce shortage. And FDA is likely to continue struggling, even after the initial bolus of regulatory submissions.
a) FDA is not prepared for the avalanche of submissions it would receive for existing tests, and this would slow innovation across the industry.
First, at years 3.5 and 4 of the phaseout period, premarket submissions would flood into the Agency, and FDA reviewers would be overwhelmed with reviewing these submissions. Even if FDA’s low estimates were correct, it would receive 4,210 PMAs, product development protocols (PDPs), and Panel-Track PMA Supplements (collectively “PMA Submissions”), 4,020 De Novos, and 32,160 510(k) submissions all at once at years 3.5 and 4 of the phaseout period. This is an overwhelming amount of work for the Agency. In its entire history since the enactment of the Medical Device Amendments of 1976 (48 years), FDA has only approved 302 original PMAs and Panel-Track PMA Supplements for IVDs, 135 De Novos for IVDs, and 30,178 510(k)s for IVDs.25
The RIA itself acknowledges that FDA typically processes on average in a given year: 73 PMA Submissions; 66 De Novo requests; and 3,877 510(k)s. Based on FDA’s own estimates, however, it would experience an increase in submissions of more than 5,000 percent for PMA Submissions, more than 6,000 percent for De Novos, and more than 800 percent for 510(k)s during stages 4 and 5 of the phaseout period. FDA would be expected to review all of these premarket submissions—plus IVD kit submissions that are expected to continue to be submitted. Moreover, FDA would be expected to conduct preapproval inspections for all class III LDTs requiring PMAs. Regardless of what is negotiated in the next Medical Device User Fee Amendments (MDUFA) cycle, this would be a herculean amount of work for FDA—a work that FDA is unlikely to be able to find the resources to complete.
With regard to resources, FDA would need to begin hiring reviewers to support these applications far in advance of when user fees would be paid. Accordingly, FDA cannot brush off the increase in workload by pointing to the next MDUFA cycle and asserting that costs would be borne by the industry. Taxpayer funds would be necessary to support FDA’s activities, and the Agency has failed to provide an assessment of the costs it would impose on the country. And even if FDA had the funds to hire new reviewers, we expect that FDA would struggle to hire additional reviewers for the same reasons that laboratories would struggle to hire additional laboratory professionals.
We also disagree that FDA’s 510(k) Third Party Review Program would significantly alleviate this burden. Such program does not extend to PMAs and De Novos, and as explained earlier, most novel LDTs would require authorization through one of these pathways. Furthermore, there are currently only seven approved third party review organizations, and four of those organizations (i.e., more than half) review fewer than 40 of the hundreds of types of IVDs that may be cleared under a 510(k).26 Finally, such program has long been criticized by industry because the high rate of re-review by FDA means that utilization of such program can actually extend premarket review time.27 Accordingly, applicants are unlikely to rely on such program for clearance of LDTs.
Any traditional IVD premarket submission submitted around or after years 3.5 and 4 of the phaseout period would necessarily be caught in FDA’s guaranteed backlog. This means IVD manufacturers would also struggle to roll out new tests, slowing patient access to these tests, as well. This happened during COVID, when FDA was completely overwhelmed with EUA submissions from laboratories and FDA could not manage its regular IVD workload. During that time, FDA stopped reviewing all IVD presubmissions that were not related to COVID-19, a companion diagnostic, a breakthrough designation request, or otherwise had a significant public health impact.28 Non-COVID-19 IVD files also experienced significant delays in initiation of review.29
Furthermore, even before premarket submissions are required for LDTs at years 3.5 and 4 of the phaseout period, FDA would be flooded with presubmission requests from laboratories seeking guidance on risk classification and how to pursue marketing authorization for their tests. Compliance with FDA regulation is new for most laboratories, and laboratories would have numerous questions about the classification of potential tests (e.g., is a PMA or a De Novo more appropriate?) as well as the validation studies needed to support ultimate marketing authorization. Such presubmission requests, for which FDA does not receive revenue from a user fee, would be submitted during the next MDUFA cycle, meaning FDA would have to address such requests with its existing, limited resources. Diverting those FDA resources to LDT presubmissions would also negatively affect IVD manufacturers, as FDA would likely miss MDUFA goal dates for review of IVD presubmissions and premarket submissions during the phaseout period. This means a slower pace for bringing innovative tests to patients, regardless of whether those tests were developed by laboratories or commercial manufacturers.
This flood of presubmissions cannot be addressed through guidance documents, either. The Proposed Rule states that FDA intends to release additional guidance documents during the transition period, but in order for laboratories to benefit from such guidance documents when performing re-validation of tests, the guidance documents would need to be released almost immediately after publication of the final rule. Furthermore, even if such guidance documents were timely released, it is unreasonable to expect that such guidances would address every question from laboratories. Instead, FDA would be flooded with presubmission requests from affected laboratories upon release of the final rule, further depleting laboratory and FDA resources.
b) FDA is not prepared for the increase in workload for new and modified tests, and this would slow innovation across the industry.
Second, even after the initial flood of applications and the phaseout period is complete, FDA would continue to be vastly overwhelmed by marketing submissions for new LDTs and modifications to cleared and approved tests. The RIA estimates that each year, FDA would receive 407 PMA Submissions, 389 De Novo requests, and 3,110 510(k) submissions. But, as explained later these comments, this is a significant underestimate.
Even if FDA’s low estimates were correct, however, FDA would be overwhelmed by this increase in submissions. As noted earlier, FDA typically processes on average in a given year: 73 PMA Submissions; 66 De Novo requests; and 3,877 510(k)s. Based on FDA’s own estimates, however, it would experience an annual increase in submissions of more than 500 percent for PMA Submissions, more than 500 percent for De Novos, and more than 80 percent for 510(k)s. This significant increase in workload is unlikely to be met with an increase in personnel, particularly in light of the laboratory professional workforce shortage. For the reasons stated above, we continue to disagree that the 510(k) Third Party Review program would significantly alleviate this burden.
Traditional IVD premarket submissions also would be caught in FDA’s guaranteed backlog, which would also slow the ability of IVD manufacturers to roll out new tests, slowing patient access to these tests, as well. And as explained earlier, FDA’s workload would be further compounded by presubmission requests as laboratories unfamiliar with device regulation learn to navigate the device framework, and this increase in workload is unlikely to be alleviated through the release of guidance documents.
For all of these reasons, device regulation would undermine diagnostic innovation and patient access to critical tests. Applying device regulation to LDTs is the wrong approach.
### II. LDTs Are Subject to Robust Regulation and Review.
FDA issued its Proposed Rule amidst the backdrop of its long history of not regulating LDTs and taking inconsistent positions on LDTs. In contrast, Congress and states have implemented a clear system for regulating laboratories and LDTs for decades that promotes their accuracy and value. The Proposed Rule mentions but does not fully describe the oversight that has long been applicable to laboratories and LDTs via CLIA, state laws, and scrutiny by public and private payers. FDA has failed to provide a reasoned basis for such regulation being insufficient or an inadequate framework to address any concerns.
Below we first describe FDA’s vacillating position on LDTs and then describe the robust oversight that currently exists for laboratory testing services.
#### A. FDA’s history of inconsistent positions on LDTs
FDA has had authority under the FDCA to regulate medical devices since 1938, and in the Medical Device Amendments of 1976 (MDA) Congress significantly expanded those authorities. But in neither of those statutes, nor in any subsequent amendment to the FDCA, did Congress assign the regulation of LDTs to FDA, nor has Congress appropriated the funding or provided for user fees that could support such an expansion of FDA’s authority. Instead, Congress enacted a wholly different framework to regulate laboratory services, including the development of LDTs. Congress enacted the Clinical Laboratory Improvement Act of 1967, assigning the role of regulating laboratory services to (what is now called) the Centers for Medicare and Medicaid Services (CMS). Confirming that understanding, Congress again addressed laboratory testing by strengthening CMS’s role through enactment of the Clinical Laboratory Improvement Amendments of 1988. Indeed, CLIA ’88 was enacted by Congress specifically to strengthen the oversight of LDTs. But nowhere in the legislative history of CLIA ’67 or CLIA ’88 did Congress suggest that FDA had any regulatory role over LDTs as devices. In fact, FDA was never even considered.
FDA did not even claim the authority to regulate LDTs until nearly 60 years after the enactment of the FDCA and 20 years after the MDA. In a 1992 draft Compliance Policy Guide (CPG), FDA alluded to “laboratories … manufacturing [LDTs] … and utilizing these unapproved products for diagnostic purposes.” FDA never finalized that CPG. Four years later, in a regulatory preamble to a proposed rule that would regulate not LDTs, but analyte specific reagents (ASRs – which are components used in diagnostic tests), FDA mentioned that it had not “actively regulated” LDTs and might do so in the future. But in the preamble to the Final Rule regarding ASRs, FDA explained that LDTs “contributed to enhanced standards of medical care in many circumstances and … significant regulatory changes in this area could have negative effects on the public health,” and FDA imposed no meaningful regulatory requirements on LDTs.
Since that time, FDA has claimed at various points that it has authority to regulate LDTs as devices, but it has never actually exercised that claimed authority in a comprehensive manner. In 2006 and 2007, FDA proposed to regulate a subset of LDTs that use software by issuing two different draft guidance documents. That effort was abandoned. FDA then claimed authority over narrow categories of tests and some laboratories have acquiesced to FDA’s claimed authority. The last time FDA proposed to comprehensively regulate LDTs, via draft guidance documents in 2014, the Agency never followed through, and the draft guidance documents were never finalized. In recent years, even the position within HHS has vacillated regarding FDA’s authority to regulate LDTs as devices. Just three years ago, an HHS legal memorandum was made public in which the General Counsel of HHS acknowledged significant limitations on FDA’s ability to regulate LDTs.
Confirming that FDA currently lacks authority over LDTs, Congress has long considered whether to grant FDA new authority to regulate LDTs under a non-device framework. The most recent effort was Congress’s consideration of the Verifying Accurate Leading-edge IVCT Development (VALID) Act, which was debated as part of the Consolidated Appropriations Act of 2023, and re-introduced as recently as March of this year. The VALID Act would have established a new product category under FDA’s jurisdiction—in vitro clinical tests (IVCTs)—that would have included both IVDs and LDTs. If LDTs were devices, this legislation would be unnecessary. Congress’s serious consideration of this legislation in 2022 confirms that Congress never provided FDA authority to regulate LDTs as devices.
Notwithstanding this history, FDA is once again asserting that Congress granted it regulatory authority over LDTs using its device authorities. However, as explained further below, this is wrong (Congress granted FDA no such authority), and as explained above it is an ill-advised policy position that stands to harm patient health (device law would undermine innovation and patient access to important LDTs).
#### B. CLIA applies to all clinical laboratories and LDTs.
CLIA establishes a framework for the regulation of laboratories and laboratory testing services—including LDTs. CLIA requires that all LDTs are developed and performed only in laboratories certified to perform high-complexity testing and under the direct control and supervision of highly trained clinical laboratory professionals.
##### 1. Under CLIA, laboratories rely on the expertise of highly trained professionals.
Under CLIA, high-complexity laboratories that develop and perform LDTs are overseen by a laboratory director, the majority of whom are licensed physicians in the state, and the rest of whom hold an earned doctoral degree in chemical, physical, biological or clinical laboratory science and a certification by an HHS-approved board. Moreover, CLIA requires that a laboratory may also require support from: (1) a technical supervisor, who has additional training or experience in high-complexity testing within the particular specialty or subspecialty of testing performed by the laboratory; and (2) a clinical consultant qualified to consult with and render opinions to the laboratory’s clients concerning the diagnosis, treatment and management of patient care. The clinical consultant must either meet qualifications equivalent to a laboratory director, or otherwise be a doctor of medicine, doctor of osteopathy, or doctor of podiatric medicine licensed to practice in the state. And all high-complexity testing personnel must either (a) be a licensed physician, (b) have earned a doctoral, master’s or bachelor’s degree in a chemical, physical, biological or clinical laboratory science, or medical technology, or (c) have earned an associate degree in laboratory science or medical laboratory technology, or equivalent education and training. Accordingly, laboratory developed testing services are performed only by highly skilled and trained laboratory professionals.
The responsibilities of the laboratory director and clinical consultant underscore the value of the services provided by clinical laboratories. In addition to overseeing the operation and administration of the laboratory, the laboratory director is responsible for ensuring that selected test methodologies “have the capability of providing the quality of results required for patient care,” “reports of test results include pertinent information required for interpretation,” and “consultation is available to the laboratory’s clients on matters relating to the quality of the test results reported and their interpretation concerning specific conditions.” The clinical consultant is expressly responsible for “provid[ing] consultation regarding the appropriateness of the testing ordered and interpretation of test results.”
These activities of the laboratory director, clinical consultants, and other professionals employed by laboratories, such as accredited genetic counselors, all may fall within the practice of medicine, and are recognized under state laws as such. These activities are core to the professional services provided by laboratories that enable ordering providers to provide the highest quality clinical care for their patients.
##### 2. CLIA imposes strict quality requirements and proficiency standards.
Additionally, development and performance of LDTs are subject to strict quality controls under CLIA. When an LDT is developed, high-complexity laboratories must “before reporting patient results, establish for each test system the performance specifications for the following performance characteristics, as applicable: (i) Accuracy. (ii) Precision. (iii) Analytical sensitivity. (iv) Analytical specificity to include interfering substances. (v) Reportable range of test results for the test system. (vi) Reference intervals (normal values). (vii) Any other performance characteristic required for test performance.” Indeed, these requirements apply specifically when a laboratory modifies an FDA-cleared or -approved test or develops “a test system not subject to FDA clearance or approval (including methods developed in-house and standardized methods such as text book procedures)”.
Then, like all other non-waived tests performed in the high-complexity laboratory, the LDT remains subject to the laboratory’s extensive quality system that requires, among other things, establishment and performance of calibration and control procedures, maintenance and function checks for equipment, instruments, and test systems, and on-going quality monitoring.46
CLIA further requires that laboratories enroll and participate in approved proficiency testing programs, which serve as external quality control programs for laboratories.47 Proficiency testing requires that the laboratory test blinded samples according to their typical laboratory procedures and report the results back to the approved proficiency testing program for evaluation. The laboratory successfully participates in proficiency testing if it obtains the testing scores outlined in CLIA regulations, and fails if it does not obtain such scores.48 Importantly, the laboratory must participate in proficiency testing “for each specialty, subspecialty, and analyte or test in which the laboratory is certified under CLIA.”49 If the laboratory fails to successfully participate in proficiency testing, then CMS may impose sanctions, including suspension, limitation, or revocation of the CLIA certificate.50 If a test offered by the laboratory is not included in an approved proficiency testing program, as may happen with a novel LDT, then the laboratory must verify the accuracy of such test at least twice annually.51 Studies have found that LDTs developed under the CLIA framework can perform as well or better than FDA-cleared or approved test kits.52
##### 3. CLIA is supplemented by rigorous accreditation standards.
CLIA sets a minimum standard applied to clinical laboratories, but many laboratories are subject to more stringent requirements imposed by their accrediting organization. Under CLIA, laboratories can receive certification for high-complexity testing via either a certificate of compliance based on compliance with the CLIA regulations as written, or via a certificate of accreditation based on compliance with the requirements of a CMS-approved accreditation organization.53 To be approved, however, the accreditation organizations must apply standards “equal to or more stringent than the standards” under CLIA.54 And indeed, accreditation organization standards generally are more stringent than the standards under CLIA. For example, the College of American Pathologists (CAP) is more prescriptive regarding methods for establishing performance specifications for LDTs,55 and specialty CAP checklists often have additional, specific requirements for analytical validation of tests within a specialty.56 CAP specifically requires that laboratories clinically validate all LDTs using either (i) a clinical validation study, generally consisting of at least 20 samples or (ii) peer-reviewed literature.57 The specialty CAP checklist for molecular pathology specifically states that “[i]t is essential that the laboratory director or designee use professional judgment in evaluating the results of [clinical validation] studies and in monitoring the state-of-the-art worldwide as it applies to newly discovered gene targets and potential new tests, especially those of a predictive or incompletely penetrant nature.”58
#### C. State laws impose additional requirements on laboratory testing services.
Clinical laboratories are subject to additional requirements under state laws. For example, Florida imposes additional licensing requirements for laboratory personnel operating in the state.59 Moreover, some states like California, Maryland, New York, Pennsylvania, and Rhode Island impose additional licensing and permitting requirements for any laboratory that offers testing on specimens from those states.60 These requirements extend beyond the laboratories within those states to laboratories across the country if that laboratory offers tests to the state’s residents.
New York’s clinical laboratory law warrants special attention. Any laboratory testing specimens from New York patients, whether located in New York or not, must obtain approval of individual LDTs, consistent with its risk classification, from state authorities.61 To obtain New York approval to perform an LDT, the laboratory must satisfy the applicable general standards and specialty standards for a test,62 and submit a full method validation, including information specified in a general or specialty-specific checklist, and a risk attestation form.63
The method validation requires submission of detailed information for the state’s review. For example, for molecular genetic testing, laboratories are required to include a description of the test, information regarding specimen and requisition requirements, information about materials and methods (including reagent recipes, a step-by-step protocol, assay controls, and more), validation data, and information about results and interpretation.64 The risk attestation requires submission of additional information including: for clinical claims or direct references to recognized diseases/conditions, full citations to references or supporting clinical or laboratory data and/or publications if clinical trials/studies were performed; an explanation of which critical and/or essential information (if any) is generated to inform or influence treatment of a patient; and a description of the potential impact of an inaccurate result.65 These requirements are robust, but they are efficient – the amount of data required by New York is less than would be required by FDA under device law, yet it is sufficient to evaluate the analytical and clinical validity of the tests.
#### D. Payers scrutinize LDTs for coverage decisions.
The clinical validity of tests is also closely scrutinized by both public and private payers. For example, the Molecular Diagnostic Program (MolDX) provides Medicare coverage for molecular diagnostic tests, including LDTs, only once those tests have demonstrated analytical validity, clinical validity and clinical utility.66 To obtain coverage, laboratories must submit dossiers with scientific
information to demonstrate these standards and the requirements of the specific coverage determination are met, and those dossiers are reviewed by unbiased subject matter experts. The MolDX program has been adopted in 28 states and additional US territories, and according to MolDX, most molecular labs in the United States operate within its jurisdiction. MolDX reviews over 1,500 tests per year, and it has reviewed approximately 20,000 tests, a vast majority of which are LDTs, to date since the program was established in 2011.67
Private payers also have recognized the value of novel LDTs to provide quality health care. For example, one study analyzed coverage policies from the 19 largest U.S. private payers with publicly available policies and found that all payers covered certain noninvasive prenatal screening (NIPS) testing in high-risk singleton pregnancies based on robust clinical validity studies and modeled evidence of clinical utility, and eight of those payers also covered NIPS testing in average risk pregnancies, citing clinical validity studies and updated professional guidelines.68
Accordingly, it is simply false to refer to LDTs as unregulated, inadequately regulated, or unscrutinized. High-complexity laboratories are subject to multi-layered regulation, and individual LDTs are scrutinized by federal regulatory regimes (CLIA), state regulatory regimes (state clinical laboratory laws), accrediting organizations (e.g., CAP), proficiency testing entities, federal coverage programs, private payers, and individual clinicians in search of the best care for their patients.
### III. FDA’s Proposed Rule Fails to Recognize the Significant Contributions of LDTs to the Public Health.
As explained in the following subsections, FDA’s characterization of LDTs in the Proposed Rule is misleading and ignores the significant contributions LDTs make to clinical care. Subsection (A) explains how LDTs have driven innovation in clinical care across therapeutic areas, and subsection (B) explains how LDTs are critical to meeting clinical care needs, including by improving access to testing. FDA’s Proposed Rule and the RIA fail to consider the harms to public health of eliminating the LDT diagnostic innovation pipeline and removing life-saving tests from the market.
#### A. LDTs drive advances in the public health by innovating at the pace of science.
High-complexity laboratories that develop and perform LDTs have been responsible for some of the most cutting-edge and important innovations and breakthroughs in clinical care in our country. As explained further below, LDTs have pioneered new areas of science by (1) driving medical innovation and laying the groundwork for development of standardized test kits; (2) detecting and driving our public health response to emerging threats; and (3) supporting therapeutic product clinical trials. FDA’s Proposed Rule and the RIA, fail to consider the harms to public health of eliminating LDTs that serve these important roles.
##### 1. LDTs have driven medical innovation and established new standards of care.
LDTs have been at the forefront of medical innovation for decades. In many cases, standard, routine FDA-cleared and -approved tests were first available only as LDTs in specialized laboratories.69 In each case, LDTs were for many years the only available diagnostic tests for these conditions, and the analytical and clinical data generated by these LDTs later paved the way for clearance and approval of tests for similar intended uses.
**BRCA1/BRCA2.** The high rates of breast cancer mortality in women of certain families led to a decades-long search for the causes of inherent susceptibility to the disease. In February 1994, a team of researchers led by Mark Skolnick at Myriad Genetics, in conjunction with collaborators at the NIH, sequenced BRCA1 (BReast CAncer gene 1).70 The laboratory began offering testing for hereditary breast and ovarian cancer susceptibility in 1996. Today, testing for BRCA1/BRCA2 mutations have become the standard of care for breast and ovarian cancer. Millions of women have been tested for mutations in these genes, which has led to better and earlier treatments and saved lives.
**HSV Encephalitis.** The WHO estimates that 3.7 billion people under age 50 (67%) globally have Herpes simplex virus (HSV) type 1 and another 491 million (13%) have HSV type 2.71 HSV is the most common cause of fatal encephalitis worldwide.72 Until the mid-1990s, the preferred method of diagnosing HSV infection was through an invasive brain biopsy procedure that carried a significant risk of morbidity.73 Around 1995, however, laboratory scientists developed a polymerase chain reaction (PCR) test that performed equivalently to brain biopsy.74 For nearly 20 years, the only method of PCR diagnosis for HSV encephalitis was an LDT. It was not until 2014 that FDA cleared a PCR test for diagnosis of the same.75
**CMV.** The CDC estimates that over half of adults have been infected with Cytomegalovirus (CMV) by age 40.76 CMV is a form of herpes virus, and although a healthy person’s immune system usually keeps the virus from causing illness, it can occasionally cause serious problems. It is one of the most common opportunistic infections following solid organ and hematopoietic stem cell transplant, and if left untreated and the virus invades certain tissues, it can cause liver, lung, heart, and bacterial infection and even death.77 In the early 1990s, laboratory scientists developed a PCR test that could detect CMV infection in the plasma of transplant recipients.78 LDTs were the sole method of diagnosing CMV until 2012.79 During the intervening years, transplant physicians routinely used LDTs to screen asymptomatic patients in transplant centers and assess therapeutic treatment efficacy.80
**KRAS Mutations.** The KRAS gene (Ki-ras2 Kirsten rat sarcoma viral oncogene homolog) is one of the most commonly mutated oncogenes in numerous cancers, such as non-small cell lung cancer, pancreatic ductal adenocarcinoma, and colorectal cancer.81 Though cetuximab was lauded as a promising treatment for patients with colorectal cancer, a landmark 2006 study demonstrated that KRAS mutation is highly predictive of cetuximab resistance.82 Molecular pathology laboratories developed LDTs to detect KRAS mutations, and KRAS mutational profiling quickly became the standard of care for patients with metastatic colon cancer. It was not until 2014, however, that FDA approved a companion diagnostic to screen for KRAS mutations.
**NGS for oncology.** In addition to the single-gene tests described above (BRCA1/2 and KRAS), LDTs have also driven the development of standard-of-care next generation sequencing (NGS) for oncology, more broadly. For example, current lung cancer guidelines recommend testing for over 10 tumor biomarkers at the time of diagnosis, and a study by Aggarwal, et al. shows that molecular genotyping before first line therapy is initiated leads to longer survival. Although FDA began approving IVDs applying NGS technology for oncology applications starting in late 2016, the approved applications for such technology were initially narrow. And while such indications have since expanded, they are the result of more than a decade of development and refinement under the LDT framework.
There are numerous additional examples like these, where innovative LDTs have improved patient care for many years, even decades before there was an FDA-authorized standard kit. LDTs have long been a critical element of American medical innovation.
##### 2. LDTs are a critical public health tool.
LDTs are essential for responding to public health threats in various forms, from emerging pathogens, to rare pathogens, to synthetic drugs. Their ability to be rapidly developed, validated, and performed makes them uniquely important to responding to emerging and constantly shifting public health needs. A few examples are demonstrative.
First, LDTs have always been at the forefront of providing access to testing for new and emerging pathogens, such as COVID-19, MPOX, Swine Flu, and Enterovirus D68, where FDA-cleared and -approved tests were not available until long after the need for testing arose. For COVID-19 in particular, LDTs were absolutely essential to the American public health emergency (PHE) response. As an initial matter, scientists relied on LDTs to diagnose COVID-19 even before the Secretary of HHS declared a PHE. For example, the first U.S. case of COVID-19 was diagnosed on January 20, 2020, using an unapproved assay developed and performed at the Centers for Disease Control and Prevention, i.e., a CDC LDT. As explained further below in these comments, commercial LDTs were a vital component of the American response to the COVID-19 pandemic, and in contrast to the portrait painted by the Proposed Rule, FDA’s policies ultimately recognized the importance—and quality—of these tests. Unfortunately, that recognition came approximately one month after the Agency’s intervention prevented America’s clinical laboratories from bringing LDTs to the public that would have facilitated contact tracing and allowed the pandemic to be more rapidly brought under control.
More generally, a complex set of factors influence test developers’ decisions to develop new diagnostic tests and ramp up manufacturing capacity and/or laboratory testing capacity in the face of an emerging pathogen. However, these dynamics are less of a challenge for laboratories developing LDTs, and accordingly, laboratories are often the first developers taking action to develop tests in such circumstances.
Second, LDTs continue to be important for detecting rare and infectious pathogens where there is no FDA-cleared or -approved diagnostic available. For example, no FDA-approved tests were available to detect avian influenza virus, chikungunya virus, Ebola virus, Middle Eastern respiratory syndrome virus, severe acute respiratory syndrome virus, or Zika virus when those pathogens first emerged. In the absence of FDA-cleared or -approved diagnostics, clinical laboratories developed, validated, and implemented LDTs that facilitated the rapid treatment and appropriate isolation of patients, thereby slowing the spread of potentially deadly infections. In the immediate wake of infectious disease outbreaks, clinical laboratories play a vital role in rapidly diagnosing pathogens and decreasing overall mortality. LDTs are equally essential to the diagnosis of rare diseases. To this day, LDTs remain the only available diagnostics to detect the pathogen that causes high-risk human papilloma virus in oropharyngeal cancers and the genetic mutations that cause Huntington’s Disease and epidermolysis bullosa.
Third, LDTs are vitally important to our public health response to the evolving drug overdose epidemic, where novel psychoactive substances (NPS)—including benzodiazepines, fentanyl, and other opioids—are appearing and fading from the market faster than IVD test kits can be cleared or approved. This means that frequent and rapid modifications to tests are necessary to meet provider needs. One ACLA member laboratory reported validating new LDTs at least twice annually to keep pace with new and emerging drugs, and that it added over 70 new analytes to its NPS LDTs in the last 14 months. Two ACLA member laboratories—Laboratory Corporation of America Holdings (“Labcorp”) and Aegis Science Corporation (“Aegis”) developed LDTs for detecting xylazine over a year before FDA issued its alert regarding xylazine in November 2022. FDA’s alert acknowledged that “[r]outine toxicology screens do not detect xylazine, and additional analytical techniques are required to detect xylazine when it might be involved in illicit drug overdoses.” To date, over a year after FDA’s alert, there are still no FDA-cleared or -approved xylazine IVD test kits, but ACLA member laboratories perform thousands of life-saving tests for xylazine every month using the LDTs they have developed. There also are no FDA-cleared or -approved test kits for many other NPS drugs, including many fentanyl analogues and designer drugs. Keeping pace with NPS requires deep expertise, ongoing investment, and rapid implementation of updates. Device law is simply inconsistent with these requirements, and FDA regulation of NPS LDTs would create a significant risk that the tests would fall behind, leading to major public health challenges.
##### 3. LDTs advance therapeutic product development.
LDTs are also a vital component of therapeutic product development. Clinical trial assays (CTAs) are critical for collecting safety and effectiveness data about an investigational therapeutic product, and they are routinely developed as LDTs because no FDA-cleared or -approved assay is available. Moreover, because the assay cut-off may be adjusted over the course of product development (e.g., from early-phase (I/II) to late phase (III) clinical trial testing), therapeutic product sponsors frequently turn to high-complexity laboratories with the expertise and ability to nimbly validate modifications to the assays as needed. LDTs also are often developed for performance as CTAs to identify patients most likely to benefit from an investigational therapeutic product and may be the basis for a later cleared or approved companion diagnostic.
In many cases, LDTs developed for use as a CTA are available only to support drug development. For example, an ACLA member laboratory developed an LDT specifically for use in clinical trials of a then-investigational gene therapy product for treating hemophilia. The LDT measured endogenous factor VIII clotting protein developed by a patient after treatment with the gene therapy product, i.e., to measure the effectiveness of the gene therapy. The therapeutic product has since been approved with a companion diagnostic offered by a different laboratory, but the CTA has not been commercialized.
In other cases, drug developers partner with multiple laboratories to develop LDTs as CTAs to support enrollment of patients with rare diseases and conditions into a clinical trial. Partnership
#### B. LDTs are essential for meeting current clinical care needs.
LDTs are essential for meeting current clinical care needs because they are often the best available testing solution for patients. As discussed below, (1) many clinical tests are available *only* as LDTs either because no FDA-cleared or -approved test exists for a particular disease, condition, or patient population, or because patients do not have access to a cleared or approved IVD. In other cases, (2) even where an FDA-cleared or -approved test exists, an LDT for the same disease or condition performs better than the cleared or approved test, and has accordingly become the standard of care. The Proposed Rule would cause many of these tests to be withdrawn from the market. However, the Proposed Rule and the RIA failed to consider how withdrawal of these life-saving assays would harm the public health.
##### 1. LDTs are often the only available tests for patients.
In many cases, LDTs are the only available testing solution for patients because there is no approved or cleared test for a particular disease or condition, or the approved or cleared test is inaccessible to the patient. LDTs have been developed to address unmet clinical needs for patients, and approved or cleared IVDs have been modified as LDTs to increase access to testing for patients.
First, there are many diseases and conditions for which there is no approved or cleared IVD, and in these cases, the patients’ options are to receive a diagnosis supported by results from an LDT, or no *in vitro* diagnostic information at all. For example, the only tests available to help diagnose Rett Syndrome—one of the most common genetic causes of developmental and intellectual impairment in girls—are novel LDTs. There are no FDA-cleared or -approved alternatives for these patients. Given the economics of commercial test development, rare diseases frequently lack a commercialized, FDA-cleared or -approved test. Laboratories have filled this gap by developing tests for a very small group of people, thereby meeting unmet clinical needs.
Second, even when an approved or cleared IVD exists, it may not be available or accessible to a patient for a variety of reasons (e.g., no local laboratory with instrumentation compatible with the cleared or approved test kit; insufficient testing capacity at local laboratories using the cleared/approved test kit). In these cases, laboratories may modify existing IVD test kits to use the laboratory’s instrumentation, increase testing capacity by leveraging high-throughput instrumentation, or extending specimen stability to allow samples to be received from more remote locations.
For example, the BD Multitest™ 6-color TBNK Reagent is a cleared flow cytometry reagent intended for use to identify and determine the percentages and absolute counts of T, B, and natural killer (NK) cells, as well as the CD4 and CD8 subpopulations of T cells in peripheral blood. According to the 510(k) decision summary, specimens must be stained within 24 hours of blood draw. However, many patients do not live within close enough proximity to a laboratory with flow cytometry testing capability for their sample to be tested locally. Instead, their specimen needs to be sent to a reference laboratory, which could take more than 24 hours. Accordingly, one ACLA member that operates a high-complexity reference laboratory has performed extended stability studies to validate testing on specimens stained within 48 hours of collection, thereby expanding access to this test for patients who cannot be served by a local laboratory.
As another example, the KRONUS Zinc Transporter 8 Autoantibody (ZnT8Ab) ELISA Assay is intended for the semi-quantitative determination of autoantibodies to Zinc Transporter 8 (ZnT8) in human serum, and may be useful as an aid in the diagnosis of Type 1 diabetes mellitus. According to the instructions for use, “[s]era to be analyzed should be assayed soon after separation or stored ... at or below -20°C.” However, once again, many patients do not live within close enough proximity to a laboratory that performs this assay such that the specimen can be analyzed immediately, and storage of specimens “at or below -20°C” is not always possible. Accordingly, one ACLA member had validated specimen stability with this assay at room temperature and for an increased amount of time between collection and analysis, thereby extending the stability specifications for the assay when performed in its high-complexity laboratory.
These types of modifications to the cleared or approved test kit transform the testing service to performance of an LDT. Virtually all reference laboratories depend on this flexibility to meet the needs of their patients. However, under the Proposed Rule, many of these modifications would not be made because the requirement for obtaining an FDA marketing authorization would create too large of a barrier.
Third, even when a cleared or approved IVD exists, the scope of the clearance may not be adequate to reach an important patient population. Accordingly, LDTs are an essential tool for improving access to testing for underserved patient populations. For example, the Aptima Combo 2® Assay is intended to aid in the diagnosis of chlamydial and/or gonococcal urogenital disease using the PANTHER System. According to the instructions for use, “[t]he performance of the AC2 assay has not been evaluated in adolescents less than 14 years of age.” However, there are patients less than 14 years of age that need to be tested, including to support investigations into potential cases of sexual abuse. Accordingly, one ACLA member has validated this test system for use in patients less than 14 years of age. As another example, and as discussed further below, although some cleared/approved newborn screening tests exist, hospitals frequently rely on LDTs because the list of diseases for which newborns are screened far exceeds the cleared indications for IVD kits. The Proposed Rule’s most likely effect, however, would be to deprive patients access to these life-saving tests.
##### 2. LDTs perform better than cleared or approved tests.
LDTs are also important to meet current clinical needs because, in many cases, they perform better than, and are preferred by clinicians over, cleared or approved alternatives. This often happens when the technology underlying a cleared or approved test has become outdated, the scope of the cleared or approved test is too narrow, or the cleared or approved test is associated with poor performance. In these cases, an LDT that uses modern, improved technology, performs with greater analytical validity, and can be used to support greater clinical care rapidly becomes the standard of care with nearly uniform preference among clinicians.
For example, there are some cleared/approved IVDs for newborn screening, but these test kits screen for a limited number of diseases and conditions, and do not include most genetic disorders. Rapid whole genome sequencing (rWGS), on the other hand, is a genetic testing method that can diagnose any one of thousands of Mendelian disorders in seven days or less. The incredible power of rWGS is that it allows for a clinician to order a single test and obtain genetic information to inform a diagnosis in an incredibly rapid manner, even when there is a constellation of clinical findings present in the patient. One study reported that for acutely ill newborns, rWGS generated a diagnosis within a median time of 3 days for 40% of patients, and led to a change in medical care for 32% of patients. rWGS is by far the most comprehensive genetic screening tool.
Mass spectrometry tests for detecting hormones, drugs, and proteins are another important example of how laboratory science rapidly eclipses FDA-cleared and -approved tests. Mass spectrometry methods offer analytical advantages over conventional immunoassay-based approaches, but even FDA has acknowledged that “[m]ass spectrometry-based in vitro diagnostic devices that measure proteins and peptides are underutilized in clinical practice.” Many clinical practice guidelines recommend the use of mass spectrometry-based tests for clinical management of hormone disorders such as congenital adrenal hyperplasia, Cushings Syndrome, late-onset hypogonadism in males, and polycystic ovary syndrome, as well as generally for the measurement of testosterone. Other mass spectrometry-based clinical proteomic LDTs have been developed to measure proteins with functions related to endocrinology, microbiology, cancer, and Alzheimer’s disease.
Another important example is antimicrobial susceptibility testing (AST), where FDA-cleared and -approved tests do not meet modern performance standards. Currently, FDA approves specific drug/organism combinations used in cleared automated testing instruments, but those specific combinations quickly become outdated as organisms rapidly change their susceptibility over time by acquiring resistance to antimicrobials. Accordingly, international organizations such as the Clinical and Laboratory Standards Institute (CLSI) provide updated recommendations on what drug levels determine resistance for a particular organism, but manufacturers cannot adjust to these updated recommendations without obtaining additional FDA clearance. The result is that many previously FDA-cleared AST panels are inaccurate, providing clinically wrong information on which drugs are most likely to be effective at treating a particular infection. Rather than provide such inaccurate information, many laboratories report out more accurate information using LDTs. A similar issue exists for test kits with listed interfering substances. As new therapies are introduced, there are new possibilities of interfering substances impacting certain test results. Rather than accepting the possibility that test results could be negatively impacted, laboratories often validate procedures to account for these new interfering substances using LDTs.
Finally, some FDA-cleared and -approved tests do not even meet modern CLIA and CAP performance standards. For example, FDA cleared a hematology analyzer with several % CV values for leukocytes (white blood cells) above 10% and two % CV values for body fluid red blood cells above 4%, failing the criteria for acceptable performance under the new CLIA proficiency testing rules. As another example, CAP requires specimen stability studies for all LDTs, but FDA has authorized some IVDs without data to support test-specific specimen stability.
FDA’s Proposed Rule fails to consider the impact that would result from FDA regulation related to these issues. FDA must consider the increased costs that would be associated with these categories of tests, such as the cost of continually updating ASTs, the costs of obtaining and sustaining approvals for virtually all mass spectrometry tests—or the costs to patients and our health care system if those tests are withdrawn by laboratories or cannot be updated in a timely manner as a result of FDA regulation.
### IV. FDA’s Characterization of LDTs is Inaccurate.
FDA’s assertion that the Proposed Rule is necessary is based on a flawed characterization of LDTs, and ACLA strongly disagrees with FDA’s characterization of LDTs as “problematic.” As explained in the following subsections: (A) FDA’s methodology for critiquing LDTs is fundamentally flawed because rather than systematically reviewing available evidence, FDA relies on anecdotes and unproven complaints, and it does not establish a baseline for comparison; and (B) FDA’s critiques of specific LDTs or categories of LDTs are misguided. This faulty “evidence” cannot be the basis for any proposed policy regarding LDTs.
#### A. FDA’s methodology for critiquing LDTs is flawed.
FDA is proposing to initiate sweeping regulation of LDTs on the basis of flimsy and inaccurate data. The Proposed Rule points to four main sources of evidence: (1) literature; (2) allegations/reports to FDA; (3) FDA’s experience reviewing submissions; and (4) news stories. However, all of this “evidence” is anecdotal and/or unverified, and FDA would never accept this type of “evidence” from any regulated entity as the basis for a regulatory decision. FDA cannot finalize the Proposed Rule based on anecdotes, especially when it has the tools to systematically collect the information it needs to make informed policy decisions.
First, FDA selectively shares information about LDTs that it asserts are “problematic,” but it makes no attempt to contextualize such examples within the very large market of available LDTs and decades of reliance on such tests. For example, FDA estimates that 1,200 high-complexity laboratories offer a total of 80,400 LDTs, but publicly available information suggests this number is higher. For example, considering that only 200 U.S. laboratories were reportedly offering 37,124 genetic tests for clinical purposes in November 2022, 80,400 LDTs is likely a significant underestimate of all available LDTs today.
Even if FDA were correct to be concerned about the identified LDTs (it is not), those LDTs would represent only a tiny fraction of a percent of LDTs being performed today, or ever. Based on our count in reviewing the Proposed Rule and the cited references, FDA appears to have identified approximately 160 LDTs that it implies are unreliable or otherwise problematic. However, even using FDA’s estimate of 80,400 available LDTs, FDA’s anecdotal references reflect only ~0.2% of available LDTs. Stated differently, FDA has offered no evidence of harm with respect to 99.8% of currently available LDTs. FDA also makes no attempt to contextualize its concerns in the decades of reliance on LDTs, during which time likely billions of LDTs have been performed to inform patient care. Instead, FDA acknowledges that it has not “systematically collect[ed] information” on LDTs.
proposes to apply its device authorities to such tests “[b]ased on current safety signals,” and points to “limitations in the data” as justification for extrapolating evidence in its cost-benefit analysis. ^123^
Second, many of FDA’s sources of “evidence” are unverified, and it is inappropriate to base this sweeping regulatory action on unsubstantiated anecdotes and conjecture. For example, FDA states that it has “received multiple complaints, adverse events reports, and other allegations identifying problems with IVDs offered as LDTs,” but then immediately admits in a footnote that “FDA has not confirmed the veracity of the allegations or facts in every complaint report, and allegation.”
^124^ FDA likewise points to legal complaints filed by consumers, shareholders, litigants, and investors, but these complaints—by definition—are based on unproven facts. If LDTs actually performed poorly, treating physicians would stop using them and would call attention to the medical community regarding the bad test experience. But this is not the case: physicians continue to rely on LDTs every day to inform patient care.
Third, even if FDA’s stated concerns with LDTs were verified, the Agency has not demonstrated that these concerns would be addressed by FDA regulation. This is a recurring issue with FDA assertions that it must regulate LDTs to protect the public health. Indeed, following FDA’s 2015 memo citing 20 case studies of LDTs that it claimed constituted “public health evidence for FDA oversight of laboratory developed tests,” an analysis authored by the Association for Molecular Pathology (AMP) demonstrated that the harms identified by FDA were largely fictional and few would actually be addressed by FDA regulation. ^125^ And FDA’s current assertions that it must regulate LDTs to protect the public health are similarly unjustified because the Agency has offered no comparison to the prevalence of these concerns with cleared and approved IVDs. FDA has not demonstrated that LDTs present any greater risk than cleared and approved IVDs.
FDA raises concerns that LDTs sometimes yield inaccurate results, but cleared and approved IVDs also yield inaccurate results. Cleared and approved IVDs do not have perfect analytical or clinical validity. In fact, every test has a certain sensitivity and specificity, reflecting that false positives and false negatives are possible. Depending on a variety of factors, the sensitivity and specificity of tests may be relatively high, but in other cases, the sensitivity and specificity may be lower. For example, in 2022, a novel kidney test was classified through the De Novo pathway with sensitivity ranging from 76% to 93% and specificity ranging from 45% to 51%, and with precision/reproducibility studies generating high coefficients of variation across sites and lots (9.1% to 18.3%). ^126^ Notwithstanding that level of accuracy, FDA concluded that the value of having this test available to clinicians outweighed the potential for false negative and false positive results. But applying the same reasoning that FDA applies to LDTs, the fact that this test has inaccurate results would render this test “problematic.”
FDA also receives reports and allegations regarding poor performance of cleared and approved IVDs. FDA’s own Manufacturer and User Facility Device Experience (MAUDE) database includes many complaints associated with various approved or cleared IVDs. Furthermore, there have been many recalls of FDA-cleared or -approved diagnostics for quality or other issues that impact the accuracy of those tests. In short, FDA regulation is not a panacea, and the claims embedded in the Proposed Rule vastly overstate the claimed benefits of subjecting LDTs to the burdens of FDA regulation.
FDA’s proposal to apply device authorities to LDTs on the basis of anecdotal and unproven evidence without comparison to available evidence for IVDs is hypocritical of an agency that demands much more from the entities it regulates. The Agency demands that device applications are supported by systematically collected “valid scientific evidence,” ^127^ and accepts real world evidence only when the underlying data meets this threshold. ^128^ The Agency should not be proposing sweeping policy changes on the basis of anything less. In fact, FDA’s own regulation provides that “[i]solated case reports, random experience, reports lacking sufficient details to permit scientific evaluation, and unsubstantiated opinions are not regarded as valid scientific evidence,” ^129^ which is exactly the type of evidence that FDA is relying upon to justify this vast expansion of its regulatory reach.
#### B. FDA’s specific critiques are inaccurate.
It is not possible, nor necessary, to respond to every allegation that FDA makes in its Proposed Rule in this composed comment period. ^130^ Nonetheless, it is imperative to correct the record with regard to certain categories of tests that FDA has broadly characterized as problematic. In particular, ACLA was disappointed with how FDA mischaracterized the quality, validity, and importance of LDTs for COVID-19, NIPS, and oncology. FDA cannot finalize the Proposed Rule based on its mischaracterization of these tests.
##### 1. FDA’s characterization of COVID-19 LDTs is inaccurate.
FDA’s characterization of COVID-19 LDTs is both incomplete and inaccurate. FDA completely ignores that LDTs were critical to the American response to the PHE, and instead draws inaccurate conclusions that threaten to erode the public’s trust in clinical laboratories. As an initial matter, the first confirmed case of COVID-19 in the United States was diagnosed by an LDT, even before the PHE was formally declared. And as the pandemic evolved, LDTs continued to be a source of reliable testing.
Specifically, once the PHE was declared, LDTs were among the first reliable testing options available to Americans because test kits were not available. Although FDA granted an EUA for the CDC SARS-CoV-2 molecular diagnostic test kit, the test kit could not be validated by other laboratories and was unusable for weeks. ^131^ By relying only on IVDs for COVID testing, American testing capacity lagged far behind that of other countries. ^132^ It was only after FDA issued a more flexible policy to allow laboratories developing LDTs to step in that testing capacity for Americans soared. Within two and a half months of issuing the policy, 245 laboratories had notified FDA that they would begin testing. ^133^
FDA’s characterization of COVID-19 LDTs in the preamble to the Proposed Rule is also based on anecdotal evidence that is improperly extrapolated without context. For example, FDA points to the first 125 COVID-19 LDT EUA submissions as proof that laboratories do not perform appropriate or adequate validation studies. ^134^ The Agency claims that 82 of these submissions “showed test design or validation problems,” but fails to acknowledge that many of these supposed problems were a direct result of incomplete and constantly changing guidance from FDA, as well as the realities of responding in real-time to a public health emergency where laboratories were doing all they could to expand the testing capacity of the country.
In particular, in FDA’s memorandum detailing this assessment of the first 125 COVID-19 LDT EUA submissions, the Agency asserts that issues with validation included that “laboratories did not provide minimal descriptive information about their validation studies in the EUA request for FDA to assess the performance.” However, failure to provide this descriptive information does not affect—at all—the quality of the validation studies themselves. Rather, failure to provide this information reflects that laboratories, accustomed to validating tests pursuant to CLIA, CAP, New York State requirements, and other industry standards, did not have clear or consistent direction from FDA regarding which information to provide in an EUA request.
As another example from the memorandum, FDA asserts that “[t]he most common issue with analytical validation was related to use of synthetic DNA or small fragments of synthetic RNA,” rather than viral RNA, but then immediately admits that “viral RNA was difficult to obtain through April 2020, and so FDA had recommended,” but did not require, “that if synthetic RNA was used, validation should include full length or long strand RNA to closely approximate natural viral RNA.” FDA also acknowledged that “alternative approaches, such as creating contrived specimens with synthetic DNA, can be used, particularly in the early stages of an emergency when availability of viral RNA is limited.” It is wrong to portray clinical laboratories as being unable to perform appropriate and adequate validation studies when such studies were performed based on FDA guidance and the best available materials in the midst of a global pandemic.
It is also wrong to suggest that FDA’s dissatisfaction with the quality of EUA submissions directly translated to bad tests, particularly when “[i]n the majority of cases, the FDA worked with the laboratories to correct the issues and permit continued testing.” Indeed, in a similar context—EUAs for MPOX diagnostics—a published report details how FDA’s requests for additional validation studies or data did not meaningfully affect test performance and offered minimal benefits. Laboratories report similar experiences with COVID-19 diagnostics.
Finally, it is wrong to suggest that the identified challenges with test design and validation were unique to laboratories. Rather, as FDA acknowledged, “[s]imilar problems were seen with commercial manufacturers” at the time. And, contrary to the implication that LDTs perform worse than test kits, at least one study found 100% agreement between certain commercial and laboratory tests for SARS-CoV-2. Moreover, throughout the public health emergency, there were reported accuracy and quality concerns with EUA-authorized test kits.
Other evidence cited by FDA also cannot reasonably be construed to suggest that CLIA-certified, high-complexity clinical laboratories systematically produced bad COVID-19 tests. For example, FDA cites a *ProPublica* report on a COVID-19 test offered by a laboratory in Chicago that missed 96 percent of positive cases, but that laboratory had so many CLIA deficiencies that a CMS report concluded the public was put in “immediate jeopardy” by the laboratory’s operation. Accordingly, the poor performance of this laboratory’s COVID-19 LDT is not indicative of the performance of LDTs developed by high-complexity laboratories that are operating in compliance with CLIA.
##### 2. FDA’s characterization of non-invasive prenatal screening (NIPS) is inaccurate.
NIPS is widely viewed as a breakthrough in prenatal care, but FDA’s characterization of these tests reflects a fundamental misunderstanding of their intended use and their role in prenatal care. First, FDA’s preamble distorts the difference between screening and diagnostic testing—a basic tenet of laboratory medicine. NIPS analyzes cell-free DNA that is naturally shed by the placenta cells into the pregnant patient’s blood. NIPS tests are screening tests: they are intended to assess whether a pregnant patient may be carrying a fetus at an *increased risk* of having a genetic disorder. Accordingly, a “positive” NIPS result indicates that the fetus is at higher risk of having a genetic disorder, but it is not a diagnosis. To obtain a firm diagnosis, further diagnostic testing should be used. However, a “negative” diagnostic test result does not mean that the “positive” NIPS result was wrong or a “false positive.” As an analogy, a mammogram indicating risk of breast cancer is not “wrong” just because a biopsy or other follow-up testing reveals that the patient does not have breast cancer. The mammogram did its job: it selected a subset of patients who needed further evaluation. NIPS serve a similar purpose.
Moreover, NIPS are not “problematic” just because they identify many more patients at increased risk of carrying a fetus with a rare disease than the number of fetuses actually expected to be born with such disease. This is completely expected when screening large populations for extremely rare diseases, even when the test has near perfect sensitivity and specificity. To demonstrate, if a screening test has 99.9% sensitivity and specificity, then 1 out of every 1,000 patients without the condition would still be expected to receive a positive screening result. But if fewer than 1 in 1,000 patients in the population are expected to have the condition based on disease prevalence, then the number of positive screening results in patients without the condition would necessarily exceed the number of positive screening results in patients who actually have the condition. For example, when applied to DiGeorge Syndrome, which affects 1 in 4,000 births, the NIPS test would be expected to identify five times as many potential cases than there would be confirmed diagnoses. As acknowledged by the *New York Times* article cited by FDA, in a population of 20,000 pregnant patients, a test with 99.9% sensitivity and specificity—nearly perfect analytical validity—would be expected to identify 25 patients at higher risk of carrying a fetus with DiGeorge Syndrome, even though only 5 of those patients would be expected to receive a confirmed diagnosis. These results are not an indication that the test is unreliable.
As with all screening tests, the goal of NIPS is to identify patients at elevated risk of a disease or condition, in this case, pregnancies with elevated risk of having chromosomal or genetic abnormalities. The tests are not meant to be diagnostic, and patients should not be using screening tests to make decisions without obtaining appropriate diagnostic testing. To revisit an earlier analogy, a physician would not recommend a mastectomy on the basis of a mammogram alone without confirmatory testing. If patients and providers are making decisions on the basis of screening tests alone, then there is a need for better education on the role of these tests.
Second, FDA’s mischaracterization of NIPS ignores the significant public health benefits of these screening tests. Without a screening test, the only information a pregnant patient can obtain about the genetic health of their fetus must be obtained by invasive diagnostic procedures like chorionic villus sampling (CVS) and amniocentesis. Both methods require collection of cells or fluids proximal to the fetus and carry a risk of miscarriage. Moreover, CVS generally is not performed until 10-12 weeks of pregnancy (and may require follow-up blood tests between 16-18 weeks of pregnancy), and amniocentesis generally is not performed until 14-20 weeks of pregnancy. In contrast, NIPS utilizes a blood draw taken from the expectant patient, making it non-invasive, and can be performed around 10 weeks of pregnancy. NIPS is also a significant improvement over the previously available screening technology—maternal serum screening (MSS)—which, while noninvasive, generally is not performed until 15-22 weeks of pregnancy and reportedly identifies more patients than NIPS for follow-up diagnostic testing that ultimately receive a negative diagnostic result. The availability of NIPS to screen for common chromosomal abnormalities can help a large majority of patients avoid more invasive tests like CVS and amniocentesis that have greater associated risks, including infection and miscarriage. Indeed, multiple studies have confirmed a significant reduction in invasive prenatal procedures since the introduction of NIPS.
Studies have confirmed the technical performance and clinical validity of NIPS using cell-free DNA, and current clinical guidelines recommend NIPS for pregnant patients. For example, the current guidance from the American College of Obstetricians and Gynecology (ACOG) recommends that prenatal genetic screening, including NIPS, as well as diagnostic testing should be discussed with **all pregnant patients regardless of maternal age or risk of chromosomal abnormality,** and among available screening options, “[c]ell-free DNA,” i.e., NIPS, “is the most sensitive and specific screening test for the common fetal aneuploidies,” though it is “not equivalent to diagnostic testing” (emphasis in original). Notably, these guidelines supersede the 2012 ACOG statement that FDA cited in Reference 11 to the Proposed Rule, purportedly supporting that such tests should not, at that time, be used in the general, low-risk population. Consistent with the available scientific evidence and clinical guidelines, payers have also recognized the value of NIPS and have made determinations that such tests yield useful and clinically valid information.
##### 3. FDA’s characterization of oncology tests is inaccurate.
Finally, we are deeply disappointed in FDA’s mischaracterization of LDTs developed and performed in the oncology field. Innovation in testing is of paramount importance to making advancements in the clinical care of oncology patients, but the Proposed Rule fails to recognize the important benefits of LDTs in this space. For example, long before there were any approved or cleared diagnostic test kits for evaluating genetic risk of developing certain hereditary cancers, high-complexity laboratories were developing and offering these tests, giving patients greater opportunity for clinical care. There are numerous examples of the lifesaving innovations pioneered by laboratories in this space. We noted several such examples in the prior sections: testing for BRCA mutations associated with breast and ovarian cancer, testing for KRAS mutations associated with non-small cell lung cancer, pancreatic ductal adenocarcinoma, and colorectal cancer, and NGS technology, more broadly. We also noted in prior sections how clinicians continue to rely on LDTs today to provide the most up-to-date information about their patients, beyond newly discovered and validated biomarkers.
Moreover, some of the references cited in the Proposed Rule regarding oncology LDTs are flawed and/or misconstrued. Two of the references warrant special attention: a study by Pfeifer et al. comparing reference samples (Reference 12 in the Proposed Rule) and the Friends of Cancer Research (FOCR) study on tumor mutational burden (TMB) LDTs (Reference 14 in the Proposed Rule).
First, the Proposed Rule cites a study by Pfeifer et al. that claims to have found that only 7 of 19 laboratories that tested the same samples with LDTs correctly reported all results. This study has been discredited, however. In late September 2023, the CAP Molecular Oncology Committee reanalyzed the data from this study, adjusting for confounding conditions, and found that “laboratories consistently have high detection rates” for the tested variants. Moreover, based on this reanalysis, the results from the original study cited by FDA “are not generalizable to all molecular oncology testing and should not be used to market products or change policy affecting all molecular oncology testing.”
Second, FDA cites the FOCR study to imply that TMB LDTs are unreliable, claiming the study “found substantial variability among [TMB] tests manufactured by laboratories.” However, the data from such study actually support that inter-assay variability of TMB LDTs is comparable to the variability observed between FDA-authorized assays. Specifically, in addition to LDTs, the study included two FDA-authorized IVD assays, and while the study did not conduct pairwise comparisons of TMB results between assays, a preliminary analysis based on data provided in the FOCR publication shows similar, and in some cases greater, variability between the FDA-authorized assays than between the FDA-authorized assays and LDTs included in the study.
Moreover, FDA’s naked assertion that the FOCR study showed empirical variability among test results fails to recognize the important scientific and clinical context in which such test results are interpreted. As noted in the publication, the empirical variability across assays was observed to increase with increasing TMB value. But TMB test results are only semi-quantitative, and above a specified cutoff there is limited to no clinical impact for the patient. Even a high degree of variability at TMB values well above the cutoff would have limited to no clinical impact because variability would not cause results to fall below the cutoff. Importantly, these cutoffs are assay-specific to account for each assay’s unique performance characteristics. However, differences in assay-specific cutoffs were not addressed or reported in this study.
Furthermore, the study was neither designed nor conducted to evaluate whether there was any clinical impact of observed variability among TMB tests from different laboratories. Rather, the study was designed and conducted as a collaborative effort including IVD and LDT assay developers to identify sources of variability between assays, to develop recommendations on the design of TMB assays, and to support transparency with the goal of furthering community understanding of TMB assays and results. Using the study to imply that LDTs may not provide accurate or reliable results misrepresents the design and results of this study.
Finally, other evidence cited by FDA is anecdotal and presented without important context. In particular, the Proposed Rule cites “[a]n article published earlier this year [that] detailed an oncologist’s experience with false results from an unapproved blood-based multi-cancer detection IVD offered as an LDT and intended to screen for more than 50 types of cancer (Ref. 16).” As an initial matter, as in the context of NIPS, cancer screening results are not “false” just because a definitive diagnostic test yields a different result. But beyond that point, this summation of the
reference leaves out important context about the analytical validity of the test at issue. The article tells the story of only one positive result in a patient determined not to have cancer, and one negative result in a patient who ultimately did have cancer. But as explained in the article, the oncologist in the story has encountered only one other “false positive” out of about 2000 test results in over 18 months, and “[s]he also discovered two positive signals for cancer ... that were confirmed with follow-up tests,” both of which were caught “remarkably early, in time for treatment.”^161^
Finally, FDA itself has recognized the role that LDTs can play in informing treatment decisions in the oncology space. This past summer, FDA announced a pilot program that would allow certain oncology drugs that require companion diagnostics to be approved without a corresponding FDA-approved companion diagnostic.^162^ Instead, FDA would publish information about the performance characteristics of the CTA used in clinical studies of the drug. With that information, laboratories would then be able to develop LDTs to inform patient treatment decisions.
For all of these reasons, FDA has mischaracterized LDTs in the preamble to the Proposed Rule. This faulty characterization cannot serve as the underlying rationale for imposing the ill-fitting device framework on LDTs. As discussed below, FDA’s cost-benefit analysis for the Proposed Rule is also flawed and cannot support finalizing the Proposed Rule.
### V. FDA’s Cost-Benefit Analysis is Flawed in Numerous Ways and Cannot Support Finalizing the Proposed Rule.
FDA fails to grasp the impact that finalizing this proposed rule would have on laboratories, patients, and other stakeholders. ACLA strongly disagrees with the cost-benefit analysis in the Proposed Rule and the RIA. Below we summarize key points regarding how FDA (A) underestimates the costs of the Proposed Rule, and (B) overestimates the benefits of the Proposed Rule, that the Agency should consider and incorporate into any final regulatory impact assessment.
Additionally, as demonstrated by the analysis of Professor Chris Carrigan in Exhibit I, FDA’s economic assessment fails to adhere to the standards described in the academic literature as well as OMB’s Circular A-4. These fundamental concerns result in an RIA that: 1) significantly understates costs by failing to quantify a key ancillary effect; 2) substantially inflates benefits by misusing benefit transfer methods; 3) provides limited ability to evaluate reasonable alternative regulatory approaches; and 4) offers minimal discussion of the distributional effects, including those on marginalized and underserved communities. ACLA incorporates by reference that analysis.
#### A. FDA underestimates the costs of the Proposed Rule.
Applying device regulation to LDTs, as proposed, would have significant negative impacts on the availability of tests that are available only as LDTs, innovation in diagnostic and laboratory science, and broader access to testing. However, FDA uses numerous assumptions and guesswork to derive its estimates of costs associated with the Proposed Rule. For an agency that seeks to ground its work in scientific analysis and robust evidence, this analysis is concerning.
As an initial matter, FDA made no attempt to collect information about the number of high-complexity CLIA laboratories or LDTs currently being offered that would be affected by the Proposed Rule, despite the Agency having the tools to do so. For example, FDA could have coordinated with other HHS agencies, CMS and CDC, to collect information from CLIA-certified laboratories regarding the number of laboratories that are high-complexity laboratories and the number of LDTs offered by each such laboratory. Laboratories applying for CLIA-certification must submit Form CMS-116, which requires a list of the non-waived tests the laboratory will offer, including whether the test is moderate- or high-complexity.^163^ FDA also could have issued an RFI seeking information regarding the number of high-complexity clinical laboratories and the number of LDTs currently being offered.
FDA did not do any of this. Instead, FDA has proposed rulemaking on the basis of anecdotal evidence and extrapolations about the potential impact to industry, patients and other stakeholders. Under the Administrative Procedure Act, the Agency “must examine the relevant data and articulate a satisfactory explanation for its action including a rational connection between the facts found and the choice made.” *Motor Vehicle Mfrs. Ass’n of U.S., Inc. v. State Farm Mut. Auto Ins. Co.*, 463 U.S. 29, 43 (1983). Where (1) key data is readily available to an agency, or (2) certain data is critical to the agency’s decision but the agency fails to either make an effort to collect that data or explain why it was unable to collect it, a court should find that the agency failed to “examine the relevant data and articulate a satisfactory explanation for its action.” See, e.g., *Rural & Migrant Ministry v. EPA*, 565 F. Supp. 3d 578, 599–600 (S.D.N.Y. 2022); *Innovator Enterprises, Inc. v. Jones*, 28 F. Supp. 3d 14, 26 (D.D.C. 2014). This is not a scenario where the data is unobtainable, nor is there a valid reason for FDA not having the data. See *F.C.C. v. Fox Television Stations, Inc.*, 556 U.S. 502, 519 (2009) (explaining that there “are some propositions for which scant empirical evidence can be marshaled” and that “it is one thing to set aside agency action under the Administrative Procedure Act because of failure to adduce empirical data that can readily be obtained [and] something else to insist upon obtaining the unobtainable.”).
As a result of FDA proceeding without data necessary to support its analysis, FDA has significantly underestimated the costs of complying with the Proposed Rule. As explained further below, this underestimate stems from a number of errors in FDA’s analysis, including:
- Underestimating the number of affected laboratories, the number of LDTs that are currently available, and the number of LDTs that laboratories develop annually;
- Underestimating the number of currently available LDTs and new LDTs that would require different premarket submissions;
- Underestimating the cost of test validation and preparation of premarket submissions for LDTs; and
- Underestimating the cost of compliance with other device regulations for LDTs.
When these costs are more accurately estimated, the negative consequences for laboratories, patients, FDA, and other stakeholders are immense. As explained earlier in these comments, these costs include removal of important tests from test menus due to the cost of compliance, and not due to any reliability or accuracy concerns; significant slow-down in diagnostic innovation by laboratories due to competing demands for limited resources; reduced testing capacity at laboratories due to competing demands for limited resources and potential closures of laboratories; and slower availability for innovative diagnostics due to constrained resources at FDA.
##### 1. FDA has underestimated the number of affected laboratories, the number of LDTs that are currently available, and the number of LDTs that laboratories develop annually.
FDA has estimated there to be approximately 1,200^164^ laboratories that would be affected by the Proposed Rule and that such laboratories offer, on average, 67 tests per laboratory, leading to an estimate of 80,400 tests potentially affected. FDA reached these estimates by extrapolations from the New York State database of tests, but publicly available sources support estimates that are higher. For example, in CMS’s most recent update to the CLIAC, the agency reported 34,266 laboratories that have a certificate of compliance or accreditation, i.e., 34,266 laboratories that perform moderate- and/or high-complexity testing.^165^ It is unlikely that only 3.5% of these laboratories perform high-complexity testing and offer LDTs, as suggested by FDA’s estimates.
FDA’s estimate of 67 tests per laboratory also is far too low. Several ACLA members report offering hundreds or even thousands of LDTs. And this number would align with other publicly available estimates of LDTs. For example, a paper by Halbisien and Lu in 2023^166^ found that as of November 2022, there were a total of 37,106 genetic tests offered in the US for clinical purposes. The paper also estimates that in 2022, 3,097 new genetic tests were made available. Assuming that an equivalent number of new tests were first offered in 2023 (99.5% of which are clinical tests), the total estimate for genetic tests alone on the US market is 40,000 tests. This estimate is limited to genetic tests, almost all of which are offered as LDTs. FDA’s estimate also does not account for LDTs that would continue to be introduced from now until whatever time that premarket submissions are required under any final phaseout policy, likely adding tens of thousands of additional tests.
Similarly, FDA has significantly underestimated the number of new LDTs that would become subject to regulation. FDA has estimated that 7,776 new LDTs would be offered each year, based on an estimated average of 6 new LDTs per laboratory per year, adjusted to account for LDTs offered by new laboratories. But as noted above, the Halbisien and Lu paper estimates that, for genetic tests alone, 3,097 new tests were made available in 2022.^167^ Moreover, as the RIA acknowledges, some large reference laboratories may develop as many as 100 new LDTs per year. Further, adjustments and updates to FDA-regulated tests would trigger the need for new FDA submissions. FDA needs to account for this reality.
##### 2. FDA’s estimates regarding premarket review are misguided.
With respect to LDTs that are currently offered, the Proposed Rule assumes that 4,210 tests would require a PMA Submission, 4,020 would require a De Novo, 32,160 would require a 510(k), and the rest would be exempt from premarket review. This is a significant underestimate across submission types. FDA’s underestimate stems from several mistakes including: (1) underestimating the total number of LDTs that would require a premarket submission; (2) underestimating the ratio of LDTs that are novel and would require PMA approval or De Novo Classification; and (3) overestimating the ratio of LDTs that would be 510(k)-exempt.
First, as explained above, FDA has underestimated the number of currently available LDTs. Accordingly, even if FDA were correct that of all existing LDTs, only 5.2% would require PMA Submissions, only 5% would require De Novo requests, and only 40% would require 510(k)s, FDA would receive far more submissions—PMA Submissions, De Novos, and 510(k)s—than it anticipates.
Second, FDA has underestimated the number of LDTs that are novel and would require PMA approval or De Novo Classification. As discussed earlier in these comments, novel LDTs that lack a predicate device would require PMA approval or a De Novo classification because their technologies have surpassed that of FDA-cleared/approved devices, or because they are intended for a use for which there is no cleared/approved alternative. For example, as stated above, there are currently approximately 40,000 genetic LDTs currently available, and there are not currently available class I or class II genetic tests that could serve as predicate devices. The vast majority of these genetic LDTs would be required to undergo the PMA or De Novo process. Other testing methodologies rely entirely on LDTs. For example, as described above, virtually all mass spectrometry testing is done by LDTs.
The conclusion that most LDTs would require a PMA or De Novo is supported by FDA’s own data. In the MDUFA IV Fourth Quarter Performance report, the Agency reported that of 7 LDT submissions it received in FY2023, 5 were for PMAs, 1 was for a De Novo, and only 1 was for a 510(k).[^168] Throughout the entirety of MDUFA IV, the Agency reported that of the 49 LDT submissions it received in FY2018 through FY2022, 28—over half—were PMAs, 10 were De Novos, and 11 were 510(k)s.[^169]
Third, FDA also has overestimated the ratio of LDTs that would be 510(k)-exempt and, accordingly, significantly underestimated the number of LDTs that would require a premarket submission. FDA has estimated that 50% of LDTs would be 510(k)-exempt, but this is wrong. Only a small number of LDTs would fall within a 510(k) exemption. Rather, in most cases, a 510(k) submission or a PMA supplement would be required because the laboratory is offering a modified version of a cleared or approved IVD. For all of these reasons, FDA’s estimates of 4,210 PMA Submissions, 4,020 De Novo applications, and 32,160 510(k) submissions for existing LDTs is dramatically understated.
FDA’s estimates regarding new and modified LDTs that would be subject to premarket review on an ongoing basis suffer from similar flaws. ACLA disagrees with FDA’s estimate that, each year, FDA would receive 407 PMA Submissions, 389 De Novo requests, and 3,110 510(k) submissions. This is based on an estimated 7,776 new LDTs per year, and as noted above, this is a significant underestimate. Even if FDA’s estimated percentages were correct (5.2% PMA Submissions, 5% De Novos, and 40% 510(k)s), far more tests would require premarket submissions than estimated. But FDA is wrong about those estimates for the same reasons described above for existing tests. Accordingly, FDA would receive significantly more PMA Submissions and De Novos for novel tests that lack a predicate device, as well as 510(k)s for non-exempt tests.
##### 3. FDA has underestimated the cost of test validation and preparation of premarket submissions for LDTs.
Moreover, FDA has grossly underestimated the costs of bringing an LDT through the premarket review process. FDA estimates that costs of preparing and submitting a premarket submission is approximately $4.38 million for a PMA, $564,674 for a De Novo Classification Request, and $274,930 for a 510(k) requiring a method comparison study or $526,182 for a 510(k) requiring a moderately complex clinical study. However, these estimates do not reflect the real-world costs of conducting additional studies to support premarket submissions, and other elements of the cost estimates are unrealistically low. Earlier in these comments, we discussed the significant challenges of conducting validation studies according to FDA’s requirements to support clearance or approval of tests. But even if those challenges could be overcome, the costs of test validation and premarket submission is significantly higher than FDA estimated in its RIA.
With respect to costs not reflected in FDA’s estimates, preparation of submissions for existing tests would require laboratories to re-validate their existing tests because FDA’s design controls under 21 CFR section 820.30 cannot be applied retroactively to an already-designed test. However, FDA’s RIA clearly claims that in estimating the costs of PMA, 510(k) and De Novo requirements, it can “exclude[] costs that would already be part of compliance with the QS requirements under Stage 3, including costs of developing design controls,”[^170] even though FDA’s one-time cost assessment for complying with QS requirements under Stage 3 does not account for these requirements. Specifically, although the one-time cost assessment for Stage 3 includes general design controls under 21 CFR section 820.30(a), it does not include design and development planning, design review, design verification, design transfer, design changes, or the design history file under 21 CFR section 820.30(b) through (j). All of these elements are required for a compliant quality system to support a PMA approval, De Novo classification, or 510(k) clearance. They are conspicuously missing from FDA’s RIA, and they must be considered either under Stage 3 as part of the one-time annual cost of compliance with QS requirements or under Stages 4 and 5 as part of the cost for bringing a premarket submission to FDA.
Moreover, even if FDA exercised some flexibility with regard to leveraging existing validation studies, FDA’s estimates do not consider the costs associated with conducting additional validation studies to satisfy FDA’s expectations where those studies were not required under existing regulatory frameworks. As discussed earlier in these comments, FDA often requires additional validation data that laboratories and other reviewing entities (e.g., CLIA, CAP, New York State) have not determined to be necessary.
Other costs also are significantly underestimated. As just one example of many, FDA estimates that identifying a predicate device for a 510(k) would require only 1.5 hours, costing only $123.48. While that theoretically could have been true in the past and in the simplest of cases for an experienced regulatory professional, it would take laboratories inexperienced with FDA’s regulatory regime much, much longer to identify an appropriate predicate today, especially in the context of FDA’s evolving policies related to the 510(k) program. In particular, even if a predicate could be identified in a short amount of time, it would take much, much longer to identify a predicate device according to FDA’s “best practices” as announced in draft guidance in September.[^171] According to this draft guidance, it is not enough to identify a “valid” predicate; sponsors are expected to identify a valid predicate that: (1) has been cleared using “well-established methods,” (2) continues to meet or exceed safety performance expectations, taking into account post-market reports of design-related malfunctions and adverse events, (3) does not have “unmitigated use-related or design-related safety issues,” including consideration of FDA safety communications; and (4) is not subject to “an associated design-recall.” Understanding these requirements, let alone applying them, would take significantly longer than 1.5 hours, even for a seasoned FDA regulatory professional.
FDA also underestimates the costs of conducting required clinical studies. The RIA estimates that clinical studies would cost approximately $2.83 million for a PMA, $311,553 for a De Novo Classification Request, and $314,065 for a 510(k). However, these clinical studies can be far more expensive. One ACLA member was required to pay $2,000 per sample for a colorectal test. Based on that cost, a single submission requiring 650 supporting samples at a cost of $2,000 for each sample would cost $1,300,000 just to obtain relevant samples.[^172] And that cost does not include the numerous other costs associated with running clinical studies, preparing applications, interacting with FDA, and otherwise processing applications. FDA also fails to recognize that access to appropriate tissue samples and other orthogonal test methods are severely limited for certain types of tests.
Other examples of underestimates of costs include FDA’s estimates for preparing regulatory submissions and holding pre-submission meetings. FDA estimates that the total cost of preparing a regulatory submission for a De Novo Classification Request is only $124,998, failing to recognize the greater cost of the FY2024 user fee for such submission ($145,068). FDA also estimates the costs of pre-submission meetings with FDA are only $2,000 to $2,500 across submission types, but sponsors spend significant amounts of time preparing pre-submission requests, reviewing initial feedback from FDA, and preparing for and holding meetings with the Agency. Moreover, a novel assay may require several pre-submission meetings. FDA’s suggestion that sponsors spend only $2,000 to $2,500 of time and resources to prepare for such meetings is a gross underestimate.
##### 4. FDA has underestimated the cost of ongoing compliance with other aspects of device regulations.
Finally, FDA underestimates the costs of ongoing compliance with other aspects of device regulations, even when premarket submissions are not required. For Stage 1, FDA bases its cost estimate for complying with medical device reporting (MDR) requirements on the approach taken for its 2014 final rule on *Medical Device Reporting: Electronic Submission Requirements*, which is an inappropriate comparison. This rule revised existing postmarket medical device reporting requirements as applicable to manufacturers already familiar with MDR reporting requirements. Laboratories, however, would start from scratch. It would not be sufficient to modify existing SOPs. Wholly new SOPs for complaint evaluation and MDRs would be required and employees would need to be educated and trained on these procedures. FDA’s cost estimate for complying with corrections and removals reporting requirements, based on its 2020 notice, *Agency Information Collection Activities; Submission for Office of Management and Budget Review; Comment Request; Medical Devices; Reports of Corrections and Removals*, suffers from the same flaw.
For Stage 2, FDA’s cost estimates for complying with registration and listing, labeling, and investigational use requirements suffer from the same flaws as in Stage 1, plus additional complexities specific to the nature of LDTs. For example, FDA estimates that a general/operations manager would require 3 hours to complete registration and listing for a single establishment and the LDTs offered therein. However, before laboratories can list their LDTs, they first must complete a regulatory assessment of the likely classification of each LDT, i.e., determine whether any particular LDT is class I, class II, or class III, and determine within which classification regulation/product code the LDT fits. For laboratories inexperienced in FDA regulation and classification of medical devices, this would be a significant undertaking and require far more than 3 hours to complete for FDA’s estimated 67 LDTs per laboratory. And such regulatory analysis would be extremely consequential, likely driving the laboratory’s strategy for premarket submissions, to the extent submissions would be pursued. Accordingly, laboratories could not rush through such analysis to satisfy FDA’s registration and listing requirements. Furthermore, FDA’s tables outlining costs of registration and listing also do not appear to include the annual registration fee, which in FY2024 would be $7,653 per laboratory. There currently are no waivers or reductions for registration and listing fees for small establishments, businesses, or groups.
With respect to labeling, FDA estimates that a general/operations manager would require 20 hours to redesign existing labeling for LDTs to comply with labeling requirements. However, it is not clear—at all—what the labeling requirements are for LDTs. Because LDTs are not a product, they have no packaging to which a label could be applied, nor are there existing instructions for use beyond the laboratory’s procedure manual. FDA has not addressed how laboratories are expected to comply with labeling requirements, and even if FDA forces out a draft guidance within a year after finalization of the Proposed Rule, laboratories would be left scrambling to figure out how to comply by Stage 2 of the phaseout policy. Furthermore, 20 hours is a gross underestimate of the time required to additionally design and implement new processes to meet the labeling controls requirements in 21 CFR Part 820.
FDA also dramatically underestimates the costs of complying with investigational use requirements. As an initial matter, FDA’s estimate that only 6.75% of investigational LDTs would require an application for an investigational device exemption (IDE) is flawed. This assumption is based on (1) the number of IDE applications FDA currently receives divided by the number of IVD marketing submissions FDA ultimately receives, and (2) FDA’s assumption that only 50% of LDTs would require a premarket submission. As discussed earlier, FDA’s assumption that only 50% of LDTs would require a premarket submission is deeply flawed. Moreover, this estimate completely ignores clinical trial assays developed solely for the purpose of supporting drug/biological clinical trials, where these assays are never intended for commercialization as a diagnostic assay. For example, screening patients for trials often requires development of several CTAs by different laboratories across the country to identify sufficient eligible patients for enrollment. Where the assays affect treatment of patients in a clinical trial, an IDE application may be necessary for each CTA, even though only one marketing submission for a companion diagnostic may ultimately be submitted. FDA has failed to consider these CTAs in its estimate.
Additionally, FDA’s estimates of the costs of complying with investigational use requirements ignores the costs of complying with the abbreviated requirements for non-significant risk devices. FDA’s estimate of costs applies only to those investigational LDTs that would require an IDE application. However, non-exempt investigational LDTs that are not significant risk also must comply with abbreviated requirements related to labeling, IRB approval, informed consent, monitoring, recordkeeping, and reporting. FDA has failed to consider the costs of compliance for non-significant risk LDTs used in clinical trials.
FDA also has underestimated the costs of ongoing compliance associated with quality system requirements. Aligning current laboratory quality requirements under CLIA, CAP, international standards such as the International Organization for Standardization (ISO) 15189, New York State Department of Health, and other applicable state laws with a shifting FDA quality regime is a complex exercise. FDA estimates that establishing an FDA-compliant quality system would require only $60,466 per laboratory for one-time costs, but this estimate fails to account for some of the most significant quality requirements related to design controls, purchasing controls and acceptance activities. Table 23 of the RIA lists the one-time annual requirements for establishing an FDA-compliant quality system, but it accounts only for “general” design controls under 21 CFR sections 820.30(a) and does not account for any other design control requirements under 21 CFR sections 820.30(b) through (j), as discussed above, nor does it account for purchasing controls under 21 CFR section 820.50 or acceptance activities under 21 CFR sections 820.80 and 820.86. All of these quality system requirements are fundamental to demonstrating that a device is manufactured consistent with FDA’s quality requirements. Accordingly, FDA’s estimates for establishing a compliant quality system are deceivingly low.
Furthermore, FDA does not even attempt to quantify the costs of laboratories grappling with the shifting quality system requirements as FDA considers finalizing amendments to the quality system regulation to incorporate by reference the 2016 edition of ISO 13485, Medical devices – Quality management systems for regulatory purposes. Even if the requirements of this ISO are similar in some respects to the current quality system regulation under 21 CFR Part 820, shifting to this new standard in the midst of a regulatory overhaul for LDTs would necessarily increase the costs to laboratories attempting to establish an FDA-compliant quality system. For example, responsible laboratories acting expeditiously to establish a quality system under 21 CFR Part 820 would incur additional costs when the regulation changes to reference ISO 13485, and they are forced to revisit completed work to incorporate this changed standard. FDA has not considered the impact of this shifting regulation on the costs of compliance for laboratories.
#### B. The claimed benefits of the Proposed Rule are dramatically overstated.
FDA claims that the Proposed Rule would generate substantial benefits and cost savings. The Agency claims that FDA regulation of LDTs would alleviate misdiagnoses and incorrect treatments that result from LDTs, promote more timely diagnoses, and reduce legal costs associated with lawsuits. FDA’s benefit calculations are entirely speculative, relying on a number of shaky assumptions and questionable analytic steps. Moreover, the underlying studies cited by the Agency to support its analysis are flawed and cannot be used to generalize across LDTs.
##### 1. FDA’s overall approach to calculating the benefits of the Proposed Rule is fundamentally flawed.
Before turning to the specific evidence cited by FDA in its benefit calculations, there are several overarching flaws in FDA’s approach. As we discussed previously, the LDTs cited by FDA in its benefits calculations represent a vanishingly small fraction of the number of LDTs available today and relied upon by physicians. FDA could have begun this regulatory process by requesting data from the laboratory community on the performance of LDTs, so that a systematic or more representative analysis could have been included in the Proposed Rule and RIA. FDA chose not to do that. Instead, FDA opted to go forward with a Proposed Rule and RIA by selecting a handful of examples and then extrapolating those isolated examples to the entire laboratory community. Extrapolating claimed misdiagnoses – using cherrypicked examples, while simultaneously ignoring other evidence of high quality LDTs – is inappropriate. This raises the same concerns expressed above regarding FDA’s failure to “examine the relevant data and articulate a satisfactory explanation for its action including a rational connection between the facts found and the choice made.” *Motor Vehicle Mfrs. Ass’n of U.S., Inc. v. State Farm Mut. Auto Ins. Co.*, 463 U.S. 29, 43 (1983).
Further, although FDA pays lip service to the fact that no test is perfect, the analysis employed starts with the premise that if LDTs were regulated as devices, problems associated with inaccurate test results would all but evaporate. That is obviously not the case. No diagnostic test, whether offered as an LDT or offered as an FDA-approved or -cleared test, is 100% accurate. Stated differently, every test has a certain sensitivity and specificity, reflecting that false positives and false negatives are expected in some number of patients. These risks are unavoidable and well accepted. Depending on a variety of factors, the sensitivity and specificity may be relatively high (e.g., in some cases exceeding 99%), but in other cases, the sensitivity and specificity may be lower. FDA knows this. For example, in 2022, FDA cleared a De Novo application for an assay to detect kidney stress in patients at risk of acute kidney injury. In clinical validation studies, the data reflected the test’s sensitivity ranged from 76% to 93% and the test’s specificity ranged from 45% to 51%. Notwithstanding that level of accuracy, FDA rightly concluded that the value of having this tool available to clinicians outweighed the potential for false negative and false positive results.
Moreover, even when the sensitivity and specificity are quite high (e.g., 99%), such tests will necessarily yield a number of false results when the prevalence of a condition is extremely rare. Furthermore, there have been many recalls of FDA-approved or -cleared diagnostics for quality or other issues that impact the accuracy of those tests.178
Were FDA to conduct an impact analysis that uses only IVD kits with relatively high false positive/negative rates, IVDs for use in rare disease populations, and recalled devices, and then extrapolate those results to the entire IVD industry, the results would be poor. Such an analysis would likely conclude that FDA-approved or -cleared assays are causing innumerable harms to the health care industry and that a different FDA regulatory regime, assumed to cure all the claimed problems, would yield significant benefits. That would be a wholly inappropriate and unfair analysis. But that is exactly what FDA has done here. It has identified a small handful of LDTs, portrayed those examples in the worst light possible, extrapolated those results to the entire LDT community, and then made an assumption that FDA regulation would cure all faults. This is not a fair picture of LDTs and not an accurate picture of the benefits that could result from FDA regulation of LDTs as devices.
Finally, FDA’s benefit calculations flow from claimed inaccuracies associated with LDTs and an assumption that each inaccurate result associated with an LDT leads to a misdiagnosis and/or inappropriate treatment decisions. But in virtually every case, diagnostic testing is used in connection with other assessment tools and clinical judgment. Again, FDA knows this. For example, the cleared intended use of the kidney stress test system cited above states that the test “is intended to be used in conjunction with clinical evaluation in patients who currently have or have had within the past 24 hours acute cardiovascular and/or respiratory compromise and are ICU patients as an aid in the risk assessment for moderate or severe acute kidney injury (AKI) within 12 hours of patient assessment.” In other words, clinicians should interpret the output of the diagnostic test in conjunction with other assessment and clinical judgment. LDTs are no different. Physicians and other clinicians must take the output of the test and consider it together with other resources and experience. The result of the assay is one input – usually amongst many inputs – used to decide on a course of treatment for a patient. FDA’s analysis must account for this.
##### 2. **FDA’s estimates rely on flawed studies and examples.**
a) The data and studies underlying FDA’s estimate of expected reduction in misdiagnosis are flawed.
FDA estimates the probability of misdiagnosis from “problematic LDTs” by considering three probabilities: (1) the probability that a misdiagnosis occurs after testing with an IVD (as opposed to another method of diagnosis); (2) the probability that an LDT was used in the diagnosis; and (3) the probability that the LDT was “problematic.”179 To the extent that these probabilities are supported by underlying studies (and one is not), those studies are flawed.
First, FDA assumes that “50% of misdiagnoses occur after testing” with an in vitro diagnostic test, presumably including both IVDs and LDTs. There is no data underlying this estimate. Moreover, as explained above, the result of the assay is one input – usually amongst many inputs – used to decide on a course of treatment for a patient. Even if a misdiagnosis occurs after use of a diagnostic test, it is wrong to attribute that misdiagnosis to the test alone.
Second, FDA significantly overestimates the probability that an LDT is used to diagnose a patient, and accordingly, overestimates how many misdiagnoses may be avoided if so-called “problematic” LDTs were removed from the market. In its RIA, FDA quotes a 2023 report from Grand View Research that “LDTs constitute about 50% of total in vitro-diagnostics devices that are used in some laboratories.”180 FDA then extrapolates this single statistic to estimate that “50% of IVDs are IVDs offered as LDTs.” It is wrong to extrapolate this single statistic that applies only to “some laboratories,” and it is also a gross overestimate based on other available data. Although there is a very high number of LDTs currently available and more are being developed every day, the ratio of LDTs versus IVDs performed in the clinical setting is significantly less than 50%. In a study by Rychert, et al., laboratory test orders at an academic medical center were reviewed to determine how frequently LDTs were ordered by clinicians.181 The study found that of over 3 million tests ordered in a single year, only 116,583 (3.9%) were LDTs. The volume was higher in the cancer center compared with the university hospital (5.6% versus 3.6%, respectively), but nowhere near FDA’s estimate of 50% of all tests ordered. The study also found this in the context of LDTs constituting a higher proportion of the distinct assays that were ordered. Of 1,954 distinct assays ordered over the course of the study, 880 (45%) were LDTs. This study supports that while there is a very high number of distinct LDTs that have been developed and innovated by laboratories, the rate at which they are used compared to IVDs is much lower than FDA estimates. Accordingly, FDA’s estimates that 50% of diagnostic errors would be avoided by FDA regulation of LDTs is inaccurate and must be reassessed by the agency.
Third, FDA has significantly overestimated the number of LDTs that are “problematic.” FDA relies on the SPOT/Dx Pilot Publication authored by Pfeifer et. al from 2022, which FDA cites in support of the notion that 47% of LDTs are “problematic.”182 The SPOT/Dx pilot found that 9 out of 19 oncology LDTs had significantly lower performance than FDA-approved companion diagnostics. FDA then extrapolates that result to assert that there are potentially a significant number of deaths associated with preventable misdiagnoses due to problematic LDTs. Extrapolating yet further, FDA asserts that device regulation of such tests would prevent these misdiagnoses and would therefore result in savings of $27.7B (VSLY 3%). As an initial matter, it is inappropriate to use this single, small study to characterize the performance of all LDTs across multiple disciplines. But even if it were sound scientific practice to extrapolate from a single study (which it is not), relying on the Pfeifer study is not appropriate. A more recent analysis of the SPOT/Dx pilot data by Zehir et al., using proficiency testing methods, reached a fundamentally different conclusion.183 Specifically, by adjusting for confounding variables, the reanalysis found that LDTs had comparable performance to FDA-regulated tests. Moreover, Zehir et al. also conducted an assessment of LDTs based on data from CAP proficiency testing programs and found that the overall detection rates for single nucleotide variants (SNVs) and multinucleotide variants (MNVs) were 97.2% (2,671 of 2,748) and 91.8% (1,853 of 2,019), respectively. The paper concludes that “CAP PT program data demonstrate that laboratories consistently have high detection rates for KRAS and NRAS variants.” In addition, the authors warn that the “SPOT/Dx pilot results are not generalizable to all molecular oncology testing and should not be used to market products or change policy affecting all molecular oncology testing.”
b) The examples on which FDA relies to extract claimed benefits from regulating LDTs are flawed.
In addition, FDA’s RIA attempts to extract supposed benefits of regulating LDTs from isolated problems with COVID tests. As we have previously noted, FDA’s Proposed Rule dramatically distorts the COVID experience and the role that laboratories played throughout the pandemic. FDA’s RIA again cites its flawed analysis of the first 125 COVID EUA requests submitted to FDA. As we have discussed above, it is wholly misleading for FDA to use the first EUA requests – submitted in rush of activity in order to contribute to the public health, often before relevant guidance from FDA was available – as a basis for evaluating COVID tests more broadly, much less for evaluating LDTs more broadly. But in its RIA, FDA takes it a step farther. FDA refers to a single LDT for COVID offered in Chicago. But as FDA well knows, it is impossible to extrapolate that single test to a broader basis to evaluate LDTs. Moreover, the laboratory at the center of this story engaged in fraud and was out of compliance with CLIA. Even if the laboratory leveraged only cleared and approved IVDs, the results would likely have been the same. FDA regulation would not have changed the outcome.
The other examples that FDA relies on for claimed benefits suffer from similar flaws. For example, FDA points to a single laboratory test called StatinCheck that, in FDA’s view, lacked clinical validity, and NIPS tests. FDA fails to explain why the StatinCheck test lacks clinical validity, making an evaluation of FDA’s claimed benefits impossible. Similarly, FDA cites NIPS tests and notes alleged issues with false positive results associated with rare variants. As we previously noted, FDA has the NIPS story exactly backward. Laboratories that pioneered NIPS testing should be lauded for their remarkable contribution to the public health and reducing health care costs. Prior to NIPS, women would either skip the screening step and proceed directly to invasive diagnostic tests that are associated with higher incidence of adverse events and higher costs or they would proceed first with a different screening method that identified far more women for follow-up, invasive diagnostic testing than identified through NIPS. NIPS is highly accurate and has reduced the rate at which women routinely seek invasive diagnostic testing, thus reducing the number of women unnecessarily exposed to such risks.184 Although it is true that certain very rare variants are associated with false positive results, that is a necessary function of ensuring that such tests have sufficient sensitivity to detect true positive rare variants. This is why NIPS are not intended as definitive diagnostic tests for such rare diseases and should not be used in that way. But the fundamental point is that NIPS tests have advanced the public health immeasurably. It is improper for FDA to ignore the obvious benefits of LDTs that are offered as NIPS.
##### 3. FDA’s analysis excludes studies showing the value of LDTs.
FDA ignores other studies demonstrating that LDTs perform at least as well as FDA-approved or -cleared IVDs. For example, a 2017 study by Kim et al.,[^185] compared the performance of LDTs and FDA-approved assays for key biomarkers used for companion diagnostics, including BRAF, EGFR, and KRAS mutations. That analysis found that in “6,897 proficiency testing responses, both LDTs and FDA-CDx exceed 97% accuracy combined across all comparable molecular oncology proficiency testing samples.” The study concluded that “[t]hese findings support both the excellent and equivalent performance of both LDTs and FDA-CDx in clinical diagnostic testing.” Further, the study observed that many laboratories using FDA approved CDx modified those tests to “allow for more clinical practice variety.”
Other recent studies have affirmed the value of LDTs in improving care and saving lives. As one example, in 2021, Dimmock et al. published the results of “Project Baby Bear,” which evaluated the benefits of implementing whole genome screening protocols in five California hospitals.[^186] Specifically, acutely ill patients who were less than one year old and within one week of hospitalization or had just developed an abnormal response to therapy, were screened by an LDT using rWGS-based rapid precision medicine (RPM). The study evaluated two prespecified primary outcomes—changes in medical care because of rWGS results and changes in the cost of care because of rWGS at 4 months, 12 months, and 18 years after return of results. The results were clear – rWGS proved to be a valuable tool in clinical decision making. Of the 184 babies whose DNA was sequenced in this project, rare genetic diseases that explained the infant’s admission were diagnosed in 74 babies (40%), genetic variants of uncertain significance (VUSs) were identified in 21 babies (11%), and no diagnosis was made in 89 babies (48%). Most diagnoses were of very rare disorders that would not be expected to have been seen by the child’s providers previously in their careers. The authors of the paper concluded that “the five-site quality improvement project known as Project Baby Bear developed a real-world system for the rapid delivery of whole-genome sequencing that improved outcomes and decreased costs of care. This project has demonstrated that hospitals and payors with similar systems of rapid precision medicine can deploy rWGS for critically ill children in a cost-effective manner.”
As the above discussion and examples illustrate, the Proposed Rule and RIA cherry-pick allegedly poor performing tests in an effort to extrapolate significant economic benefits from FDA regulation of LDTs. But this is not an accurate picture. There are numerous LDTs that perform as well as, or better than, FDA regulated tests and that yield significant benefits. In subjecting these high performing LDTs to device regulation, FDA is imposing costs without any corresponding benefit to the public health. And in imposing such costs on high performing tests, FDA would deprive laboratories of resources needed to continue to develop novel diagnostics. FDA’s Proposed Rule currently ignores this reality.
##### 4. FDA’s Proposed Rule would not reduce litigation costs for laboratories.
FDA also claims that compliance with FDA regulations may reduce the incidence of litigation. In fact, subjecting laboratories to regulation as device manufacturers could potentially increase legal exposure under product liability law (although this would turn on the law of each state). For LDTs approved under PMAs, federal preemption may be available to mitigate the risks of product liability suits.[^187] But according to FDA’s estimates, only a small fraction of LDTs would be subject to PMA requirements. Further, there is no shortage of litigation associated with FDA-regulated devices, so there is no basis for FDA to assume FDA regulation would somehow decrease lawsuits associated with LDTs.
### VI. The Proposed Rule Raises Significant Legal Concerns.
As the foregoing sections make clear, FDA should not go forward with the Proposed Rule because it is a bad policy choice. Subjecting LDTs to device law would harm the public health in numerous ways. But there is an even more fundamental reason that FDA should not go forward: finalizing the Proposed Rule would exceed the authority granted to FDA by Congress and would raise serious constitutional concerns. As discussed at the beginning of these comments, although FDA has claimed at various points over the last 30 years that it has authority to regulate LDTs as devices, it has never exercised that claimed authority in a comprehensive manner in the 85 years it had authority over devices. Instead, clinical laboratories developing LDTs have been regulated under a separate statute and regulatory regime – CLIA – and complementary state laws. FDA is steering out of its lane in attempting to exercise jurisdiction over LDTs, with dangerous consequences for the public health.
#### A. LDTs are not “devices” under the FDCA.
In enacting the FDCA, Congress provided FDA with authority to regulate discrete categories of products. Each category of products – whether it be drugs, biologics, devices, or other product types – is subject to specific statutory definition. As explained below, LDTs are not devices according to the plain text of the FDCA. That conclusion is confirmed by the legislative history of the FDCA, which shows that Congress rejected a more expansive definition of the term, and by Congress’s later enactment of CLIA, which established a regulatory framework for laboratories that develop and perform LDTs, and pursuant to which laboratories have been operating for 35 years (55 for laboratories subject to the original Clinical Laboratory Improvement Act of 1967). Furthermore, other provisions of the FDCA and FDA regulations confirm that LDTs do not become devices simply because they use devices. If Congress intended to provide FDA with authority to regulate LDTs as devices under the FDCA, it would have done so clearly.
##### 1. LDTs are not “devices” according to the plain text of the FDCA.
Categorizing LDTs as “devices” would be inconsistent with the FDCA’s plain text because LDTs are not physical objects. Under FDCA § 201(h), the definition of “device” comprises only physical objects, including “[a]n instrument, apparatus, implement, machine, contrivance, implant, *in vitro* reagent, or other similar or related article, including any component, part, or accessory, which is ... intended for use in the diagnosis of disease or other conditions”. LDTs are not physical objects. LDTs are methods of using various tools and devices to derive information relevant to a treatment decision to be made by a medical professional and patient. FDA’s repeated insistence that an LDT is a device reflects a deep and fundamental misunderstanding of the nature of LDTs, as we described in depth earlier in these comments.
FDA’s contention that an LDT is an “apparatus,” a “contrivance,” or “article” that is “similar or related to” “instrument[s]” and “*in vitro* reagent[s],” 88 FR 68,017, cannot be squared with the fact that LDTs are not particular material things (or simply particular combinations of material things), but rather are services. Canons of statutory construction dictate that “words grouped together in a list should be given related meaning.” *Dole v. United Steelworkers of Am.*, 494 U.S. 26, 36 (1990). Here, in common usage, the other terms listed in the definition of “devices” (instrument, implement, machine, implant, *in vitro* reagent) are all tangible objects, and thus the terms “apparatus” and “contrivance” should likewise be given that meaning. This conclusion is bolstered by the term “article” as a catch-all at the end of the list. The Oxford English Dictionary defines “article” as a “particular material thing, esp. one belonging to a specified class; a commodity; an item of goods or property.” [^Article](https://www.oed.com/dictionary/article_n?tab=meaning_and_use#38461235) (last visited November 6, 2023). Consistent with this definition, courts have consistently construed the term “article” to mean “material things.” *See, e.g., ClearCorrect Operating, LLC v. Int’l Trade Comm’n*, 810 F.3d 1283, 1291 (Fed. Cir. 2015) (construing the term “articles,” in accordance with its “ordinary or natural meaning,” in the Tariff Act to mean material things, and thus the term did not cover electronically transmitted digital data); *ClearCorrect Operating, LLC v. Int’l Trade Comm’n*, 819 F.3d 1334; 1336-37 (Fed. Cir. 2016) (finding the panel majority was correct in interpreting the word “articles” in section 337 to mean “material things” where that interpretation is mandated by the plain meaning of the word, the context of the statute and entire statutory scheme, and the legislative history).
The conclusion that “devices” include only physical products is consistent with the fact that other provisions of the FDCA that require the presence of an object, e.g., shipment and receipt in interstate commerce, commercial distribution, and holding for sale. Other provisions of the FDCA discuss devices in ways that only make sense if applied to physical products, like the requirement to repair, replace, or refund the purchase price of a device under section 518(b). The frequency of such statutory references is a powerful confirmation that Congress understood “devices” to encompass only tangible products and not intangible professional services. Several of FDA’s promulgated regulations for devices similarly can only be understood when applied to a tangible product. Unlike devices, LDTs cannot be packaged or affixed with a label that bears a unique device identifier. *See* 21 CFR Part 801. Additionally, FDA’s quality system regulation defines the word “product” to include “in-process devices, finished devices, and returned devices.” 21 CFR § 820.3(r). Clinical laboratories may use articles to develop and perform LDTs, but that does not transform LDTs into articles themselves.
Moreover, the term “*in vitro* reagent” does not include LDTs because an LDT is not an *in vitro* reagent. An *in vitro* reagent is a chemical or mixture used to elicit a chemical reaction. *See, e.g.*, 21 CFR §§ 809.10(a) (requiring the label of an IVD that is a “reagent” to include its name, “quantity, proportion or concentration”, as well as “storage instructions adequate to protect the stability of the product,” and “a declaration of the net quantity of contents”); 809.10(d) (describing the labeling for “general purpose laboratory reagents (e.g., hydrochloric acid)”); 809.10(e) (describing the labeling for “analyte specific reagents (e.g., monoclonal antibodies, deoxyribonucleic acid (DNA) probes, viral antigens, ligands)”). *In vitro* reagents are one component used in diagnostic tests, but they are not the tests themselves. The fact that Congress gave FDA authority over one discrete article used to perform an LDT does not equate to Congress giving FDA authority over LDTs themselves.
Finally, LDTs did not become devices just because they have become more sophisticated. FDA asserts in the Proposed Rule that regulation is justified because LDTs have become more complex and are used to screen or diagnose complex and important medical conditions. However, FDA cannot justify applying device regulation to LDTs that are not within FDA’s jurisdiction for devices. If FDA believes that any market changes could justify regulation of some LDTs but not others, then the burden is on the Agency to explain why those changes make a difference under the statute, i.e., why those changes mean that certain LDTs are devices, as defined in the FDCA. LDTs do not meet the definition of a device, and the fact that modern LDTs have become more advanced or that LDTs screen/diagnose important diseases does nothing to change that conclusion.
##### 2. The legislative history of the Medical Device Amendments and CLIA confirm that LDTs are not “devices” under the FDCA.
Because the text of the FDCA makes it clear that LDTs are not devices, it is not necessary to consider legislative history. *See, e.g., Mohamad v. Palestinian Auth.*, 566 U.S. 449, 458-59 (2012). Nevertheless, in this situation, the legislative history of the FDCA and CLIA only strengthens the conclusion that LDTs are not devices.
a) Congress rejected a broader definition of “device” when enacting the MDA.
The legislative history of the Medical Device Amendments of 1976 (MDA) is consistent with the reading that devices are physical objects and, accordingly, do not include LDTs. Congress’s Conference Report on the bill refers to devices as “products” and “articles.” H.R. Rep. No. 94-1090, at 62, 65 (1976) (Conf. Rep.). The House Report also refers to devices as “products,” “machines,” and “articles.” H.R. Rep. No. 94-853, at 6 (1976). Moreover, the House Report notes that, “generally, the term ‘device’ is used in the bill to refer to an individual product or to a type or class of products, except where one device is indicated for multiple intended uses. Id. at 14. Finally, the Senate Report stated that the bill carefully defined “device” so as to specifically include implants, in vitro diagnostic products, and other similar or related articles. S. Rep. No. 94-33, at 17 (1975). FDA points to the use of the term “diagnostic service” in a Senate Report that accompanied an earlier iteration of the bill, see 88 Fed. Reg. 68,018, but what Congress referred to as “devices” were “diagnostic products,” and the “device” described in the example discussed by the Report was a “diagnostic machine, the ‘Radioscope.’” S. Rep. No. 93-670, at 3-4 (1974) (“One popular area for quack devices has been diagnostic products. During the 1950’s, the biggest source of such devices was the Electronic Medical Foundation of San Francisco.... There were estimated to be about 5,000 of the devices [a diagnostic machine called the Radioscope] throughout the country.... The blood-spotted paper was put into a slot of the electrical device called the ‘Radioscope’ while the operator stroked with a wand the abdomen of a person holding metal plates connected to the device.”) (emphasis added).
In adopting the definition of “device” at section 201(h) that is limited to articles, Congress rejected a more expansive definition that would have included “systems.” As FDA points out in the preamble to the Proposed Rule, the regulations for “in vitro diagnostic product” at 21 CFR Part 809 refer to such products as “systems” and “test systems,” and FDA repeatedly asserts that LDTs are “devices” because they are “test systems.” 88 FR 68,017–19. But these regulations for in vitro diagnostic products, and particularly the definition of in vitro diagnostic product at 21 CFR § 809.3, were promulgated before the 1976 Medical Device Amendments. Reorganization, Republication and Recodification, Title 21—Food and Drugs, Chapter I—Food and Drug Administration, Department of Health, Education, and Welfare, Subchapter H—Medical Devices, 41 Fed. Reg. 6896 (Feb. 13, 1976) (making a nonsubstantive change to reorganize and move the definition of “in vitro diagnostic product” from 21 CFR 328.3 to 21 CFR 809.3, prior to enactment of the Medical Device Amendments on May 28, 1976). And when the MDA was enacted, “device” was defined to include neither the term “test system” nor “system.” Congress did not adopt that wording in 1976 or at any time since, further buttressing the fact that FDA’s reliance on that regulation or the concept of a “test system” is misplaced.
FDA also has previously asserted that the addition of “in vitro reagents” into § 201(h) was intended to capture LDTs, but that is not so. See FDA, Draft Guidance: FDA Notification and Medical Device Reporting for Laboratory Developed Tests (LDTs), at 5 (Oct. 3, 2014). As an initial matter, as explained above, an LDT is not an in vitro reagent. Moreover, the legislative history of the MDA makes clear that the addition of items to the list of articles qualifying as devices—including in vitro reagents—did not expand the device definition beyond tangible articles. The House Report explains that “[t]he new definition retains (in somewhat more precise detail) provisions of existing law that a device is an article or component thereof,” while making changes to distinguish drugs and devices by reference to chemical action and metabolism. H.R. Rep. No. 94-853, at 14.
b) Congress’s subsequent enactment of CLIA confirms that LDTs are not “devices” under the FDCA.
Twelve years after Congress established FDA’s device authority in the MDA, Congress passed the Clinical Laboratory Improvement Amendments of 1988 (CLIA), which strengthened and transformed the regulatory scheme applicable to clinical laboratories, including those performing LDTs. Neither CLIA nor its legislative history acknowledges any then-existing FDA authority to regulate LDTs. The enactment of CLIA was driven in part by the desire for greater oversight over Pap testing, which was performed entirely by LDTs. See H.R. Rep. No. 100-899, at 16 (“Evidence was presented to the Committee that, in many laboratories, high numbers of false negative results were being reported. At the least, women have been given a false sense of security and discouraged from seeking proper care.”). Sen. Rep. No. 100-561 at 5 (“Screening for cervical cancer through use of the Pap smear is the most common type of cytological examination. ... Unfortunately, there is much evidence of seriously inadequate performance by laboratories doing cytological testing.”). At the time, FDA had not cleared or approved any devices for Pap tests to screen women for cervical cancer. However, there was no discussion of FDA oversight for Pap tests or cervical cancer screening in the legislative history of CLIA. Nor were there any Congressional inquiries into FDA regarding a derogation of its responsibilities regarding such tests. Surely, if regulation of LDTs, such as Pap tests, were an FDA responsibility, there would have been an outcry that FDA had abdicated its responsibility to protect the public health. In stark contrast, FDA’s responsibility to regulate LDTs was not mentioned at all. What is more, the House Report stated that laboratories “were governed by two separate and distinct statutes, Medicare and CLIA”—not the FDCA—and the Report’s section on the “Current Regulatory System” does not even mention FDA. H.R. Rep. No. 100-899, at 11-12 (1988).
Moreover, in enacting CLIA, Congress established a set of detailed requirements for laboratories that are entirely separate from the FDCA’s requirements for device manufacturers. For example, rather than requiring clinical laboratories to register and list under FDCA § 510(c), laboratories must obtain a certificate prior to soliciting or accepting specimens for laboratory examinations or procedures under PHSA § 353(b). In addition, rather than requiring clinical laboratories to comply with good manufacturing practices (GMP) or the quality system regulation (QSR) to ensure that LDTs are valid and reliable, CLIA requires laboratories to: (1) maintain adequate quality control and quality assurance programs to assure the “validity and reliability” of the tests and “the proper collection, transportation, and storage of specimens and the reporting of results,” PHSA § 353(f)(1)(A); and (2) participate in regular proficiency testing, PHSA § 353(f)(1)(D) & (f)(3). CLIA also established a framework according to which states could enact their own clinical laboratory laws, and if such laws were “equal to or more stringent” than the requirements under CLIA, clinical laboratories in such state could be exempt from CLIA. 42 U.S.C. § 263a(p)(2). Two states have obtained such CLIA-exempt status—Washington and New York—and one of those states (New York) expressly reviews and approves LDTs.
Furthermore, CMS regulations expressly distinguish between laboratory tests that are cleared or approved by the FDA and those that are not. Under 42 C.F.R. § 493.1253(b)(2), laboratories must establish performance specifications prior to reporting results from a “modifie[d] ... FDA-cleared or approved test system, or ... a test system not subject to FDA clearance or approval (including methods developed in-house and standardized methods such as textbook procedures) ...” (emphasis added). These performance specifications include accuracy, precision, analytical sensitivity, analytical specificity to include interfering substances, reportable range of test results for the test system, reference intervals (normal values), and any other performance characteristic required for test performance. 42 C.F.R. § 493.1253(b)(2). CMS’s recognition that there are “test system[s] not subject to FDA clearance or approval” is fully consistent with Congress’s understanding in enacting CLIA that such test systems were not “devices” regulated by FDA.
Because Congress did not consider FDA as having authority to regulate laboratories, applying FDA authorities in addition to CLIA would introduce inconsistencies into the regulation of LDTs. FDA promotional requirements restrict the information that a device manufacturer can share about a regulated device. See, e.g., 21 C.F.R. § 801.6 (misleading statements); 21 C.F.R. § 807.97 (misbranding by reference to premarket notification). However, CLIA requires laboratories to offer consultation on interpreting test results for specific patient conditions. See 42 CFR § 493.1445(e)(9) (requiring the laboratory director to “[e]nsure that consultation is available to the laboratory’s clients on matters relating to the quality of the test results reported and their interpretation concerning specific patient conditions”). Likewise, FDA requires a manufacturer to obtain approval or clearance for labeling changes to devices, but CLIA requires laboratories to provide pertinent updates on testing information as soon as it is available. See 42 CFR § 493.1291(e) (“Pertinent updates on testing information must be provided to clients whenever changes occur that affect the test results or interpretation of test results.”). The CLIA requirements that permit licensed pathologists to share interpretive and off-label information regarding tests performed in their laboratories is consistent with the right of such pathologists to practice medicine within the scope of their licenses. FDA restrictions on providing such interpretive and off-label information, on the other hand, would limit such pathologists’ ability to practice medicine within the scope of their licenses.
Congress’s enactment of a regulatory structure for clinical laboratories that is inconsistent with FDA regulation of LDTs as devices precludes FDA from asserting jurisdiction over LDTs. *See FDA v. Brown & Williamson Tobacco Corp.*, 529 U.S. 120, 125–26 (2000).[^188]
##### 3. LDTs do not become devices because they use devices.
LDTs do not become devices just because devices are used in performing an LDT. This is recognized in FDA regulations. Specifically, FDA regulations do not require a person providing a service with a device to be the manufacturer of the device, and therefore, no premarket review is required for the device used by the person. For example, 21 C.F.R. § 807.65(i) exempts from registration “[p]ersons ... whose major responsibility is to render a service necessary to provide the consumer (i.e., patient, physician, layman, etc.) with ... the benefits to be derived from the use of a device; for example, a ... clinical laboratory ... whose primary responsibility to the ultimate consumer is to ... provide a service through the use of a previously manufactured device.” Under section 510(k) of the FDCA and 21 C.F.R. § 807.81(a), FDA’s premarket requirements apply only to “[e]ach person who is required to register” an establishment. Because clinical laboratories are not required to register, they are not required to submit premarket notifications for the testing services they offer. Thus, FDA’s regulatory framework already recognizes that services performed with devices are not themselves devices.
#### B. Had Congress provided FDA with authority over LDTs, it would have done so expressly.
Under the “major questions doctrine,” as recently cemented by the Supreme Court in *West Virginia v. EPA*, 142 S. Ct. 2587 (2022), courts require “something more than a merely plausible textual basis” when an agency asserts “sweeping and consequential authority.” *Id.* at 2608–09. The seminal “major questions” case is *FDA v. Brown & Williamson Tobacco Corp.*, 529 U.S. 120 (2000), where the Court rejected FDA’s claim that its “drug” and “device” authority gave it the power to regulate tobacco products, concluding that “Congress could not have intended to delegate [authority] of such economic and political significance ... in so cryptic a fashion.” *Id.* at 160. The Court also reasoned that “FDCA’s overall regulatory scheme,” “subsequent tobacco-specific legislation,” and Congress’s rejection of legislative proposals to give the FDA jurisdiction over tobacco all indicated that the FDA was precluded from regulating tobacco products. *Id.* at 159–61.
LDTs represent a longstanding, significant part of the U.S. healthcare system and play a critical role in delivering dynamic healthcare solutions to patients. Yet with no express statutory authorization, FDA has proposed to regulate this important sector in a manner that would fundamentally alter the market. As in *Brown & Williamson*, it is implausible that Congress chose to delegate to FDA an issue of “such economic and political significance ... in so cryptic a fashion.” 529 U.S. at 160. The Supreme Court has recently and repeatedly counseled that federal agencies should “hesitate before concluding that Congress meant to confer [rulemaking] authority” regarding issues of vast “economic and political significance” where the statutory basis for such a regulatory action is unclear. See *West Virginia v. EPA*, 142 S. Ct. 2587, 2595 (2022); *King v. Burwell*, 576 U.S. 473, 485–86 (2015); *Utility Air Reg. Grp. v. EPA*, 573 U.S. 302, 324 (2014). The Proposed Rule runs directly contrary to that admonition. FDA relies on a strained interpretation of “device” that is not grounded in text or legislative history and that would have major consequences, not only economically but also for health care across the United States. The definition of “device” was not drafted with the understanding that it could be used to regulate a service in this manner. Additionally, as in *Brown & Williamson*, the overall FDCA regulatory scheme, as detailed below at V.C-D, and subsequent legislation specific to clinical laboratories, as detailed above at V.A.2.b, evince a Congressional understanding that LDTs do not fall within the FDCA’s scope. Finally, Congress has considered—and has so far declined to enact—legislation that would have given FDA authority to regulate LDTs. See H.R. 8616 – VALID Act of 2022 (117th Cong.); H.R. 4128 – VALID Act of 2021 (117th Cong.). See *West Virginia*, 142 S. Ct. at 2614. Given its lack of statutory basis, FDA should not suppose that it has the power to regulate LDTs in this manner.
#### C. LDTs cannot be subject to any FDCA authorities that require devices to be introduced or delivered into interstate commerce for commercial distribution.
Looking beyond the FDCA’s “device” definition to other provisions of the statute confirms that the FDCA’s device authorities clearly were not intended to cover LDTs. To start with, many of FDA’s authorities to regulate devices require that devices be introduced or delivered for introduction into interstate commerce for commercial distribution. See, e.g., FDCA §§ 510(k) (“Each person who is required to register under this section and who proposes to begin the introduction or delivery for introduction into interstate commerce for commercial distribution of a device intended for human use shall, at least ninety days before making such introduction or delivery, report to the Secretary ... action taken by such person to comply with requirements under section 514 [related to performance standards] or 515 [related to premarket approval] which are applicable to the device.”) (emphasis added); 515(b)(1) (explaining that the Secretary must require premarket approval when a class III device “was introduced or delivered for introduction into interstate commerce for commercial distribution before May 28, 1976,” “is of a type so introduced or delivered,” and “is substantially equivalent to another device within that type[.]”); 518(a)(1) (triggering notification requirements when the Secretary determines that, among other things, “a device intended for human use which is introduced or delivered for introduction into interstate commerce for commercial distribution presents an unreasonable risk of substantial harm to the public health[.]”). But LDTs are not, and indeed cannot be, introduced or delivered for introduction into interstate commerce for commercial distribution.
The FDCA defines “interstate commerce” as “(1) commerce between any State or Territory and any place outside thereof, and (2) commerce within the District of Columbia or within any other Territory not organized with a legislative body.” 21 U.S.C. § 321(b). But “[t]he typical LDT ... never physically leaves the laboratory. There is no ‘introduction’ and no ‘delivery.’”[^189] That is because LDTs are “intended for clinical use and designed ... [to be] used within a single laboratory[.]” Citizen Petition Denial Response from FDA CDRH to ACLA re: Docket No. FDA-2013-P-0667 at 1 (July 31, 2014) (hereinafter “FDA CP Response”). For this basic structural reason, an LDT being performed cannot logically be considered commerce between any state or territory.
Even if LDTs are introduced or delivered for introduction into interstate commerce, they are not introduced for “commercial distribution.” “Commercial distribution” is defined under 21 C.F.R. § 807.3(b) to mean “any distribution of a device intended for human use which is held or offered for sale,” and excludes “[i]nternal or interplant transfer of a device between establishments within the same parent, subsidiary, and/or affiliate company.” In a Compliance Policy Guide (CPG), FDA interpreted commercial distribution to require delivery of the device to purchasers or consignees. FDA, CPG § 300.600 (“Commercial Distribution with Regard to Premarket Notification (Section 510(k))”) (1978, reissued 1987). Specifically, under this CPG, FDA will consider a device in commercial distribution without delivery only if the manufacturer can establish that, among other things, it had accepted or been prepared to accept at least one purchase order before enactment of the MDA “generally with delivery to occur immediately or at a promised future date.” (Id. emphasis added). Thus, FDA has interpreted “commercial distribution” to mean that, at the very least, delivery of the device is anticipated. And notably, a court has upheld this CPG’s interpretation of “commercial distribution.” *U.S. v. An Article of Device Consisting of 1,217 Cardboard Boxes*, 607 F. Supp. 990, 993-95 (W.D. Mich. 1985). In *An Article of Device Consisting of 1,217 Cardboard Boxes*, the court cites CPG 7124.26, which contains identical language regarding delivery of the device, stating such CPG was “the current expression of the [FDA’s] interpretation of ‘commercial distribution,’” as well as a letter from FDA in which the Agency explained that the requirements for “commercial distribution” would be satisfied if there were “adequate documentation of separate, specially labeled packaging, and at least one sale prior to May 28, 1976” (emphasis added). The court then concluded that the explanation in the letter, “together with the agency’s compliance policy guide 7124.26, is a reasonable interpretation of the phrase ‘commercial distribution’.” *Id.* at 994-95.
FDA contends that “commercial distribution” “does not require the physical transfer of an object” but only that a device be “on the market.” 88 Fed. Reg. 68,021. But that gloss ignores FDA’s longstanding interpretation of “commercial distribution,” which requires actual or anticipated delivery.
For these reasons, LDTs cannot be subject to any FDCA authority that requires introduction or delivery into interstate commerce for commercial distribution. This includes FDA’s premarket review requirements under FDCA § 510(k), among many other provisions. This statutory context confirms that LDTs fall outside the scope of “devices.” Other provisions of the FDCA also discuss “devices” in ways that only make sense if applied to physical objects. See, e.g., FDCA §§ 513(a)(2)(B) (“labeling” for devices); 514(a)(2)(C) (“labeling for the proper installation, maintenance, operation, and use” of a device); 519(f) (labels that “bear a unique identifier” so that a device can be tracked); 515(c)(1)(C) (“the manufacture, processing, and, when relevant, packing and installation” of a device); 518(b) (requiring a “manufacturer, importer, distributor, or retailer” of a device to “repair,” “replace,” or “refund the purchase price”).
In response to this argument, FDA offers a blithe retort that such tests would then just have to go through the PMA or De Novo pathway. This conclusion—that a device not subject to section 510(k) is independently subject to section 515 or 513(f)(2) of the FDCA—is not supported by the text of the FDCA or FDA’s own interpretation of the statute. Rather, submission of a premarket application under section 515 or a De Novo request under section 513(f)(2) satisfies the requirement to submit a 510(k) premarket notification, which generally applies to all devices unless subject to a specific exemption.
Specifically, section 510(k) of the FDCA requires a premarket notification prior to introduction of “a device,” not a device that is not otherwise subject to premarket approval requirements, De Novo classification requirements, investigational device exemption, or that is otherwise 510(k) exempt. The 510(k) requirement thus applies broadly across all devices, but exemptions from the 510(k) requirements have been added to the FDCA (e.g., for certain class I and
With regard to PMA applications and De Novo classification requests, FDA has interpreted the statute such that a PMA application under section 515 or a De Novo classification request under section 513(f)(2) satisfies the requirement for a premarket notification under section 510(k). In its 1976 proposed rule establishing the Part 807 regulations for premarket notifications, the Agency explained that “[a] premarket notification under § 807.81 is not required for a device for which a premarket application under section 515 of the act, or for which a petition to reclassify from class III to class I or II under section 513(f)(2) of the act, is pending before FDA. For such devices, the other submissions will serve the purpose of a notification under section 510(k) of the act." Proposed Rule, Establishment Registration and Premarket Notification Procedures, 41 Fed. Reg. 37458, 37460 (Sept. 2, 1976). In the final rule establishing such regulations, FDA confirmed this interpretation, explaining that “[i]f a premarket approval application has been submitted, a premarket notification submission would not be required since FDA would already be advised of the intent to market.” See Final Rule, Establishment Registration and Premarket Notification Procedures, 42 Fed. Reg. 42520, 42523 (Aug. 23, 1977) (emphasis added).
Moreover, even if FDA were right that LDTs would need to resort to the PMA or De Novo pathway (which it is not), this argument ignores a more fundamental point: it defies logic that Congress would create a system to regulate LDTs where foundational provisions would not apply. By FDA’s own estimates, some 80% of LDTs that require premarket review would be subject to the 510(k) premarket notification process. The fact that the principal pathway to market for devices (not to mention other aspects of the FDCA) would be unavailable to LDTs is further evidence that the device regulatory framework was never intended to reach LDTs. This argument also would further undermine FDA’s estimate of the costs associated with the Proposed Rule, as the tens of thousands of LDTs that FDA had estimated to be eligible for the 510(k) pathway would be subject to the lengthier, more expensive PMA and De Novo pathways.
#### D. LDTs are not “held for sale” as required under FDCA Section 301(k).
As an additional basis, FDA has asserted that it may regulate LDTs under Section 301(k) of the FDCA by claiming that LDTs are “held for sale.” This argument fails under a commonsense reading of Section 301(k) and applicable case law.
Under 301(k), the following acts are prohibited: “The alteration, mutilation, destruction, obliteration, or removal of the whole or any part of the labeling of, or the doing of any other act with respect to, a food, drug, device, tobacco product, or cosmetic, if such act is done while such article is held for sale (whether or not the first sale) after shipment in interstate commerce and results in such article being adulterated or misbranded.” 21 U.S.C. § 331.
As an initial matter, LDTs are not “article[s]” “held for sale.” A physician’s test order for an LDT service is satisfied by the laboratory performing in-house testing services and reporting back to the ordering physician the result of that service, not by the laboratory transferring title to and possession of the testing methodology or protocol to the ordering physician as a third-party purchaser.
This view comports with the case law, which extends FDA’s jurisdiction to regulate drugs and devices after release by the original manufacturer, but only insofar as such regulated products are being delivered or transferred to another ultimate consumer. In this regard, *U.S. v. Regenerative Sciences, LLC*, 741 F.3d 1314 (D.C. Cir. 2014), is inapplicable to LDTs. In *Regenerative Sciences*, the court stated that a drug—doxycycline—was adulterated when mixed with cells from patients, and then such drug-cell mixture was held for sale when administered to a patient for treatment. This does not occur with LDTs, however, which by definition are not transferred to anyone, but performed by the developer. Thus, LDTs are not “held for sale.” For example, “held for sale” does not include use of a device to facilitate the work of a healthcare professional where that device is not transferred to the patient. See *Shahinian v. Kimberly-Clark Corporation*, No. 14-CV-8390, 2017 WL 11595343 (C.D. Cal. Mar. 7, 2017) (holding surgical gowns were not “held for sale” because they “were bought for the use of [the] hospital staff, the ‘ultimate consumer’ of the product”).
In cases cited by FDA in its Citizens Petition Denial Response and by HHS in the Charrow Memorandum, the regulated drug or device product was delivered or transferred from one party (typically a doctor) to an ultimate consumer (typically a patient). See Citizen Petition Denial Response from FDA Center for Devices and Radiological Health to ACLA re: Docket No. FDA-2013-P-0667 at 1 (July 31, 2014); *United States v. Cassaro, Inc.*, 443 F.2d 153, 156 (1st Cir. 1971) (citing *Hippolite Egg Co. v. United States*, 220 U.S. 45, 54 (1911), for the proposition that the “held for sale” standard of section 301(k) has long been afforded a liberal reading, encompassing “all articles, compound or single, not intended for consumption by the producer”); *United States v. Sullivan*, 332 U.S. 689, 697 (1948) (cited for the proposition that section 301(k)’s “held for sale” requirement is “designed ... to extend the [FDCA’s] coverage to every article that had gone through interstate commerce until it finally reached the ultimate consumer”); see also *United States v. Evers*, 643 F.2d 1043, 1050 (5th Cir. 1981) (summarized by FDA as “stating that physicians holding drugs for use in their practice may be considered to hold them for sale within the meaning of section 301(k) of the FDCA,” and where such drugs were delivered to an ultimate consumer, i.e., the patient); *United States v. Diapulse Corp. of Am.*, 514 F.2d 1097, 1098 (2d Cir. 1975) (which FDA quoted for the proposition that “devices, used in the treatment of patients, may properly be considered ‘held for sale’ within the meaning of the Food, Drug, and Cosmetic Act,” and where the device at issue was administered to patient); *United States v. Rhody Dairy, L.L.C.*, 812 F. Supp. 2d 1239 (E.D. Wash. 2011) (holding that drugs are “held for sale” when they are administered); *United States v. Torigian Labs., Inc.*, 577 F. Supp. 1514, 1521 (E.D.N.Y. 1984) (“All articles held for purposes other than personal consumption—whether to be sold or given away—are deemed to be held for sale under the Act.”); *Articles of Animal Drug Containing Dithiazolstibestrol*, 528 F. Supp. 202, 205 (D. Neb. 1981) (“This Court subscribes the view that an article of drug or device is ‘held for sale’ if it is used for any purpose other than personal consumption”). This does not occur with LDTs, or any component of an LDT. Only the test report, which includes patient-specific information yielded from performance of an LDT, is transferred back to the ordering physician, and a test report is not a device.
Even if LDTs were “held for sale,” section 301(k) only applies while LDTs are “held for sale ... after shipment” in interstate commerce. By definition, LDTs are never shipped in interstate commerce. They are performed only within the laboratory in which they are developed. To the extent that the methods for performing LDT services are transferred anywhere, it is between laboratories under common ownership and control, which then independently validate such methods. This is not “interstate commerce,” as reflected by its exclusion from the definition of “commercial distribution.” 21 CFR § 807.3(b).
#### E. Imposing device law on LDTs would violate the First Amendment.
The FDA’s proposal to regulate LDTs—that is, to regulate intangible methodologies, as opposed to the manufacture and sale of physical articles, and the communications between laboratory directors, clinical consultants, and ordering providers—raises serious constitutional concerns.
The design and execution of LDTs, as well as the communication of test reports to healthcare providers, inherently involves constitutionally protected speech. As explained earlier in these comments, the responsibilities of a high-complexity laboratory director and clinical consultant include ensuring that reports of test results include pertinent information required for interpretation and consulting with the ordering physician (or other health care professional) regarding the appropriateness of the testing ordered and the interpretation of test results. 42 CFR §§ 493.1445 & 439.1457. Accordingly, laboratory directors and clinical consultants are required to share information regarding clinical meaning of analytical test results, including their viewpoints on the meaning of that information for a particular patient. In this way, laboratories act as providers of health care services and are meaningfully different than device (or drug) manufacturers that principally make promotional claims about products and do not provide similar clinical care services.
However, FDA regulation of LDTs as medical devices would necessarily chill this speech. Turning laboratories into medical device manufacturers would restrict speech because device manufacturers and their employees are limited to communicating information that is “on-label,” i.e., consistent with the approved or cleared labeling of a device. Accordingly, laboratory directors and clinical consultants would be restricted from sharing any information about the meaning of a test result if FDA has not authorized that speech.
To the extent that FDA would regulate speech about the interpretation of test reports based on its content (for example, limiting test report statements, or statements made during a clinical consultation, regarding the effect of a patient’s genetic makeup on drug response until FDA has reviewed or approved such statements), or viewpoint (for example, limiting expression in a test report, or during a clinical consultation, of a view that is a matter of scientific debate, such as the relative importance of a particular biomarker to diagnosing a particular disease), strict scrutiny, or at a minimum heightened scrutiny, applies. See *NIFLA v. Becerra*, 138 S. Ct. 2361, 2371–75 (2018) (speech by professionals is not exempt from the rule that content-based regulations of speech are subject to strict scrutiny); *Sorrell v. IMS Health Inc.*, 564 U.S. 552, 565 (2011) (heightened scrutiny applied to regulation of speech in aid of pharmaceutical marketing). Strict scrutiny properly applies to such speech because it does not propose a commercial transaction and is not an advertisement or otherwise clearly commercial. See *Bolger v. Youngs Drug Prods Corp.*, 463 U.S. 60, 66–67 (1983).
Even under the less stringent standards applicable to commercial speech, FDA would be hard-pressed to justify its restrictions because FDA could achieve its stated goals through alternative, less-intrusive means. Under *Central Hudson Gas Elec. Corp. v. Public Serv. Comm’n*, 447 U.S. 557 (1980), a three-part test applies to determine whether a restriction on lawful and not misleading commercial speech is permissible: (1) the asserted governmental interest must be substantial, (2) the regulation must be in proportion to that interest, and (3) the regulation must be designed carefully to achieve the government’s goal. *Central Hudson*, 447 U.S. at 564. Here, although FDA asserts a general concern about unreliable LDTs, it does not identify a particular substantial governmental interest in controlling what non-misleading information may be communicated in a test report. See *Amarin Pharma, Inc. v. FDA*, 119 F. Supp. 3d 197, 225–27 (S.D.N.Y. 2015). The FDA is also unlikely to be able to show that “the regulatory technique” proposed (that is, the application of speech-limiting “device” regulations to LDTs) is in proportion to whatever substantial “interest” it may have. *Central Hudson*, 447 U.S. at 564. The FDA has an interest in ensuring that misleading information is not communicated in a test report, but requiring burdensome FDA approval or clearance of any change in reporting suppresses far more expression than would serve the FDA’s
Finally, in this dynamic, cutting-edge industry, there is a serious risk that regulating LDTs as devices would undermine the goal of ensuring that appropriate information is conveyed to providers in connection with the tests they order. As the CLIA regime recognizes, clinical laboratories should be able to provide pertinent updates on testing information as soon as it is available. FDA regulation of LDTs as devices would prevent that expression.
#### F. FDA regulation would interfere with the practice of medicine.
Laboratories employ licensed pathologists, genetic and clinical counselors, and other licensed medical professionals, and these professionals are an integral part of patients’ medical teams. As explained in section II.B, above, the laboratory director is responsible for ensuring that selected test methodologies “have the capability of providing the quality of results required for patient care,” “reports of test results include pertinent information required for interpretation,” and “consultation is available to the laboratory’s clients on matters relating to the quality of the test results reported and their interpretation concerning specific conditions.” 42 CFR § 493.1445(e)(3)(i), (e)(8) - (e)(9). The laboratory also must be staffed with someone who qualifies as a clinical consultant, who is expressly responsible for “provid[ing] consultation regarding the appropriateness of the testing ordered and interpretation of test results.” *Id.* § 493.1457.
In practice, many clinical laboratories have entire medical teams dedicated to these functions, which include the application of medical judgment when interpreting test results, annotating test reports, and consulting with the patient’s care team. Regulating laboratories as device manufacturers would restrict the ability of these medical professionals to fully express their medical judgment, which may include the practice of medicine as recognized by law in some states. *See, e.g.,* Utah Code Ann. §§ 58-67-102(19)(a) (“Practice of medicine” means “(i) to diagnose ... by any means or instrumentality”) & 58-67-102(12)(a) (“Diagnose” means “to examine in any manner another person, parts of a person’s body, substances, fluids, or materials excreted, taken, or removed from a person’s body, or produced by a person’s body, to determine the source, nature, kind, or extent of a disease or other physical or mental condition”). In particular, the attendant restrictions on providing interpretations or off-label information would interfere with their ability to appropriately consult with ordering physicians. FDA is prohibited, however, from regulating the practice of medicine under section 1006 of the FDCA. See also *Buckman Co. v. Plaintiffs’ Legal Comm.,* 531 U.S. 341, 350 (2001) (FDA’s “mission [is] to regulate ... without directly interfering with the practice of medicine.”)
#### G. The NPRM Fails to Comply with Section 553(b) of the Administrative Procedure Act.
As amended by the Providing Accountability through Transparency Act of 2023, Section 553(b) of the Administrative Procedure Act requires that a Notice of Proposed Rulemaking include “the Internet address of a summary of not more than 100 words in length of the proposed rule, in plain language, that shall be posted on the Internet website under section 206(d) of the E-Government Act of 2002 (44 U.S.C. 3501 note) (commonly known as regulations.gov).” 5 U.S.C. § 553(b)(4). The NPRM fails to comply with this requirement, as it does not include the Internet address at which such a summary may be found, nor does the rulemaking docket for the Proposed Rule at regulations.gov include any summary of the rule, much less “summary of not more than 100 words in length of the proposed rule, in plain language.”
That omission undermines the ability of stakeholders—particularly smaller laboratories and their employees—to understand FDA’s proposal and participate meaningfully in the public comment process. Congress determined that a “plain language” summary is essential to providing “accountability” and “transparency” in rulemaking proceedings, Pub. L. No. 118-9, § 1, and thus mandated that every “notice of proposed rulemaking ... shall include” the required summary, 5 U.S.C. § 553(b)(4) (emphasis added). FDA accordingly must publish a concise summary of its proposal, reissue the Notice of Proposed Rulemaking with the mandatory Internet address included, and then restart this proceeding with a new public comment period.
### VII. The Agency Could Revise the Rule to Reduce, but not Eliminate, the Net Negative Impact of the Rule to Public Health.
As explained in these comments, ACLA believes that FDA should not finalize the Proposed Rule. As a matter of law, the Proposed Rule exceeds FDA’s authority and raises significant constitutional issues. Moreover, even if FDA had authority to move forward (which it does not), the Proposed Rule should be abandoned because it is bad policy. However, the Proposed Rule seeks comment on FDA proposals that FDA suggests could lessen the harm caused by the Proposed Rule. If FDA nonetheless decides to ignore the deficiencies set forth in these comments and proceeds in finalizing the Proposed Rule, it could adopt certain approaches to lessen the harm caused by the Proposed Rule. However, we emphasize that none of these, individually or collectively, would cure the legal or policy deficiencies identified throughout these comments, nor would they completely eliminate the harm of the Proposed Rule such that its benefits would outweigh its costs. Nothing in the following comments should be regarded as ACLA conceding that FDA has a legal or public policy basis to proceed with this rulemaking.
#### A. Grandfathering for existing tests.
To reduce but not eliminate the net harm of the rule, all LDTs that are first made available prior to publication of the final rule could be subject to ongoing enforcement discretion and not be expected to comply with premarket submission requirements or quality system requirements related to design controls. This mitigation would reduce the costs for both laboratories and FDA related to the backward-looking exercise of re-validating and submitting applications for existing tests. Accordingly, it would also mitigate the harms to patients from important tests being culled from existing test menus and would lessen (but not eliminate) the need to divert existing resources currently focused on innovation and clinical testing, thus lessening the net negative impact of the rule to innovation and patient access to important tests.
Failing to grandfather existing tests from at least these portions of FDA regulation also would improperly disregard the legitimate reliance interests of clinical laboratories that offer these LDTs, as well as the interests of the patients who would otherwise benefit from tests suddenly rendered uneconomical. See *DHS v. Regents of the Univ. of Cal.,* 140 S. Ct. 1891, 1913-15 (2020) (failing to consider reliance interests of DACA recipients, and weigh those interests against competing concerns, was arbitrary and capricious). Those reliance interests are substantial, given FDA’s decades-long policy of generally not enforcing device requirements with respect to LDTs and the countless business decisions affecting the landscape of the U.S. health care system that have been made against the backdrop of that policy.
Importantly, FDA’s proposed exemptions for “1976-type” LDTs are neither adequate nor sensible to lessen the high costs to laboratories and patients in the Proposed Rule. The exemption for “1976-type” LDTs is limited only to those tests that use “manual techniques (without automation).” However, these types of tests are few and far between. Even simple laboratory tests that existed in 1976 have since been updated to leverage automated systems, such as automatic pipetting, that improve the accuracy, consistency, and quality of such tests. For example, while a cytogenetics test *can* be performed without automated instrumentation, it is commonly performed using an automated metaphase finder to locate cells for karyotype and analysis. As another example, differential cell counts used to be performed manually by a laboratory technician performing a manual blood smear and counting cells; but now, automation lines draw the blood, prep the smear, and count the cells, with only certain abnormal findings triggering a manual review by a technician or pathologist. This extremely narrow exemption, therefore, would only encourage less accurate, less consistent, and lower quality methods of testing. Instead, FDA could further mitigate the net negative impact of the rule by exempting all LDTs that are offered prior to finalization of the rule, regardless of complexity or risk-level.
It would mitigate the net negative impact of the rule to a lesser degree to grandfather only those tests that have been previously approved by New York State—regardless of risk classification. Such tests have been evaluated for their analytical and clinical validity by a third party that FDA itself previously has relied upon for third-party reviews. However, we note that grandfathering tests approved by the state of New York would be inadequate to completely alleviate laboratories from having to cull certain tests from their menus and to prevent FDA from being overwhelmed by marketing submissions at years 3-5 and 4 of the phaseout period. This is because such a policy would not extend to laboratories outside of New York that do not offer tests nationally, e.g., local, specialty laboratories, and New York does not review and approve all LDTs. For example, New York does not review and approve LDTs for multi-analytic immunohistochemistry stains, which it considers to be performed by “standard methods.”[^190]
#### B. Extended implementation timeline.
The implementation timeline could be extended for all tests to reduce, but not eliminate, the net harm of the rule. Four years to phase in an ill-fitting regulatory regime is hardly appropriate given the significant amount of work that would be needed to bring active indications to compliance. Even in 2014, when FDA proposed through draft guidance to phase-in device regulation of LDTs, the Agency proposed a 9-year transition period.[^191] In the VALID Act, a bill for which FDA gave substantial input and which was re-introduced as recently as March 2023, a transition period of up to 10 years was available for certain tests in addition to grandfathering of all LDTs available at the time of enactment.[^192] Extending the implementation timeline would enable laboratories to stretch their existing resources more efficiently compared to the implementation timeline as proposed, such that fewer personnel would need to be completely diverted away from their existing innovation/testing activities to focus on backward-looking re-validations and establishing FDA-compliant quality and postmarket systems. It would also mean that fewer new personnel would need to be hired, and, ultimately, fewer existing tests may need to be culled from test menus due to competing demands for limited resources that make obtaining clearance or approval for all existing tests impossible. Accordingly, this would reduce, but not eliminate, the negative impact of the rule to innovation and access to testing. Finalizing the Proposed Rule without extending the transition period would harm the reliance interests of clinical laboratories engendered by FDA’s decades-long policy of generally not enforcing device requirements with respect to LDTs. See DHS v. Regents of the Univ. of Cal., 140 S. Ct. 1891, 1913-15 (2020) (where agency is “not writing on a blank slate,” it must consider reliance interests).
Additionally, FDA could further extend the implementation timeline for LDTs approved by New York State that are introduced after publication of the final rule to reduce, but not eliminate, the net harm of the rule. As discussed above, New York State evaluates the analytical and clinical validity of LDTs, and extending the transition period for these tests would be consistent with the recognition that they have already been evaluated by a third party for analytical and clinical validity. In addition to the reduced harm to laboratories and patients that would accrue from a longer implementation timeline, this would also lessen the burden to FDA of reviewing thousands of submissions submitted all at once when submissions become due. Instead, FDA could focus on those tests for which there has been no independent review and would still receive at a later date premarket submissions for tests that have received New York State approval. This was the approach adopted in VALID, where tests approved by New York State under molecular specialties would have received an additional 5 years for transition, and all other tests approved by New York State would have received an additional 2 years.
ACLA disagrees with all discriminatory applications of LDT regulation based on the type of entity offering the LDT, including but not limited to the proposal in the Proposed Rule to extend the implementation timeline only for small laboratories with revenues below a certain threshold. There is no public health basis for granting only these small laboratories a longer transition period, and doing so would be completely inconsistent with one of FDA’s underlying arguments in the Proposed Rule – that the same regulatory requirements should apply to the same activities, regardless of where or by whom they are performed.
#### C. New York State and MolDX programs.
FDA could recognize approvals by New York State and coverage decisions by MolDX as clearances and approvals of LDTs for purposes of device regulation to reduce, but not eliminate, the net harm of the rule. As detailed above, both of these programs review LDTs for their analytical and clinical validity based on detailed technical submissions. Accordingly, FDA could reduce, but not eliminate, net harm from the rule by recognizing their decisions as satisfying the FDA requirement for clearance or approval by exercising enforcement discretion for tests that have gone through such programs, or, at minimum, structure an expedited approval/clearance pathway that would alleviate the burden of FDA re-review of such tests. Likewise, with respect to LDT clinical trial assays that New York State permits to be used for clinical management without prior approval, FDA could reduce the net harm of the rule by continuing enforcement discretion with respect to such clinical trial assays. Without leveraging these programs, by FDA’s own estimate, the Agency would face an annual increase in premarket submissions of 500% for PMA Submissions, 500% for De Novos, and 80% for 510(k)s. Leveraging these programs would reduce, but not eliminate, the burden on both laboratories and FDA associated with implementation of the Proposed Rule.
#### D. Flexible modifications policy.
To lessen the burden on laboratories and FDA associated with premarket submissions for modifications to cleared and approved tests as discussed above, FDA could develop a flexible approach that enables laboratories to modify cleared and approved tests without premarket review.
For example, the VALID Act would have allowed CLIA-certified high-complexity laboratories or the marketing authorization holder (if not a high-complexity laboratory) to make certain modifications to an approved test without seeking independent premarket review. Modifications exempt from premarket review would have included modifications that do not (a) significantly change the indications for use, except for some changes to specimen type; (b) cause the test to no longer comply with mitigating measures or restrictions (conceptually similar, but not the same, as special controls); (c) significantly change performance claims or significantly and adversely change performance; or (d) adversely change the safety for individuals who come in contact with the test. Importantly, the VALID Act made clear that modifications to extend specimen stability would have been exempt as long as they met such requirements. And FDA still has a flexible policy for modifications by high-complexity laboratories to EUA-authorized COVID-19 tests. Under the current COVID-19 Testing Guidance, a high-complexity CLIA-certified laboratory can modify an EUA-authorized test, including one for which the laboratory does not hold the EUA, if the modifications do not change the indications for use set forth in the EUA and do not change the analyte specific reagents.193
A flexible policy for such modifications, established through complementary amendments to the FDCA and CLIA regulations or through continued FDA enforcement discretion, could reduce loss of availability of important tests that are modified to enhance performance and improve patient access. Specifically, FDA, CMS, and CDC could reduce but not eliminate the net harm of the rule by coordinating on complementary regulations to distinguish between modifications to cleared or approved IVDs, which would remain subject to CLIA exclusively, and novel LDTs for which FDA might require premarket review. To maximize harm reduction, this flexible modifications policy would need to extend to grandfathered tests, as well, because failure to do so would quickly render any grandfathering policy obsolete as modifications are routinely made to improve performance and adjust to changing circumstances.
The VALID Act also proposed a Technology Certification Program, under which test developers that received a technology certification order could introduce non-high-risk tests without individual tests undergoing premarket review. To be eligible to participate in the program, the developer had to have demonstrated expertise in a particular technology and a commitment to quality systems. In addition to reducing the administrative burden for non-high-risk tests, the program necessarily would have accommodated modifications to such tests. To reduce the net harm from the Proposed Rule, FDA could consider whether it could establish a similar program (as it did with the Digital Health Precertification Program) to facilitate a more flexible policy toward modifications and the introduction of new tests. To the extent that FDA believes that such a program would not be appropriate, or if FDA believes that it lacks legal authority to implement such a program, those positions should be considered and explained.
#### E. Enforcement discretion for low-volume tests.
FDA could continue to exercise enforcement discretion for low-volume tests, at least for the requirements for premarket review, to reduce but not eliminate the net harm of the rule. As detailed earlier, many LDTs are not used at volumes that justify the cost of a premarket submission (including PMAs, De Novo or even 510(k)). Although some of these tests are for rare diseases that would fit within the Humanitarian Device Exemption (HDE) pathway, many would not, given the extremely low HDE ceiling for patient groups that can be served by a diagnostic test under the HDE program. Other low volume tests would be used very infrequently, significantly less than the thresholds contemplated by the HDE program.
Even for those tests that would satisfy the thresholds for an HDE, the requirements and burdens associated with obtaining an HDE are not trivial, and in most cases the costs would not justify development and approval of the tests. Moreover, the HDE prohibits test developers from commercializing their assay except under narrow conditions. Given the public health contribution of these tests – and the fact that many would be abandoned if FDA proceeds with the Proposed Rule – FDA could exercise enforcement discretion from premarket requirements for low-volume LDTs to reduce the net harm of the rule. To do this, FDA could define a “low volume” test and fully explain the basis for any chosen volume limit for this category through notice and comment rulemaking.
#### F. Classification panels.
FDA could establish classification panels for currently available LDTs, as it did for medical devices when the MDA was enacted, to reduce the net harm of the rule. By FDA’s estimates, there are 80,400 LDTs currently available that would require premarket review. Even if these tests are grandfathered, unless there is a sensible modifications policy, FDA would quickly be flooded with premarket submissions for LDTs. But clinical laboratories are not experienced at selecting predicate devices, and even if they were, there are not suitable predicate devices for all of their tests, which would force them through the more burdensome and expensive PMA or De Novo pathway. Even low-risk novel tests would have to go through the De Novo pathway. To streamline premarket submissions for LDTs, FDA could issue an RFI regarding available LDTs and classify tests so that laboratories would have more clarity on the appropriate premarket submission pathway for their new and modified tests (and existing tests, if not grandfathered).
#### G. CLIA regulation.
FDA could consult with CMS and CDC on an alternative approach whereby CLIA regulations are updated with appropriate additional requirements for validation of LDTs, including modifications to cleared and approved IVDs and novel LDTs. If FDA rejects this approach, it must provide a reasoned basis for doing so. A mere conclusory statement that the Proposed Rule is complementary to the CLIA regulations is not only insufficient; it is patently wrong. CLIA regulations expressly acknowledge that laboratories may “modif[y] an FDA-cleared or approved test system, or introduce a test system not subject to FDA clearance or approval,”194 and the Proposed Rule creates a conflict between FDA’s regulations and CLIA’s longstanding and relied-upon regulations. CLIA also requires compliance with its own quality system regulations, requires laboratories to be inspected, and imposes fees on laboratories.
#### H. Request for information (RFI).
As explained earlier in these comments, FDA made no attempt to collect information about the number of high-complexity CLIA laboratories or LDTs currently being offered that would be affected by the Proposed Rule, despite the Agency having the tools to do so. For example, FDA could have coordinated with other HHS agencies, CMS and CDC, to collect information from CLIA-certified laboratories regarding the number of laboratories that are high-complexity laboratories and the number of LDTs offered by each such laboratory. FDA also could have issued an RFI seeking information regarding the number of high-complexity clinical laboratories and the number and type of LDTs currently being offered.
Failing to obtain this information prior to finalizing the Proposed Rule would be irresponsible and undoubtedly maximize the harm from the rule. Accordingly, FDA could potentially mitigate, but not eliminate, the harm from this proposed rule by first issuing an RFI for information about high-complexity clinical laboratories that would be affected and the number and type of LDTs currently available, thereby increasing the likelihood that any finalized policy is informed by accurate data.
#### I. Equal treatment of LDT developers.
ACLA strongly believes there is no reasoned basis for exempting particular laboratories from any FDA policy regarding LDTs or otherwise singling out any category of LDT developer for disparate treatment. FDA should not go forward with the Proposed Rule with special, different rules for small laboratories, large laboratories, academic medical centers (AMCs), laboratories in particular states or locations, or other categories of test developers.
FDA requested comments specifically on whether a different policy should apply for LDTs offered by AMCs. ACLA appreciates the important role of AMCs in the health care delivery system and the scientific and clinical expertise developed within AMCs, and we recognize their contributions to clinical and medical research. However, as FDA notes in the Proposed Rule, there is no established definition of an AMC laboratory, and defining any other developer-based exemption would face similar challenges. Further, differences in expertise in test development and the quality of testing at AMCs and commercial laboratories are not supported by evidence. Additionally, there is no meaningful difference between the tests offered by AMCs and commercial laboratories. The test menus offered by large AMCs and commercial laboratories are similar. In that regard, both AMCs and commercial laboratories are engaged in routine testing and in supporting care for patients with rare diseases and unique conditions. Importantly, establishing an exemption for AMCs could create negative health disparities for populations without access to an AMC.
In sum, there is no reasoned basis for treating particular test developers, including AMCs, differently than commercial laboratories, and doing so would be arbitrary and capricious in violation of the Administrative Procedure Act (APA). *See Bracco Diagnostics, Inc. v. Shalala*, 963 F. Supp. 20 (D.D.C. 1997) (“The disparate treatment of functionally indistinguishable products is the essence of the meaning of arbitrary and capricious.”) (citations omitted). Indeed, failure to treat similarly situated parties similarly would be regarded as arbitrary and capricious under the APA and would provide yet another basis for a legal challenge to FDA’s regulation of LDTs. *Grayscale Investments v. SEC*, 82 F. 4th 1239 (D.C. Cir. 2023); *Nasdaq Stock Market LLC v. SEC*, 38 F.4th 1126 (D.C. Cir. 2022)
### CONCLUSION
For all of the reasons stated above, the Proposed Rule should be withdrawn. Rather than expending resources to finalize the Proposed Rule, if FDA seeks to establish additional oversight of LDTs, the Agency should engage with stakeholders, including ACLA, other HHS agencies, and Congress in a renewed effort to develop legislation that would establish appropriate regulatory authority for such additional oversight.
**Exhibit 1:**
Professor Chris Carrigan, Global Economics Group, Review of the Food and Drug Administration’s Preliminary Regulatory Impact Analysis for its Medical Devices; Laboratory Developed Tests Proposed Rule
## Review of the Food and Drug Administration’s Preliminary Regulatory Impact Analysis for its Medical Devices; Laboratory Developed Tests Proposed Rule
Christopher Carrigan[^1]
December 4, 2023
### Executive Summary:
- In October 2023, the Food and Drug Administration’s (“FDA”) Office of Economics and Analysis (“OEA”) released a preliminary Regulatory Impact Analysis (“RIA”) to accompany FDA’s proposed rule, “Medical Devices; Laboratory Developed Tests” (“Proposed Rule”) as required by Executive Orders 12866 and 14094 for all rules deemed by the Office of Information and Regulatory Affairs (“OIRA”) to be 3(f)1 significant.[^2]
- OEA’s RIA fails, on several dimensions, to adhere to the standards described in the academic literature as well as the Office of Management and Budget’s (“OMB”) Circular A-4, which provides guidance to agencies in producing RIAs that fulfill the requirements of the executive orders.[^3] These issues result in an RIA that: 1) significantly understates costs by failing to quantify a key ancillary effect; 2) substantially inflates benefits by misusing benefit transfer methods; 3) provides limited ability to evaluate reasonable alternative regulatory approaches; and 4) offers minimal discussion of the distributional effects, including those on marginalized and underserved communities.
- In OEA’s analysis, the primary benefits originate in the Proposed Rule’s perceived role in reducing misdiagnoses from what OEA refers to as “problematic” laboratory developed tests (“LDTs”), which account for over 98 percent of the total benefits described in the RIA. Similarly concentrated, OEA’s estimates of the costs are largely derived from one-time and ongoing reporting, registration, and approval process requirements for LDTs. Of these costs, close to 100 percent of one-time costs and roughly 89 percent of recurring compliance costs originate in premarket approval applications, 510(k) notifications, and De Novo requirements that would apply to LDTs.[^4]
- The compliance costs OEA estimates that the Proposed Rule would impose on laboratories offering LDTs are substantial. Based on data provided in the RIA, laboratories would be required to use nearly three and a half years of their gross profits from LDTs just to be able to cover the one-time compliance costs introduced by the Proposed Rule. And this estimate does not account for the fact that gross profit excludes categories of costs that would substantially reduce what is available to laboratories to pay for these newly introduced compliance costs nor does it incorporate the actual fees laboratories would pay FDA to accompany submissions, which are considered transfers in the RIA.
- In addition to compliance costs, Circular A-4 explicitly requires agencies to consider ancillary costs in their RIAs.[^5] Further, OEA acknowledges that the significant compliance costs they estimate have the potential to force laboratories to discontinue offering certain LDTs. However, they argue they are unable to estimate these ancillary costs due to lack of data. Still, using data already presented in the RIA coupled with the approach that OEA indicates it would employ to quantify this effect reveals that the Proposed Rule would put roughly 90 percent or more of existing LDTs at risk of no longer being offered. And this assumes that all existing LDTs requiring approval would be eligible for the most cost-effective pathway, which necessitates a predicate device so is not likely to be an option for many of them, something OEA acknowledges in their analysis.
- Utilizing the same monetary estimates OEA employs in the RIA to value the benefits of extending lives reveals that the associated annual costs from lost LDTs in shortening lives would likely be double OEA’s estimate of the Proposed Rule’s annual benefits. Moreover, these recurring health costs associated with at-risk LDTs leaving the market would easily surpass, in one year, any savings associated with a reduction in the already sizable one-time approval costs because at-risk LDTs would leave the market rather than be subjected to FDA’s premarket approval process.
- Much like the RIA substantially understates the Proposed Rule’s costs, it also significantly overstates its benefits. By extrapolating benefits from only one disputed study and misapplying the results of that study to develop an estimate of lives extended by substituting FDA-approved tests for so-called “problematic” LDTs, OEA fails to adhere to Circular A-4 principles for applying benefit transfer.[^6] Even the study OEA cites indicates it is inappropriate to extrapolate to a broader set of LDTs from just their small-sample study. Further, utilizing more recent research that corrects for the errors of the flawed study on which OEA relies suggests the annual benefits are roughly one-third of what the RIA estimates.
- This does not even account for the fact that OEA’s specific approach to measuring benefits assumes that all misdiagnoses from “problematic” LDTs will be eliminated by shifting to FDA-approved tests, an assumption OEA contradicts in the RIA and is not supported in the medical literature. Employing a simpler approach that avoids this issue and allows the analysis to incorporate a larger number of medical studies examining the relative level of accuracy of LDTs and FDA-approved tests, as Circular A-4 recommends, benefits are a quarter to one-half what the RIA estimates, consistent with results from correcting OEA’s approach directly.
- Consideration of alternatives is especially important for the Proposed Rule because its considerable costs – both in complying with the rule and associated health effects from at-risk LDTs – coupled with much smaller benefits suggest that alternative, less draconian approaches may be preferred. It is notable that the current framework utilized by the Centers for Medicare & Medicaid Services (“CMS”) under the Clinical Laboratory Improvement Amendments (“CLIA”) to oversee laboratories that develop LDTs incorporates elements of an approach labeled management-based regulation in the academic literature, which is appropriately used in US regulatory contexts similar to the environment in which LDTs are developed and deployed, including by FDA itself.
- In its analysis of alternatives, OEA also briefly describes but fails to quantify net benefits for two other regulatory approaches that would still phase out the general enforcement discretion approach for LDT registration, listing, and adverse event reporting but would not subject existing LDTs to premarket review requirements. The second would also continue general enforcement discretion for LDTs receiving approval from the New York State Clinical Laboratory Evaluation Program (“CLEP”), including those developed after the final rule. Given the relevant market failure is asymmetric information, these options have the attractive quality that they feature information remedies, which Circular A-4 recommends in these types of cases. Because many of the necessary elements are already available, presenting a quantitative analysis of the benefits and costs of these alternatives should not be overly burdensome for OEA. The primary source of uncertainty would be in estimating the proportion of new LDTs that would opt for approval under New York’s CLEP rather than FDA’s processes, which could be dealt with using relative cost data or reasonable assumptions.
- Finally, Circular A-4 directs agencies developing RIAs to analyze the distributional effects of the rule. The impact of the Proposed Rule on LDT prices receives very limited attention in OEA’s RIA. Yet, for LDTs that can remain in the market, providers will be forced to raise prices to manage the burden of significant additional compliance costs. As prices rise for health care services, including diagnostic tests, because of the Proposed Rule, quantity demanded will decrease, and more so for those with higher price elasticities, including low-income as well as underinsured and uninsured individuals. Given that the latter group especially is disproportionately concentrated among minorities, they will bear more of the burden in increased mortality rates as a result. Given the Biden administration’s emphasis on broadening participation of traditionally underserved communities in the regulatory process, it would seem OEA must do much more to evaluate the distributional effects of the Proposed Rule than they currently do to fulfill adequately their obligations under Circular A-4.
- Resolving these issues – including quantifying ancillary costs, appropriately applying benefit transfer, quantifying the effects of meaningful alternatives, and considering the distributional effects of LDT price changes – will result in an RIA that adheres to basic principles outlined in Circular A-4 and reveals that, in fact, the quantified costs substantially exceed the quantified benefits of the Proposed Rule. Perhaps even more importantly, addressing these issues can allow OEA’s RIA to fulfill its role in providing a transparent view of the likely effects of the Proposed Rule such that stakeholders and the public more generally can more accurately assess whether its benefits justify its costs.
I. Background
A. Analysis Requirements for Economically Significant Rules
B. Discussion of the Central Components of OEA’s RIA
II. The RIA’s Estimate of the Proposed Rule’s Costs
A. Examining LDTs at Risk of Exiting the Market
B. Comparing Social Costs of At-Risk LDTs to the Proposed Rule’s Benefits
C. Using Industry Evidence to Substantiate Estimated Costs from Lost LDTs
III. The RIA’s Estimate of the Proposed Rule’s Benefits
A. Evaluating the Appropriateness of OEA’s Benefit Transfer Approach
B. Assessing the Benefits Associated with Shifting to FDA-Approved Tests
IV. Other Important Considerations in Preparing the RIA
A. Considering Reasonable Alternatives to FDA’s Preferred Approach
B. Separately Evaluating the Distributional Effects of the Proposed Rule
V. Conclusion
### I. Background
I was engaged by the American Clinical Laboratory Association (“ACLA”) to assess OEA’s preliminary RIA accompanying FDA’s Medical Devices; Laboratory Developed Tests Proposed Rule.¹²
I am Associate Professor of Public Policy and Public Administration at George Washington University as well as a Co-Director of the GW Regulatory Studies Center. My expertise as an academic centers on regulatory policymaking, and my research has examined a variety of topics relevant for evaluating the application of economic analysis in specific regulatory contexts, including roles that analysis plays in agency regulatory decision-making, design of informative RIAs, factors that influence rule timing and durability, and the variety of approaches that regulatory agencies employ to achieve regulatory goals. In addition to publications in leading academic journals and edited volumes focused on regulation, public policy and administration, political science, and economics, I am the author of the Cambridge University Press book, *Structured to Fail? Regulatory Performance under Competing Mandates*, and a co-editor of the University of Pennsylvania Press volume, *Does Regulation Kill Jobs?* I hold a PhD in public policy from Harvard University, an MBA from the University of Chicago, and a BA in economics from Davidson College.
In conducting my examination, I reviewed the analysis prepared by OEA from the perspective of the procedures that FDA, or any executive branch regulatory agency, is to follow when developing an RIA to support a proposed rule. In performing this analysis, I was supported by staff of Global Economics Group, who worked under my direction.
My overarching conclusion is that the RIA does not fulfill the standards for economic analysis that federal agencies are to follow in several key areas. The discussion of the Proposed Rule’s potential costs focuses primarily on compliance costs that laboratories will face in complying with the Proposed Rule if it is finalized while largely ignoring and failing to quantify, with available data, the ancillary and substantial negative health-related and mortality costs that will result from imposing a new regulatory framework on LDT providers. Additionally, the RIA makes inappropriate use of a benefit transfer approach to extrapolate benefits from only one disputed study and misapplies the results of that study to develop an estimate that significantly inflates the Proposed Rule’s benefits.
These concerns, coupled with limited quantitative consideration of reasonable alternatives and key distributional effects, lead to an RIA that significantly overstates benefits, dramatically understates costs, provides limited ability to evaluate alternative approaches relative to the Proposed Rule, and obscures significant negative distributional effects on uninsured and traditionally underserved communities. Resolving these issues will result in an RIA that adheres to basic principles outlined in OMB guidance and reveals that, in fact, the quantified costs substantially exceed the benefits of the Proposed Rule. Perhaps even more importantly, addressing these issues can allow OEA’s RIA to fulfill its role in providing a transparent assessment of the likely effects of FDA’s Proposed Rule such that stakeholders and the public more generally can more accurately assess whether its benefits justify its costs.
#### A. Analysis Requirements for Economically Significant Rules
OMB’s Circular A-4 provides a set of principles to guide executive branch agencies in their preparation of RIAs, which are required by Executive Orders 12866 and 14094 for all rules deemed by OIRA to be 3(f)1 significant in order to demonstrate that the benefits of that rule justify its costs.¹³ OIRA determined that FDA’s Proposed Rule is 3(f)1 significant.¹⁴
These principles, as well as best practices established in the academic literature, offer clear guidance on the elements to be included in an RIA that fulfills the requirements of the executive orders.¹⁵ These elements include:
1. A discussion of the need for the rule, based on the problem the rule seeks to remedy;
2. Consideration of not just of the rule’s direct benefits and costs but also the ancillary benefits and indirect costs or countervailing risks;
3. Careful consideration of how studies are selected if benefit transfer methods are used, recognizing that other approaches to valuing benefits are generally preferred;
4. Consideration of reasonable alternatives to the approach advocated by the agency; and
5. Examination of the distributional effects of the rule in a separate analysis.
#### B. Discussion of the Central Components of OEA’s RIA
The primary source of benefits in OEA’s preliminary RIA derives from the Proposed Rule’s role in reducing misdiagnoses from what they refer to as “problematic IVDs offered as LDTs.”¹⁶ OEA suggests that these annual benefits, which they estimate total $26.4 billion or $39.6 billion (depending on the choice of discount rate), will result from improved health outcomes in the form of reduced baseline mortality risk.¹⁷ These benefits originate from an expected reduction in misdiagnoses from in-vitro diagnostic products (“IVDs”) offered as LDTs and represent over 98 percent of the total benefits presented in the RIA.¹⁸
OEA’s estimates of the costs of the Proposed Rule are similarly concentrated, with the majority derived from focusing on the compliance costs that would be imposed on laboratories associated with one-time and ongoing reporting, registration, and approval process requirements. Close to 100 percent of the $35.5 billion primary estimate of one-time costs and 89 percent of the $4.2 billion primary estimate of recurring compliance costs derive from the premarket review, 510(k), and De Novo requirements that would apply to LDTs within four years from FDA’s publication of the final phaseout policy.¹⁹
### II. The RIA’s Estimate of the Proposed Rule’s Costs
To put the Proposed Rule’s one-time compliance costs in perspective, OEA’s primary estimate of $35.5 billion is over 1.2 times their primary estimate of 2023 annual LDT revenues, which amount to $28.6 billion.²⁰ On average, publicly traded firms offering LDTs spend 64 percent of their revenue providing their services; the remaining 36 percent of revenue is the margin of the services before operating costs, such as overhead, salaries, research and development, and administrative expenses.²¹ If one were to apply a gross margin of 36 percent (which significantly overstates the net economic margin from LDTs available to pay compliance costs) to OEA’s primary estimate of 2023 annual LDT revenues, laboratories would be required to use nearly three and a half years of those gross margin profits on LDTs just to be able to cover the one-time compliance costs introduced by the Proposed Rule. And, as suggested, this does not even account for the fact that gross margin profits substantially overstate the actual cash after expenses that would be available to laboratories to pay for these newly introduced compliance costs. Moreover, these figures do not include the actual fees laboratories would need to pay to FDA to accompany their submissions for existing LDTs, which OEA estimates would total over $1.5 billion but are considered transfers since they represent revenue for FDA.²² Perhaps most importantly, these costs represent just a fraction of the Proposed Rule’s total potential costs.
#### A. Examining LDTs at Risk of Exiting the Market
In addition to compliance costs, explicitly considering countervailing risks or indirect effects is required by Circular A-4 and critical to gain a more complete understanding of the likely effects of the Proposed Rule.²³ This is especially true if the RIA is to allow stakeholders and the broader public to assess whether the benefits of the proposed rule justify its costs as Executive Order 12866 mandates.²⁴ OEA acknowledges the possibility that laboratories “may choose to exit the market or discontinue certain IVDs offered as LDTs due to compliance costs.”²⁵ In addition, OEA suggests in the RIA an approach for estimating these costs by employing a similar methodology to what they utilized in their analysis of a previously published proposed rule, Medication Guides: Patient Medication Information. Still, OEA indicates they are unable to estimate these indirect costs due to lack of data.
However, the information that is already presented in the RIA allows one to develop a sense of the magnitude of these costs. OEA’s primary estimates for 2023 annual industry revenue and the number of LDTs on the market are $28.6 billion and 80,400 LDTs, respectively, suggesting that the average LDT generated $356,000 in annual revenue in 2023. Even before considering the costs associated with performing these tests, it is instructive that the average LDT’s annual revenue falls well below OEA’s primary estimate of $4.38 million for a premarket application (“PMA”) for approval as well as $565,000 for a De Novo classification request. OEA estimates that FDA approval for a 510(k) submission ranges from $275,000 to $526,000 depending on the complexity of the study. Therefore, many LDTs will have less annual revenue than the one-time cost for initial approval, and these costs ignore the actual fees paid by the laboratory to FDA, which is considered a transfer for purposes of OEA’s analysis.
The large one-time costs for approval relative to the revenues of LDTs means that much of the industry is at risk of exiting the market. In their RIA assessing the economic effects of FDA’s Medication Guides: Patient Medication Information proposed rule – which OEA indicated would inform their analysis for at-risk LDTs under the Proposed Rule – OEA specified that the threshold for a product to be at risk is one that does not have enough sales “to cover the cost of [Patient Medication Information] without resulting in negative accounting profit.” OEA states, “For any product with positive annual sales less than its corresponding threshold…we determine that product to be at risk of exiting the market if it is not granted a waiver or extension of the requirements of [Patient Medication Information].”
Applying OEA’s threshold for at-risk products to the case of LDTs means tens of thousands of tests would be at risk even before considering that accounting profits are a fraction of the revenue they generate. Still, following OEA’s proposed approach to focus on using gross margin to identify at-risk LDTs reveals even more clearly how much of the market would be at risk from the Proposed Rule. Assuming a gross margin of 36 percent, which, as described, represents a significant overestimate of the net economic margin from LDTs available to pay compliance costs, the yearly gross profit for the average LDT is $128,160, still well below the cost of any approval process required by FDA.
Even considering the assumed sales growth rate used by OEA in the RIA, which would mean that the average LDT would generate $164,469 in gross margin by 2028, when all existing LDTs would be subjected to premarket review requirements, significantly more than 50 percent of tests would be at risk of no longer being offered employing OEA’s established criterion. Stated differently, the gross profit of the average LDT would be less than 60 percent of the estimated cost of even the most cost-effective pathway to approval, the 510(k) with method comparison study, which requires a predicate device so is not likely to be an option for many LDTs. Moreover, this simple calculation does not even incorporate the fee that laboratories are required to pay as well as the reality that just as revenue may grow, so will the costs associated with preparing for the approval process.
Appealing to OEA’s Tables A.2 and A.3 in Appendix A which contain estimates of LDT revenue and volume by firm size to support OEA’s required analysis under the Regulatory Flexibility Act, one finds that the average LDT does not generate enough gross profit to avoid being at risk by OEA’s definition for any category of firm size. Assuming the same gross margin rate as before, average gross profit is $57,445 for LDTs from laboratories up to $100 million in annual revenue, and $259,541 for LDTs from laboratories over that size.
Those same data allow one to estimate the actual percentage of LDTs that may be at risk. Applying the assumed sales growth rate used by OEA in the RIA for LDT revenue and computing average gross profit across all size categories in 2028 when LDTs would be subject to the review requirements under the Proposed Rule, one can compute the estimated standard deviation of the distribution. Doing so and assuming LDT gross profits follow a normal distribution suggests that just over 90 percent of the universe of existing LDTs might be at risk because their gross profit is below the estimated cost of the 510(k) with method comparison study approach, even if costs are assumed to grow at only half the rate of revenues and OEA’s estimate of the associated submission fee is weighted by firm size. And the associated percentage of LDTs at risk climbs to close to 95 percent if one simply applies OEA’s 2023 data directly to perform the calculations, comparing the estimated 510(k) with method comparison cost including a weighted average of the associated submission fee against OEA’s described distribution of laboratory LDT revenue.
Further, even these estimates understate the number of LDTs at risk since they rely on gross profit rather than operating profit or, even more accurately, economic profit. Gross margin does not incorporate the full set of costs facing a firm, such as overhead, research and development, and opportunity cost, that economic profit or even operating profit would consider. As OEA even notes in its RIA assessing the economic effects of FDA’s Medication Guides: Patient Medication Information proposed rule, using gross profit “in the calculations results in threshold [revenue] values that are smaller than if we were to use economic profit. Because of this, our estimates of at-risk products may represent lower bounds.”
#### B. Comparing Social Costs of At-Risk LDTs to the Proposed Rule’s Benefits
In its computation of compliance costs, OEA assumes, without explanation, that only 50 percent of LDTs would require a premarket submission, with the other 50 percent exempt from the requirements. In fact, in the two places in the RIA where this assumption is stated, the other section is referenced, with no support provided in either place.
Nevertheless, assuming this assumption is accurate, it would mean that 40,200 of the estimated 80,400 LDTs would require a premarket submission. To gain a sense of the magnitude of the health costs connected to the loss of roughly 90 percent of the existing stock of LDTs subject to approval under the Proposed Rule, one can apply OEA’s estimates of the social value per case of an accurate diagnosis, which they use to value the benefits of the Proposed Rule. Much like FDA asserts in its analysis of the benefits of shifting from LDTs to FDA-approved tests in extending patient lives, an extensive medical literature highlights the critical role that LDTs play in delivering accurate diagnoses to save patients with potentially life-threatening conditions. Thus, not having those potentially life-saving tests at all, or forcing medical personnel to shift to tests less appropriate for detecting the underlying condition accurately, can result in premature mortality in much the same way that having a more accurate test can extend a patient’s life, as OEA suggests.
Applying OEA’s computation of the social value of an accurate diagnosis, and assuming that each lost LDT results in just one additional life that is not extended on average because the test is no longer available that year, the annual health cost in 2022 dollars would be...
between $52.8 and $79.6 billion using OEA’s central estimates. These calculations follow from multiplying the number of LDTs that would be at risk of exit based on OEA’s stated threshold by the per case value of an accurate diagnosis, as described by OEA. The variation in the computation results from whether the estimates of the value of a statistical life year are computed using either a three or seven percent discount rate. Further, these costs assume that OEA’s estimates of how lives are extended through an accurate diagnosis—which they derive by focusing on cancer specifically—are applicable to a broader range of conditions for which LDTs are used. Of course, this is precisely what OEA assumes in their analysis of the benefits of the Proposed Rule as well.
The bottom line is that, under these relatively conservative assumptions, the annual health costs associated with at-risk LDTs leaving the market would easily surpass any savings associated with a reduction in one-time approval costs because those at-risk LDTs would not be subjected to premarket approval, given they were no longer being offered at all. Stated differently, if the proposed rule’s one-time costs associated with premarket approval requirements were even reduced by 90 percent, equivalent to $32 billion, due to LDTs exiting the market, the resulting reduction would still be substantially less than the estimated societal costs from lives shortened in one year of $52.8 to $79.6 billion because of the Proposed Rule. And, unlike the one-time compliance costs, the costs associated with premature mortality from lost LDTs are recurring welfare costs, meaning these costs are incurred every year.
In the end, there is simply not enough LDT revenue dollars to move a significant portion of LDTs through the approval process. Given what OEA has proposed as the distribution of LDTs that would need PMA, 510(k), and De Novo approvals—the one-time submission costs and fees to get existing LDTs through approval would total $33.5 billion. With only $28.6 billion in annual revenue and $10.3 billion in gross margin, at most there would only be enough revenue to move 2,238 of OEA’s estimate of 4,020 LDTs through the PMA approval process before every single dollar of revenue would be exhausted—leaving 94 percent (or 37,962) of LDTs without any funds to attempt approval. And this assumes that the 50 percent of LDTs, or 40,200, that OEA claims would not need to go through the FDA approval process collectively do not earn a single dollar of revenue, obviously an illogical assumption.
Using the described cost estimation approach derived from data already presented in OEA’s RIA, it becomes clear that at least one source of cost that OEA only discusses qualitatively actually exceeds the costs that are estimated. These costs associated with lost LDTs also exceed OEA’s comparable estimate of the Proposed Rule’s annual benefits, which amount to $26.8 billion with a three percent discount rate and $40.0 billion under a seven percent discount rate. Adding in the one-time benefits that OEA computes, which range from $4.1 billion to $6.8 billion using a three or seven percent discount rate respectively, the annual cost derived solely from lost LDTs would substantially exceed the benefits in any given year.
Further, the computation of the costs of lost LDTs presented here, whose size already exceeds the estimated benefits of the Proposed Rule, does not even consider the related costs of lost innovation for those LDTs that remain in the market. It is quite common for an LDT to be modified during the course of its use to improve the quality of the test and adapt to changing conditions. A 2018 study published in JAMA Oncology reported that more than 60 percent of the laboratory participants in their study of the relative performance of FDA-approved and lab-developed oncology tests reported modifying their FDA-approved test “to broaden clinical practice, rendering them LDTs.” Under the Proposed Rule, these improvements would, in most cases, require FDA approval, thus significantly reducing the number of modifications that could have been made given the financial costs and time connected to doing so.
#### C. Using Industry Evidence to Substantiate Estimated Costs from Lost LDTs
The described estimates associated with the potential for lost LDTs are consistent with data from laboratories competing in the LDT market. Responses from an informal survey of representative members of the ACLA revealed that the overwhelming majority of LDTs they offer gross less than $5 million in revenue per year. Using the previously described estimated gross margin percentage, annual gross profit for these tests thus amounts to several times less than OEA’s estimate of the cost of taking any of these tests through the premarket approval process. In reality, annual revenue from most LDTs is much less than even this simple estimate might suggest. For example, one laboratory company reported that over 40 percent of the substantial set of LDTs that the company offers generate revenue less than even the fiscal year 2024 510(k) user fee of $21,760.
These data from industry participants reveal that the previously discussed calculations using OEA’s data—which suggest both that a large majority of LDTs offered in the market would be at risk and that the associated welfare costs under FDA’s proposed approach to oversight would be substantial—are decidedly reasonable. These at-risk assays would range from LDTs important in determining the care for patients with hematologic disease to those distinguishing rare forms of anemia from other blood conditions; and from tests used for the diagnosis of rare inherited metabolic diseases to tests available to help diagnose Rhett Syndrome, a rare neurological disorder that causes the loss of motor and language skills most commonly in girls.
In sum, by solely focusing on compliance costs in the RIA, OEA has failed to monetize a critical category of costs that has the potential for health effects resulting from LDTs exiting the market that substantially exceed the supposed benefits of the Proposed Rule. This represents a failure of the RIA to meet the standards outlined in Circular A-4 for economic analysis in rulemaking. Conducting an RIA requires consideration of the direct and indirect effects of that regulation, including any potential unintended consequences of the proposal; moreover, an RIA must treat benefits and costs in a symmetric way in performing the analysis. Thus, it is not sufficient to simply consider possible health benefits associated with eliminating or reducing the number of, in FDA’s words, potentially “problematic” LDTs without simultaneously considering the costs connected to the potential loss of welfare-enhancing and lifesaving LDTs that might no longer be offered. These costs arise because of the significant financial costs associated with complying with the regulatory framework relative to the revenue generated by laboratories in producing and performing LDTs.
### III. The RIA’s Estimate of the Proposed Rule’s Benefits
Much like with the computation of costs, OEA’s assessment of the benefits of the Proposed Rule also presents several issues. As described, over 98 percent of the total quantified benefits result from the Proposed Rule’s suggested ability to reduce misdiagnoses from “problematic” LDTs. OEA estimates a baseline annual total of 19,000 fatal cases that receive a misdiagnosis due to “problematic” LDTs, all of which they claim would be prevented by the Proposed Rule. To reach that estimate, OEA starts with a primary estimate of 160,000 misdiagnosis fatalities associated with conditions other than heart disease. This figure is then reduced by 50.0 percent to account for testing that occurs outside of IVDs and then another 50.0 percent to account for testing done by IVDs that are not LDTs. Finally, of the remaining misdiagnoses attributable to LDTs, OEA assigns 47.4 percent as their estimate of the probability the misdiagnosis resulted from an LDT that is “problematic,” yielding 19,000 misdiagnoses from “problematic” LDTs. They determine that each misdiagnosis avoided has a benefit value of $1.6 million at a three percent discount rate and $2.2 million at a seven percent discount rate—resulting in aggregate annual benefits of $26.3 billion and $39.5 billion depending on the discount rate used.
Among other issues in their computation of benefits, OEA does not adhere to established principles for preparing RIAs in two critical areas, which results in estimates of the health benefits of the Proposed Rule that are substantially inflated. First, the RIA makes inappropriate use of a benefit transfer approach to extrapolate benefits by using a single disputed study of LDT analytical accuracy, relative to including references to additional research that suggest the
#### A. Evaluating the Appropriateness of OEA’s Benefit Transfer Approach
One approach to valuing benefits in an RIA is to employ what is known as benefit transfer. Benefit transfer uses existing estimates of benefits from other studies and applies them to a new context, which in rulemaking means the context in which the rule is being contemplated. As described in Circular A-4, this method should “be treated as a last-resort option and not used without explicit justification” for a variety of reasons, including that the findings of the studies may pertain to a particular setting that is not reflective of the circumstances associated with the rulemaking.^47
In evaluating studies to include, Circular A-4 advises that “selected studies should be based on adequate data, sound and defensible empirical methods and techniques.” Moreover, populations represented in the research and the regulatory context should be similar, and the “market size (e.g., target population) between the study site and the policy site should be similar.” For example, the Circular notes that “a study valuing water quality improvement in Rhode Island should not be used to value policy that will affect water quality throughout the United States.”^48
In the Proposed Rule, the assumption that is in large part responsible for the quantified benefits is OEA’s estimate that 47.4 percent of LDTs are “problematic.”^49 To arrive at that figure, OEA relies on a 2022 study published by Pfeifer et al. in the American Journal of Clinical Pathology, in which the authors examined performance for 19 laboratories employing LDTs to determine whether a patient was well-suited for a specific type of therapy for metastatic colorectal cancer.^50 The authors found that 9 of the 19 labs, or 47.4 percent, had five or more errors, which were predominately false negatives and which reflected an error rate greater than the statistical inaccuracy of a companion FDA-approved test. OEA then uses a benefit transfer approach to extrapolate from that result to assert that 47.4 percent of all LDTs are “problematic” and, thus, a significant number of lives associated with preventable misdiagnosis could be extended under the Proposed Rule.^51
OEA’s approach raises significant issues. It is inappropriate to use a single, small study focused on one disease to characterize the performance of all LDTs across all testing disciplines. Pfeifer et al. (2022) explicitly recognize in their research the issues in making a generalized extrapolation to a large population of laboratories from their work in suggesting, “our study consisted of a relatively small number of nonrandomly selected laboratories….These laboratories and their respective LDTs may not represent the broader landscape of laboratories that perform clinical NGS in CLIA-certified environments.”^52
Perhaps even more importantly, the Pfeifer et al. (2022) study is already outdated. A more recent 2023 analysis of the same SPOT/Dx pilot data by Zehir et al. (2023) concludes that the SPOT/Dx pilot had multiple design and analytic differences with established proficiency testing programs. After remedying those issues, the authors reach a fundamentally different conclusion, explaining that LDTs exhibit “excellent” analytical performance.^53 Zehir et al. (2023) explain that most of the false negatives reported by laboratories in the SPOT/Dx pilot were the result of variants being tested with mean variant allele fractions (“VAFs”) below the participant laboratories’ limit of detection (“LOD”). As the authors’ note, under the CLIA standards, laboratories are only expected to detect and report variants with criterion standard VAFs at or above their laboratory’s assay LOD. Once laboratories are evaluated against the test results they can be expected to detect and report, more than half of what OEA determines to be “problematic” LDTs are no longer “problematic.” In fact, Table 3 of Zehir et al. (2023) indicates that only four of 19 LDTs reported five or more false negatives, not nine of 19 as reported by Pfeifer et al. (2022).^54
Because OEA heavily relies on Pfeifer et al. (2022) in their estimates of benefits, this seemingly small change in the analysis of the SPOT/Dx pilot data has a large impact on the aggregate benefits of the Proposed Rule. Shifting from nine “problematic” LDTs to four of 19 LDTs – meaning 47.4 percent to 21.1 percent – cuts out over half of the expected health benefits of the Proposed Rule. With this correction, the aggregate benefits range from $11.7 to $17.6 billion, not $26.3 to $39.5 billion as reported in the RIA.
However, this is not the only problem that results from OEA’s reliance on Pfeifer et al. (2022). Zehir et al. (2023) also note that a little over half of the false negative test results in the SPOT/Dx pilot were related to multinucleotide variants (“MNVs”) that are extremely rare or never observed in reality. As Zehir et al. (2023) describe, “[a]nother important difference between the SPOT/Dx pilot and PT programs was the inclusion of a disproportionately high number of MNVs. KRAS or NRAS MNVs are so rare that there are no examples in the AACR GENIE dataset (public release v12) of 14,328 colorectal carcinomas, yet they comprised nearly a quarter (12/54; 22.2%) of the variants in the pilot.”^55
By extrapolating from Pfeifer et al. (2022), OEA is disproportionately relying on false negatives from extremely rare or never observed MNVs in colorectal cancer to then determine what portion of the general population of tens of thousands of LDTs are “problematic.” This application of benefit transfer fails to adhere to the Circular A-4 principles on several dimensions, including choosing studies “based on adequate data, sound and defensible empirical methods and techniques,” those in which the “study context and policy context…have similar populations,” and those where the associated “good, and the magnitude of the change in that good [are] similar in the study and policy contexts.”^56 As Zehir et al. (2023) notes, the type of generalizing employed in the RIA is even a problem in evaluating oncology testing, let alone all LDTs:
Results obtained from a small pilot study focused on one disease with rare or never-reported variants at low VAFs cannot be generalized to overall laboratory performance for all types of cancer. The pilot results only reflect laboratory performance for the study samples, which represent a minute percentage of samples encountered in routine clinical practice. As stated by Harada and Mackinnon, although the MNVs in the pilot “…serve the purpose of challenging a laboratory’s informatics pipeline, they do not simulate a real-world situation,” and the study design “…does not fully align with pan-tumor genomic analysis, which most laboratories are currently implementing.”...The conclusions of the SPOT/Dx pilot about variable accuracy in the detection of genetic variants among some LDTs only apply to the samples with uncommon mutations at low-level VAFs included in the pilot and not to the performance of NGS LDTs overall.^57
Of the four remaining laboratories with alleged analytical accuracies significantly lower than the FDA-approved companion diagnostic, one of them had all of their false negatives derive...
from the extremely rare or never observed MNVs that Zehir et al. (2023) and others conclude cannot be applied to real-world situations. With this correction, only three remaining LDTs out of 19 demonstrate an analytical difference with the FDA-approved companion diagnostic. As a result, the benefits from OEA’s extrapolation fall to a range of $8.8 billion to $13.2 billion, meaning that annual benefits are actually one-third of what was estimated by OEA.
#### B. Assessing the Benefits Associated with Shifting to FDA-Approved Tests
In addition to more accurately characterizing the extent to which “problematic” LDTs exist, OEA must also consider the analytical accuracy of FDA-approved tests relative to the baseline of no change in the regulatory framework to be able to adequately measure the benefits of the Proposed Rule. As described, OEA readily admits that no test is perfect, indicating “an IVD that yields a false result in an individual case is not necessarily a problematic IVD (indeed, no test is perfect 100% of the time).” As a result, benefits from improved testing outcomes should be measured based on the incremental improvements in accuracy rates.
However, rather than evaluating incremental improvements, OEA’s approach to measuring benefits assumes that all misdiagnoses from “problematic” LDTs will go away under the proposed regulatory regime. Still, the RIA provides no basis for this assumption nor is it at all supported in the medical literature. Moreover, the approach OEA employs, using the probability of being a “problematic” LDT in its benefit calculation, is unnecessary and simply adds a complicated assumption to try to estimate.
OEA could have avoided this step altogether simply by comparing the analytical accuracy of LDTs generally to FDA-approved diagnostics and used that as the basis for determining how many misdiagnoses could be avoided. For example, if LDTs have an analytical accuracy of 97 percent compared to 98 percent for FDA-approved diagnostics, then it would be reasonable to expect that roughly one-third of the misdiagnoses could be avoided (by moving from a three percent error rate to a two percent error rate).
Academic studies, including those referenced in the RIA, find that the analytical accuracy differences between LDTs and FDA-approved diagnostics are actually not far apart and, as a result, suggest that benefits of the Proposed Rule are far lower than what OEA proposes. For example, in their study that appeared in JAMA Oncology, Kim et al. (2018) find a high rate of accuracy and comparable performance of LDTs and FDA-approved diagnostics for three common oncology analytes: BRAF, EGFR, and KRAS. The overall accuracy for LDTs was 97.1 percent relative to 97.5 percent for FDA-approved diagnostics.
Similarly, a 2019 study by Moncur et al. (2019) compares the performance of different assay methods on College of American Pathologists proficiency testing for variant analysis for BRAF, EGFR, and KRAS. Their findings demonstrate the high degree of accuracy and comparable performance across all laboratories, regardless of methodology. In fact, the authors report a percentage of acceptable proficiency testing for FDA-approved diagnostics of 97.5 percent and 97.2 percent for LDTs.
Moreover, even Pfeifer et al. (2022) – the paper that OEA relies on for other aspects of its benefits calculation – notes that the FDA comparison is not analytically perfect, suggesting, “[t]he CDx has a published positive percent agreement of 98.7% and negative percent agreement of 97.6%.” Using the Zehir et al. (2023) reanalyzed data, the negative percent agreement rate of the LDT bias analyzed was 96.8 percent for single-nucleotide variants.
Using estimates from these studies suggests the benefits of moving from LDTs to FDA-approved diagnostics could marginally improve analytical accuracy from 97.2 percent to 97.5 percent on the lower end – which would be expected to reduce misdiagnosis errors by 10.7 percent. Or, on the high end, analytical accuracy could be improved from 96.8 percent to 97.6 percent using Pfeifer et al. (2022) and Zehir et al. (2023) – which corresponds with an expected reduction in misdiagnosis errors by 25 percent. Applying these ranges to OEA’s baseline annual estimate of misdiagnosis fatalities from LDTs suggests the resulting decreases in misdiagnoses correspond to only 22.6 percent or 52.8 percent of OEA’s estimate, further indicating a substantial drop in benefits, which now range from $6.0 to $20.9 billion at the upper bound, corresponding to roughly a quarter to half of what OEA suggests.
Importantly, in addition to being a more direct method and avoiding a need to unrealistically assume that FDA-approved tests have accuracy rates of 100 percent, the alternative approach described also considers a breadth of publications as the guidance in Circular A-4 suggests an agency applying benefit transfer should do, relative to using just one disputed study. Moreover, the estimates of lives extended are consistent with the described corrected analysis using a combination of Pfeifer et al. (2022) and Zehir et al. (2023).
### IV. Other Important Considerations in Preparing the RIA
In addition to computing benefits and costs of the Proposed Rule, agencies are required in preparing an RIA to assess reasonable alternative regulatory approaches. In doing so, the agency must evaluate the benefits and costs, both quantitatively and qualitatively, of the main alternatives identified by the analysis in addition to its proposed rule. Moreover, because benefit-cost analysis focuses on economic efficiency and can obscure how benefits and costs are allocated among different sub-populations, Circular A-4 further directs agencies to “provide a separate description of distributional effects…so that decision makers can properly consider them along with the effects on economic efficiency.” Distributional effects should be “described quantitatively to the extent possible” when they “are thought to be important.”
#### A. Considering Reasonable Alternatives to FDA’s Preferred Approach
According to Circular A-4, alternatives that the agency “should consider” include contemplating different approaches to enforcement, varying the level of stringency, utilizing different regulatory instruments, particularly those that do not involve design standards and direct controls, and applying different standards for different types of regulated entities including those based on size or geography. Consideration of alternatives is particularly important for FDA’s Proposed Rule because, as described, its considerable costs, both in complying with the rule as well as the associated health effects from at-risk LDTs, raise questions around whether the benefits justify the costs.
In its assessment of alternatives in its RIA, OEA primarily focuses on variation in the timeline for compliance. In fact, these are the two alternatives for which the analysis provides quantitative estimates of both benefits and costs. The first alternative shortens the phaseout period while the second alternative lengthens it. Because the regulatory approach otherwise remains the same, the computed changes in benefits and costs derive primarily from differences in when they are realized and the associated effects of discounting. As a result, the quantitative
estimates are qualitatively similar to those for the Proposed Rule. Any analysis implementing the previously discussed recommendations to reassess the benefits and account for health-related costs connected to lost LDTs would yield quantitative estimates similar to what is described in this letter. For these reasons, focusing on the timeline for compliance is not all that helpful as a pathway to suggest meaningful alternatives that foster transparency and public participation in the rulemaking process for the Proposed Rule.
A developed academic literature on regulatory politics and policy has examined the breadth of regulatory instruments agencies may consider that can improve upon the limitations of more traditional, direct controls, of which FDA’s Proposed Rule is one example.72 One of these approaches, management-based regulation or enforced self-regulation, requires regulated entities to develop plans to manage risks associated with their operations to flexibly achieve regulatory objectives.73 After developing their plans, these same organizations are required to receive the associated regulator’s approval. From the regulator’s perspective, employing management-based regulation is most appropriate when the regulated community is characterized by a large number of heterogeneous entities with regulated outputs that are difficult to observe and monitor. This is a set of circumstances that aptly characterizes the environment in which LDTs are developed and employed.
It is notable that the current framework utilized by CMS under CLIA to oversee laboratories, including those that develop LDTs, has elements of a management-based regulatory framework. Moreover, it is an approach that is actively employed by FDA itself in at least one other similar context, food safety regulation.74 For example, CMS’ regulatory approach focuses attention on the operations of the laboratory and qualifications and training of the associated staff. It imposes on laboratories the requirement that they develop and implement quality control procedures “to monitor the accuracy and precision of the complete testing process.”75 Through its Individualized Quality Control Plan (IQCP) program, laboratories also have the opportunity to tailor their quality control plans to the realities of their “unique testing environments and patients.”76
In so doing, the current regulatory framework employed by CMS for LDTs shares similarities, both in its design as well as in the characteristics of the associated regulated laboratories, to other US contexts in which regulators are currently employing management-based regulation effectively. These include the aforementioned FDA and the US Department of Agriculture’s Food Safety Inspection Service for food production and the Occupational Health and Safety Agency for industrial chemical manufacturing to promote safe operations in their respective policy domains.77 Thus, CMS’ current approach to regulating LDTs is certainly not without precedent in similar contexts. CMS’ regulatory approach adds additional elements as well. For example, in the current regulatory environment, LDTs are also subjected to proficiency testing to ensure analytical validity and periodic CMS laboratory inspections that are characteristic of some, but not all, management-based regulatory environments.
Beyond considering variation in the compliance timeline, OEA also briefly describes but does not attempt to quantify net benefits for two other regulatory approaches that would still phase out the existing general enforcement discretion approach for LDTs with respect to certain regulatory requirements connected to the Proposed Rule, including registration, listing, and adverse event reporting.78 Moreover, they would still mandate that new LDTs as well as existing LDTs that undergo changes receive FDA approval. However, they would not subject LDTs in existence at the time of the final rule to premarket review requirements. In addition, the second of these two regulatory alternatives would also continue general enforcement discretion for LDTs that receive approval from the New York State’s CLEP, even LDTs developed after the final rule.79
One attractive element of these latter two alternatives is that they consider the economic market failure the Proposed Rule attempts to address and tailor the approach to more specifically remedy that issue. Although not identified by OEA, the market failure in this case is asymmetric information, which as described in Circular A-4, suggests “informational remedies will often be preferred,” as they provide “consumers a greater choice than a mandatory product standard or ban,”80 which is what FDA is instead proposing. For example, by exempting many LDTs from premarket review requirements while retaining labeling requirements under stage two, FDA can specifically address the failure using a relatively lower cost approach, as OEA’s primary estimates of $2.75 million in one-time and $220,000 in recurring compliance costs associated with the labeling requirement suggest.81
Much like the Proposed Rule, quantifying the benefits and costs of these two alternatives exempting existing LDTs from premarket review would likely still yield negative net benefits, at least after accounting for the sizable indirect costs associated with at-risk LDTs and a more reasonable application of benefit transfer in assessing the implications of eliminating “problematic” LDTs. However, the magnitude of the imbalance between costs and benefits is almost sure to shrink, meaning that net benefits will be relatively less negative, given they avoid the one-time compliance costs associated with the proposed rule. OEA assumes that the one-time compliance costs would be eliminated through these regulatory approaches because they largely exempt existing LDTs from premarket review, 510(k), and De Novo requirements.82 Further, at least for the first of these two alternatives, OEA estimates that ongoing annual costs would be between 51 and 58 percent of those associated with the Proposed Rule.83
Presenting a full analysis of the benefits and costs of these alternatives should not be overly difficult for OEA, given that many of the elements of that analysis are already available. For example, considering the alternative that would exempt from premarket review requirements existing LDTs as well as new LDTs that have obtained New York State approval, the primary source of uncertainty would be in estimating the proportion of new LDTs that would opt for approval under New York’s CLEP rather than FDA’s premarket approval processes.84 This information could be derived by comparing the relative costs of FDA and CLEP test approval, the latter of which is publicly available.
Even absent these data, a conservative analysis could simply assume, as OEA’s existing discussion in the RIA suggests, that this alternative would not impose compliance costs on the proportion of LDTs that opt to submit to CLEP in the existing environment. Assuming the remaining LDTs would be indifferent between undergoing FDA or New York State approval processes, the analysis can proceed by developing the key elements associated with the analysis of the Proposed Rule for these remaining tests. This includes estimating the number of new LDTs that would be at risk and the associated health costs, the compliance costs imposed on those that would still be offered, and the benefits associated with FDA or New York State approval with regard to the possibility for fewer false negative tests.
#### B. Separately Evaluating the Distributional Effects of the Proposed Rule
Often those who bear the costs of a regulation are not the same as those who enjoy its benefits. Moreover, a simple focus on net benefits in an RIA does not allow a policymaker the ability to consider distributional effects in their decision calculus. To account for this, Circular A-4 directs agencies preparing RIAs to analyze the distributional effects of the proposed rule as well. The phrase “distributional effect” references the effect a proposed rule has on sub-groups of the population or economy, including groups divided by income, race, sex, industry, or geography.85
OEA’s RIA offers limited discussion of distributional effects. The RIA does note that existing health inequities could be exacerbated or ameliorated. However, it fails to address with
any specificity the sub-groups that are at risk.
Still, it seems clear that a disproportionate amount of the Proposed Rule’s costs will be imposed on vulnerable individuals, including those with rare diseases, low-income individuals, and racial minorities.
If finalized, the Proposed Rule will lead to consolidation in the testing market and reduced competition as LDTs are forced to leave the market as they are no longer economically feasible. It is notable that the effect of the Proposed Rule on LDT prices receives limited attention in OEA’s RIA, with brief qualitative discussions in only a few places in the document.
Yet, for the LDTs that can remain in the market, providers will be forced to raise prices to handle the additional burden of significant additional compliance costs to allow those LDTs to remain economically viable.
As prices rise for health care services, including diagnostic tests, the law of demand assures that a measurable decrease in demand will occur for those services (even for insured individuals).
Importantly, low-income individuals with higher price elasticities will bear more of the burden of the Proposed Rule by taking on more of the mortality costs from price increases, as they cut back on using medical services.
Similarly, those patients that are uninsured will most feel the impact of higher prices and will be more likely to opt out of diagnostic testing. Rates of uninsurance disproportionately concentrate on minority individuals and communities. For example, the US Census estimates that 8.3 percent of Black and 17.9 percent of Hispanic individuals do not have insurance, relative to 4.9 percent for White individuals.
Perhaps those most at risk under the Proposed Rules are the vulnerable individuals that fall in subgroups of people with rare diseases. Lower volume tests will be most at risk of market exit, reduced competition, and price increases.
In light of the large compliance costs relative to the revenues of LDTs, to fulfill its obligations under Circular A-4, it would seem that OEA must evaluate the distributional effects of the Proposed Rule to a much greater extent than they currently do, taking into account declines in market access to LDTs and changes in demand for services from increases in prices. This is perhaps even more important given OIRA’s recent emphasis on broadening participation in the regulatory process in response to President Biden’s Executive Order 14094, especially among traditionally underserved communities such as those that will be significantly affected by the Proposed Rule.
### V. Conclusion
OEA’s RIA to accompany FDA’s Proposed Rule fails in certain important areas to adhere to best practices as described in OMB’s Circular A-4, as well as the accompanying literature considering the application of benefit-cost analysis to regulatory issues, which has substantial implications for the resulting estimates of benefits, costs, and distributional effects. Specifically, the analysis fails to:
1. Quantify key ancillary costs with available data;
2. Select and interpret studies in a sound manner to apply benefit transfer;
3. Consider and quantify the effects of reasonable regulatory alternatives; and
4. Recognize and quantify key distributional effects.
These limitations of the RIA lead to an analysis that significantly overstates the likely benefits, substantially understates the likely costs, and minimizes the potential substantial distributional effects of FDA’s Proposed Rule. Remedying these issues by employing approaches outlined in this letter, as well as others, will allow OEA’s RIA to demonstrate more accurately whether the benefits of the Proposed Rule justify its costs, ascertain if alternative approaches could better achieve FDA’s goals at a lower cost, and offer a more transparent account of the Proposed Rule’s likely impacts on those affected and other interested parties.
---
[FOOTNOTES]
1. Clinical Lab’y Improvement Advisory Comm., *Meeting Transcript* 16 (Apr. 12-13, 2023, Atlanta, Georgia (Virtual)), https://www.cdc.gov/cliac/docs/april-2023/14-CLIAC_April-2023_Transcript.pdf.
2. Id. at 122.
3. Michael B. Datto MD PhD, CAP, Most common deficiencies – CAP Accreditation at 7 (Nov. 8-9, 2023), https://www.cdc.gov/cliac/docs/november-2023/10_CAP.pdf.
4. In contrast, the New York State program (discussed below) uses a standard for diagnostics based on analytical and clinical validity. This was also the standard used in proposed legislation considered in recent years by Congress. ACLA believes that a standard focused on analytical and clinical validity would be a better fit for diagnostics than the device standard.
5. 21 CFR § 866.5950.
6. See FDA, *Reclassification Order for DEN170046 (23andMe PGS Genetic Health Risk Report for BRCA1/BRCA2 (Selected Variants)) (Jan. 17, 2019), https://www.accessdata.fda.gov/cdrh_docs/pdf17/DEN170046.pdf.
7. Neelam V. Desai et al., *Retrospective Cohort Study on the Limitations of Direct-to-Consumer Genetic Screening in Hereditary Breast and Ovarian Cancer*, 7 JCO PRECISION ONCOLOGY 1 (2023), https://ascopubs.org/doi/full/10.1200/PO.22.00695.
8. JR Caldera et al., *FDA Trial Regulation of Laboratory Developed Tests (LDTs): An Academic Medical Center's Experience with Mpox In-House Testing*, 169 J. CLINICAL VIROLOGY 105611 (2023), https://www.sciencedirect.com/science/article/pii/S1386653223003242?via%3Dihub.
1. Proposed Rule RIA, at p. 106.
2. Proposed Rule RIA, at p. 88-9, 106.
3. Ellis, Randall P., et al. “Health Care Demand Elasticities by Type of Service.” Journal of Health Economics (2017) 55: 232-243.
4. See, e.g., Anderson, Michael, et al. “The Effect of Health Insurance Coverage on the Use of Medical Services.” American Economic Journal: Economic Policy (2012) 4(1): 1-27.
5. United States Census Bureau, Current Population Reports: Health Insurance Coverage in the United States: 2022 (September 12, 2023), available at census.gov/library/publications/2023/demo/p60-28-1.html.
6. OMB, Request for Comments on Guidance Implementing Section 2(e) of the Executive Order of April 6, 2023 (Modernizing Regulatory Review), 88 FR 20196, (Apr. 7, 2023); Executive Order 14094, Modernizing Regulatory Review, 88 FR 21879 (Apr. 11, 2023).
17 The President and First Lady’s Cancer Moonshot: Ending Cancer as We Know It, The White House https://www.whitehouse.gov/cancermoonshot/ (last visited Nov. 7, 2023).
18 See Jenna Ryherdt et al., Laboratory-Developed Tests Account for a Small Minority of Tests Ordered in an Academic Hospital System, 160 Am. J. Clin. Pathol. 297 (2023), https://academic.oup.com/ajcp/article-abstract/160/3/297/7188944?redirectedFrom=fulltext.
19 EveryLife Found. for Rare Diseases, The Cost of Delayed Diagnosis in Rare Disease: A Health Economic Study (2023), https://everylifefoundation.org/wp-content/uploads/2023/09/EveryLife-Cost-of-Delayed-Diagnosis-in-Rare-Disease_Final-Full-Study-Report_091423.pdf.
20 We disagree that such tests should be offered under the humanitarian device exemption (HDE) under FDCA section 520(m). First, the HDE for diagnostics is limited to tests where “not more than 8,000 patients per year would be subjected to diagnosis by the device in the United States.” 21 CFR § 814.102(a)(5). Although a diagnostic may be intended to identify patients with a disease that affects no more than 8,000 patients, screening more than 8,000 patients would almost always be necessary. Indeed, even if a disease affects only 100 people in the United States, it may be necessary to test more than 8,000 patients per year to identify them. However, pursuing marketing approval for such a use would be cost prohibitive. Second, such exemption prohibits manufacturers from commercializing their assay except under narrow conditions. Developers innovating for patients with rare diseases should not be punished for their efforts.
21 K. Aaron Geno & Mark A. Cervinski, Impact of the Loss of Laboratory Developed Mass Spectrometry Testing at a Major Academic Medical Center, 28 J. Mass Spectrometry & Advances in the Clinical Lab 63 (2023), https://doi.org/10.1016/j.jmsacl.2023.02.005.
22 Id.
23 88 Fed. Reg. at 68,014 (“FDA also recognizes that some IVDs may need to come off the market, because ... the laboratory chooses not to invest resources to meet those requirements.”). It is wrong to suggest that laboratories would make this choice easily. Finalizing the Proposed Rule would force laboratories to make difficult choices about for which tests it can afford to pursue marketing authorization, and for which tests it cannot.
24 While Congress recently enacted a one-year delay to Medicare payment cuts for clinical laboratory services, that is not a permanent solution. Year-over-year cuts are scheduled to be implemented starting January 1, 2025.
25: These numbers are gathered from FDA’s PMA, De Novo and 510(k) databases and downloadable files. The PMA database search included all approvals for original PMAs and Panel-Track PMA Supplements for IVDs (approvals for PDPs are not publicly available). The De Novo database search included all De Novo classifications within the panels for Immunology, Microbiology, Clinical Chemistry, Pathology, Toxicology, Hematology, and Molecular Genetics, and accordingly, may even be an overestimate. The 510(k) database search required download of available 510(k) files, sorted to include 510(k) clearances for advisory committee categories of Immunology, Microbiology, Clinical Chemistry, Pathology, Toxicology, Hematology, and Molecular Genetics, and accordingly may even be an over estimate. These searches were conducted on November 10, 2023.
26: Current List of FDA-Recognized 510(k) Third Party Review Organizations. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfthirdparty/accredit.cfm (last visited Nov. 30, 2023).
27: See, e.g., Brian J. Miller et al., The 510(k) Third Party Review Program: Promise and Potential, 47 J. MED. SYSTEMS 93 (2023), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10465388/ (“Utilization declined from a peak of 9.3% in 2008 to 2.4%, a decline due to a multitude of factors,” including FDA re-reviews).
28: FDA, A Year Into the Pandemic: How the FDA's Center for Devices and Radiological Health is Prioritizing its Workload and Looking Ahead (Apr. 15, 2021), https://www.fda.gov/news-events/fda-voices/year-pandemic-how-fdas-center-devices-and-radiological-health-prioritizing-its-workload-and-looking.
29: Id.
67 Palmetto GBA, About Us, [https://www.dexzcodes.com/palmetto/dex.nsf/DID/FUVDWDSWOU](https://www.dexzcodes.com/palmetto/dex.nsf/DID/FUVDWDSWOU) (last visited Nov. 29, 2023).
68 Andrew P. Dervan et al., Payer Decision-Making for Next Generation Sequencing-Based Genetic Tests: Insights From Cell-Free DNA Prenatal Genetic Screening, 19 GENETIC MED. 559 (2017), [https://www.nature.com/articles/gim2016145](https://www.nature.com/articles/gim2016145).
69 Karen L. Kaul et al., The Case for Laboratory Developed Procedures: Quality and Positive Impact on Patient Care, 4 ACAD. PATHOLOGY 1 (2017), [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5528950/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5528950/).
70 Yoshio Miki et al., A Strong Candidate for the Breast and Ovarian Cancer Susceptibility Gene BRCA1, 266 SCIENCE 66 (1994), [https://courses.washington.edu/gs466/readings/miki.pdf](https://courses.washington.edu/gs466/readings/miki.pdf). [https://www.science.org/doi/10.1126/science.7545953?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed](https://www.science.org/doi/10.1126/science.7545953?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed).
71 Herpes Simplex Virus, WORLD HEALTH ORG., (Apr. 5, 2023), [https://www.who.int/news-room/fact-sheets/detail/herpes-simplex-virus](https://www.who.int/news-room/fact-sheets/detail/herpes-simplex-virus).
72 Elizabeth Matthews et al., Herpesvirus-Associated Encephalitis: an Update, 9 CURRENT TROPICAL MED. REP. 92 (2022), [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9510386/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9510386/).
73 Kaul, supra note 69, at 3.
74 See, e.g., Fred D. Lakeman & Richard J. Whitley, Diagnosis of Herpes Simplex Encephalitis: Application of Polymerase Chain Reaction to Cerebrospinal Fluid from Brain-Biopsied Patients and Correlation with Disease, 171 J. INFECTIOUS DISEASE 857 (1995), [https://academic.oup.com/jid/article-abstract/171/4/857/1032564](https://academic.oup.com/jid/article-abstract/171/4/857/1032564).
75 Kaul, supra note 69, at 3.
76 Cytomegalovirus (CMV) and Congenital CMV Infection, CDC (Aug. 18, 2020), [https://www.cdc.gov/cmv/index.html](https://www.cdc.gov/cmv/index.html).
77 CMV and Transplant Patients, CEDARS SINAI, [https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/cmv-and-transplant-patients.html](https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/cmv-and-transplant-patients.html) (last visited Nov. 8, 2023).
78 Dana G. Wolf & Stephen A. Spector, Early Diagnosis of Human Cytomegalovirus Disease in Transplant Recipients by DNA Amplification in Plasma, 56 TRANSPLANTATION 330 (1993), [https://pubmed.ncbi.nlm.nih.gov/8395098/](https://pubmed.ncbi.nlm.nih.gov/8395098/).
79 See Raymond R. Razonable & Randall T.H. Hayden, Clinical Utility of Viral Load in Management of Cytomegalovirus Infection After Solid Organ Transplantation, 26 CLINICAL MICROBIOLOGY REV. 703 (2013), [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811235/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811235/).
80 Kaul, supra note 69, at 5.
81 Yunkai Yang et al., KRAS Mutations in Solid Tumors: Characteristics, Current Therapeutic Strategy, and Potential Treatment Exploration, 12 J. CLINICAL MED. 709 (2023), [https://pubmed.ncbi.nlm.nih.gov/3667541/](https://pubmed.ncbi.nlm.nih.gov/3667541/).
82 See Astrid Lievre et al., KRAS Mutation Status is Predictive of Response to Cetuximab Therapy in Colorectal Cancer, 66 CANCER RESISTANCE 3992 (2006), [https://aacrjournals.org/cancerres/article/66/8/3992/527155/KRAS-Mutation-Status-Is-Predictive-of-Response-to](https://aacrjournals.org/cancerres/article/66/8/3992/527155/KRAS-Mutation-Status-Is-Predictive-of-Response-to).
^123^ 88 Fed. Reg. at 68008, 68010.
^124^ Id. at 68011.
^125^ AMP, *Facts FDA Ignored: An analysis of the FDA report, “The Public Health Evidence for FDA Oversight of Laboratory Developed Tests: 20 Case Studies”* (Dec. 13, 2015), https://www.amp.org/AMP/assets/File/position-statements/2015/AMPResponseFDACaseReportFinal.pdf?pass=54.
^126^ *See, e.g.,* Decision Summary for DEN130031 (NEPHROCHECK® Test system), https://www.accessdata.fda.gov/cdrh_docs/reviews/den130031.pdf (last visited Nov. 8, 2023).
^127^ See 21 CFR § 860.7(c)(1)-(2) (“[T]he agency relies only on valid scientific evidence to determine whether there is reasonable assurance that the device is safe and effective.”) & (“Valid scientific evidence is evidence from well-controlled clinical investigations, partially controlled studies, studies and objective trials with matched controls, well-documented case histories conducted by qualified experts, and reports of significant human experience with a marketed device, from which it can fairly and responsibly be concluded by qualified experts that there is reasonable assurance of the safety and effectiveness of a device under its conditions of use.”).
^128^ FDA, *Guidance for Industry and FDA Staff: Use of Real-World Evidence to Support Regulatory Decision-Making for Medical Devices* (2017), https://www.fda.gov/media/99447/download.
^129^ See 21 CFR § 860.7(c)(2).
^130^ ACLA remains disappointed that the Agency rejected multiple requests to extend the comment period beyond 60 days, even while the Agency took at least seven months to develop its proposed rule. *See* Mark McCarty, *Hillebrenner Says FDA No Longer Waiting on Congress for LDT Regulation,* Bioworld.com (Mar. 1, 2023), https://www.bioworld.com/articles/694701-hillebrenner-says-fda-no-longer-waiting-on-congress-for-ldt-regulation?v=preview (announcing FDA’s intentions to proceed with rulemaking as early as March 1, 2023).
^131^ The problems with the CDC test are well documented. *See, e.g.,* Shawn Boburg et al., *Inside the Coronavirus Testing Failure: Alarm and Dismay Among the Scientists Who Sought to Help,* Wash. Post (April 5, 2020); Suzanne Murrin, HHS Office of the Inspector General, *FDA Repeatedly Adapted Emergency Use Authorization Policies to Address the Need for COVID-19 Testing* (2022), https://oig.hhs.gov/oei/reports/OEI-01-20-00230.pdf (“CDC’s first test was unusable for many weeks while no other test was authorized.”).
^132^ Shawn Boburg, et. al., *supra* note 131 (Whereas the United States had performed a total of 2,009 tests by February 12, “[i]n South Korea, 1,000 people were being tested each day by mid-February, a number that would increase more than tenfold by the end of the month. The Geneva-based World Health Organization, meanwhile, had already delivered 250,000 diagnostic tests designed and manufactured by a German lab to 70 laboratories around the world.”). *See also,* Barbara J. Evans and Ellen Wright Clayton, *supra* note 87.
^133^ Suzanne Murrin, *supra* note 131. Indeed, FDA’s evolving COVID-19 Testing Policy recognized the accuracy and reliability of LDTs compared to IVD test kits. At one point, FDA modified its testing policy to extend to LDTs and IVDs for COVID-19 serology tests, but then retracted this policy with regard to test kits after discovering that several of the commercially manufactured tests were unreliable. FDA, *Guidance for Industry: Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency* 7 (2020) (“FDA has become aware that a concerning number of commercial serology tests are being promoted inappropriately, including for diagnostic use, or are performing poorly based on an independent evaluation by the NIH, indicating that greater FDA oversight of commercial serology tests is important to protect the public health.”) (citations and footnotes omitted). While laboratories could still introduce serology tests without EUA authorization, kit manufacturers could not. The distinction FDA drew in its own policy was clear: without FDA oversight, commercial manufacturers did not produce reliable tests; but CLIA oversight of laboratories ensured the quality of LDTs.
^134^ 88 Fed. Reg. 68011.
135. Elizabeth Hillebrenner, Associate Director for Scientific and Regulatory Programs, CDRH, FDA, Memorandum: Summary of 2020 Assessment of the First 125 EUA Requests from Laboratories for Molecular Diagnostic Tests for SARS-CoV-2 (Sept. 22, 2023).
136. Id.
137. Id.
138. Jeffrey Shuren & Timothy Stenzel, *Covid-19 Molecular Diagnostic Testing—Lessons Learned*, 383:e97 N. Eng. J. Med. (2020), https://doi.org/10.1056/nejmp2023830.
139. Caldera, supra note 10.
140. Shuren and Stenzel, supra note 138.
141. Kerry Dust et al., *Comparison of Commercial Assays and Laboratory Developed Tests for Detection of SARS-CoV-2* (2020), 285 J. Virological Methods 113970 (2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482591/.
142. See, e.g., FDA, *Potential for False Positive Results with Certain Lots of Ellume COVID-19 Home Tests Due to a Manufacturing Issue: FDA Safety Communication* (Oct. 5, 2021) https://www.fda.gov/medical-devices/safety-communications/potential-false-positive-results-certain-lots-ellume-covid-19-home-tests-due-manufacturing-issue-fda#Actions.
143. Ed Regan et al. 68012 (citing Anjeanette Damon, *The COVID Testing Company That Missed 96% of Cases*, ProPublica (May 16, 2022), https://www.propublica.org/article/covid-testing-nevada-false-negatives-northshore).
144. See CMS, *Survey of Northshore Clinical Laboratories, Inc.* (Dec. 29, 2021), https://s3.documentcloud.org/documents/21872905/northshore-clinical-labs-140d246602-form-cms-2567-12292021.pdf.
145. Indeed, this is the tradeoff for all screening tests. Screening tests will necessarily identify a greater number of patients with an elevated risk of having a particular condition than would be identified by a diagnostic test that identifies patients who definitively have a condition.
146. Sarah Kliff & Aatish Bhatia, *When They Warn of Rare Disorders, These Prenatal Tests Are Usually Wrong*, N.Y. Times (Jan. 1, 2022), https://www.nytimes.com/2022/01/01/upshot/pregnancy-birth-genetic-testing.html.
147. Mayo Clinic, *Amniocentesis*, MayoClinic.org, https://www.mayoclinic.org/tests-procedures/amniocentesis/about/pac-20392914 (last visited Nov. 3, 2023); Johns Hopkins Medicine, *Chorionic Villus Sampling (CVS)*, HopkinsMedicine.org, https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/chorionic-villus-sampling-cvs (last visited Nov. 3, 2023).
^161^ Donavyn Coffey, *Blood Test Positive for Cancer, but Is There Really a Tumor?*, **Medscape** (Feb. 17, 2023), https://www.medscape.com/viewarticle/988431.
^162^ See FDA, *Oncology Drug Products Used with Certain In Vitro Diagnostic Tests: Pilot Program* (June 21, 2023), https://www.fda.gov/medical-devices/in-vitro-diagnostics/oncology-drug-products-used-certain-in-vitro-diagnostics-pilot-program.
^163^ Form CMS-116, *Clinical Laboratory Improvement Amendments (CLIA) Application for Certification* (12/21), https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms116.pdf.
^164^ For purpose of these comments, we rely on FDA’s “primary” estimates throughout the RIA. But of course the RIA accounts for a range of costs.
^165^ Gregg Brandush, *CMS CLIA Update, Division of Clinical Laboratory Improvement and Quality* (Nov. 9, 2023), https://www.cdc.gov/cliac/docs/november-2023/2_CMS_Update.pdf.
^166^ See Alyssa L. Halbisien & Christine Y. Lu, supra note 122.
^167^ Id.
[^168]: FDA, *Quarterly Update on Medical Device Performance Goals -- MDUFA V CDRH Performance Data -- Actions through 30 September 2023* (Nov. 16, 2023), https://www.fda.gov/media/179393/download?attachment.
[^169]: FDA, *MDUFA IV (FY 2018-2022) Performance Report* (Nov. 16, 2023), https://www.fda.gov/media/173924/download?attachment.
[^170]: FDA, *Preliminary Regulatory Impact Analysis; Initial Regulatory Flexibility Analysis; Unfunded Mandates Reform Act Analysis* 76-77 (2023), https://www.fda.gov/media/172557/download?attachment (“RIA”).
[^171]: FDA, *Draft Guidance for Industry and FDA Staff: Best Practices for Selecting a Predicate Device to Support a Premarket Notification [510(k)] Submission* (2023), https://www.fda.gov/media/171838/download.
[^172]: An estimate of 650 samples is based on FDA-approved assays in various clinical areas. For example, Roche’s Elecys Phospo-Tau CSF assay was required to be clinically validated with 646 samples. Sample types such as cerebral spinal fluid would likely be far in excess of $2000/sample.
178 See, e.g., FDA, Remel, Inc. Recalls Thermo Scientific Gram Negative IVD AST Sensitive Plate for Risk of Potential False Susceptible Results, https://www.fda.gov/medical-devices/medical-device-recalls/remel-inc-recalls-thermo-scientific-gram-negative-ivd-ast-sensitive-plate-risk-potential-false (last visited Nov. 11, 2023); FDA, Class 2 Device Recall therascreen KRAS RGQ PCR Kit (24), https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRes/res.cfm?id=203179 (last visited Nov. 11, 2023).
179 RIA at 37. FDA considers a fourth probability, the probability of misdiagnosis being associated with a fatality, to calculate the annual fatalities due to misdiagnosis.
180 RIA at 38 (citing Grand View Research, Laboratory Developed Tests Market Size, Share & Trends Analysis Report By Technology (Immunoassay, Molecular Diagnostics), By Application (Oncology, Nutritional & Metabolic Disease), By Region, And Segment Forecasts, 2023 – 2030 (2023)).
181 Jenna Rychert et al., supra note 18.
182 John D Pfeifer et al., Reference Samples to Compare Next-Generation Sequencing Test Performance for Oncology Therapeutics and Diagnostics, 157 Am. J. Clinical Pathology 628 (2022).
183 Ahmet Zehir et al., supra note 157.
184 See, e.g., Rifat Mokhtar et al., Comparing Non-invasive Prenatal Testing With Invasive Testing for the Detection of Trisomy 21, 14 Cureus e31252 (2022), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9737393/ (“The high performance and effectiveness of NIPT are undeniable.”).
[^185]: Annette S. Kim et al., *supra* note 52.
[^186]: See David Dimmock et al., *supra* note 107.
[^187]: *Riegel v. Medtronic, Inc.*, 552 U.S. 312 (2008).
[^188]: In addition to enacting a different regulatory scheme for laboratories and LDTs in CLIA, Congress has established reimbursement systems for diagnostic tests that results in coverage and payment for tests that are (continued...)
[^190]: Test Approval, Dep’t of Health, Wadsworth Center, (last visited Nov. 15, 2023).
[^191]: FDA, Draft Guidance: Framework for Regulatory Oversight of Laboratory Developed Tests 26 (2014), .
[^192]: Press Release, Office of Congresswoman Diana Degette, *Lawmakers move to reform diagnostic testing in U.S., FDA says legislation is a top priority for the agency* (Mar. 29, 2023), . Text of the bill is available here: .
193 FDA, *Policy for Coronavirus Disease-2019 Tests (Revised)* at 12 (Jan. 12, 2023).
194 42 CFR § 493.1253(b)(2).
---
Footnotes after the first Conclusion:
[^1]: I am Associate Professor of Public Policy and Public Administration at George Washington University’s Trachtenberg School of Public Policy and Public Administration and a Co-Director of the GW Regulatory Studies Center.
[^2]: Laboratory Developed Tests Proposed Rule Regulatory Impact Analysis, (Oct. 3, 2023), available at fda.gov/about-fda/economic-impact-analyses-fda-regulations/laboratory-developed-tests-regulatory-impact-analysis-proposed-rule. Subsequently, this RIA is referred to as “Proposed Rule RIA.” Medical Devices; Laboratory Developed Tests Proposed Rule, 88 FR 68006 (Oct. 3, 2023); Executive Order 12866, Regulatory Planning and Review, 58 FR 51735 (Oct. 4, 1993); and Executive Order 14094, Modernizing Regulatory Review, 88 FR 21879 (Apr. 11, 2023). All referenced material cited should be considered incorporated into this comment. I would be pleased to provide copies of any cited references (subject to copyright or paywall limitations).
[^3]: OMB, Circular A-4: Regulatory Analysis (Sept. 17, 2003). OMB released an updated version of Circular A-4 on November 9, 2023. However, the previous version applies to RIAs for proposed, interim final, and direct final rules received by OIRA before March 1, 2024, and for final rules received before January 1, 2025. Therefore, OMB’s 2003 version of the Circular applies to the Proposed Rule.
[^4]: Proposed Rule RIA, at pp. 53-4, 85.
[^5]: OMB, Circular A-4: Regulatory Analysis (Sept. 17, 2003), at p. 26.
[^6]: OMB, Circular A-4: Regulatory Analysis (Sept. 17, 2003), at pp. 24-6.
¹² Proposed Rule RIA. Medical Devices; Laboratory Developed Tests Proposed Rule, 88 FR 68006 (Oct. 3, 2023).
¹³ OMB, Circular A-4: Regulatory Analysis (Sept. 17, 2003); Executive Order 12866, Regulatory Planning and Review, 58 FR 51735 (Oct. 4, 1993); and Executive Order 14094, Modernizing Regulatory Review, 88 FR 21879 (Apr. 11, 2023).
¹⁴ Proposed Rule RIA, at p. 1.
¹⁵ Proposed Rule RIA, at pp. 53-4.
¹⁶ Proposed Rule RIA, at p. 54.
¹⁷ Proposed Rule RIA, at p. 94.
¹⁸ Proposed Rule RIA, at pp. 53-4.
¹⁹ Proposed Rule RIA, at p. 85.
²⁰ Proposed Rule RIA, at p. 27.
²¹ Revenue and gross margin data were collected from publicly available information from Capital IQ for nine publicly traded laboratories that offer LDTs. The average gross margin weighted by revenue for these firms in 2022 was 36.2 percent, but gross margin does not take into account overhead, salaries, research and development, and administrative expenses. Moreover, this percentage represents an approximation, given that it considers a broader set of products and services than just LDTs. Measures of profits that account for operating expenses and opportunity costs are better measures to determine at-risk products or services. Despite the limitations of using gross margin, it is used throughout this analysis to be consistent with OEA’s analysis of at-risk products in its Medication Guides: Patient Medication Information proposed rule.
²² Proposed Rule RIA, at p. 94.
²³ OMB, Circular A-4: Regulatory Analysis (Sept. 17, 2003), at p. 26.
²⁴ Executive Order 12866, Regulatory Planning and Review, 58 FR 51735 (Oct. 4, 1993).
²⁵ Proposed Rule RIA, at p. 87.
# 611 2023-12-04_ACLA Website - FDA Proposed Rule to Regulate LDTs Should Be Withdrawn.md
METADATA
last updated: 2025-12-17 BA
file_name: 2023-12-04_ACLA Website - FDA Proposed Rule to Regulate LDTs Should Be Withdrawn.md
file_date: 2023-12-04
title: ACLA Website - FDA Proposed Rule to Regulate LDTs Should Be Withdrawn
category: regulatory
subcategory: ldts
tags:
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web_url: https://www.acla.com/fda-proposed-rule-to-regulate-ldts-as-medical-devices-would-slow-development-of-critical-lab-tests-and-should-be-withdrawn-acla-urges/
summary_short: The ACLA statement argues that FDA’s proposed rule to regulate laboratory-developed tests as medical devices should be withdrawn and summarizes ACLA’s submitted comments opposing the approach. It claims the rule would impose rigid device authorities on LDTs, reduce patient access to needed testing, slow innovation, and exceed FDA’s legal authority, while also criticizing FDA’s cost-benefit analysis as understating costs and overstating benefits.
CONTENT
Washington, D.C. – The American Clinical Laboratory Association (ACLA) today submitted [comments](https://www.acla.com/aclas-comments-on-fdas-proposed-regulation-of-laboratory-developed-tests-as-medical-devices/) urging the U.S. Food and Drug Administration (FDA) to withdraw its proposed rule to regulate laboratory developed tests (LDTs) as medical devices under the Federal Food, Drug, and Cosmetic Act.
LDTs are an indispensable pillar of the nation’s health care system, providing patients and physicians with diagnostic information to inform clinical care, power precision medicine, contribute to the discovery of novel therapeutics, and lead the fight against emerging pathogens. Laboratories and the LDTs they develop have made – and continue to make – extraordinary contributions to the public health. FDA’s proposed rule, if finalized, would jeopardize the ongoing ability of laboratories to develop and offer innovative LDTs essential to delivering the latest scientific advances in diagnostics to patient care.
“ACLA has grave concerns with FDA’s proposed rule, both as a matter of public policy and law, and urges FDA to withdraw it,” said ACLA President Susan Van Meter. “FDA fails to provide a sound justification for its unilateral action, which would impose ill-suited and inflexible medical device authorities on LDTs. The net result of this action would be to reduce patient access to essential testing, including for rare diseases, and hamper innovation in the next generation of diagnostics. Device authorities are rigid and would not allow LDTs to keep pace with scientific advances. Further, the proposed rule exceeds FDA’s legal authority, as LDTs are not devices and cannot be regulated as such.”
In its comments, ACLA provided a detailed assessment of FDA’s cost-benefit analysis included in proposed rule. In short, FDA significantly underestimates the costs associated with implementing the rule and vastly overestimates the claimed benefits.
The FDA’s proposed rule fails to recognize the essential role that LDTs play in health care delivery and the already significant federal and state regulation and assessment of LDTs. In fact, laboratories and the LDTs they offer are subject to robust regulation under federal and state statutes, supplemented by rigorous accreditation standards and review by payers.
For several years, ACLA has worked collaboratively with FDA, Congress, and key stakeholders on legislation that could have established an appropriate regulatory system for all diagnostics, complementary to the already robust oversight of LDTs. The goal has been to develop a regulatory approach that would account for the unique attributes of laboratory diagnostics while balancing diagnostic innovation, maintaining access to important tests, and regulatory oversight.
ACLA steadfastly maintains that legislation is the right – and only – approach for further oversight of LDTs. ACLA believes the proposed rule represents regulatory overreach and should be withdrawn.
Read the full comment letter [here](https://www.acla.com/aclas-comments-on-fdas-proposed-regulation-of-laboratory-developed-tests-as-medical-devices/).
# 378 2024-02-01_ACLA Website - ACLA Statement on LDT Proposed Rule Comments by FDA and CMS.md
METADATA
last updated: 2025-12-17 BA
file_name: 2024-02-01_ACLA Website - ACLA Statement on LDT Proposed Rule Comments by FDA and CMS.md
file_date: 2024-02-01
title: ACLA Website - ACLA Statement on LDT Proposed Rule Comments by FDA and CMS
category: regulatory
subcategory: ldts
tags:
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web_url: https://www.acla.com/acla-statement-on-ldt-proposed-rule-comments-by-fda-and-cms/
summary_short: The ACLA statement responds to an FDA/CMS joint release on proposed LDT regulation by reiterating ACLA’s position that LDTs are not medical devices and that FDA’s proposed rule would harm patients and stifle diagnostic innovation. It emphasizes laboratories’ role in patient care and argues for a legislative approach developed with Congress and stakeholders rather than applying the medical device framework to LDTs.
CONTENT
Washington, D.C. – In response to a [joint release](https://www.fda.gov/medical-devices/medical-devices-news-and-events/fda-and-cms-americans-deserve-accurate-and-reliable-diagnostic-tests-wherever-they-are-made) from the U.S. Food & Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS) on a proposed rule to regulate laboratory developed tests (LDTs) as medical devices, the below statement can be attributed to American Clinical Laboratory Association (ACLA) President Susan Van Meter.
“ACLA late last year provided [extensive comments](https://www.acla.com/fda-proposed-rule-to-regulate-ldts-as-medical-devices-would-slow-development-of-critical-lab-tests-and-should-be-withdrawn-acla-urges/) urging the FDA to withdraw the proposed rule that seeks to regulate LDTs as medical devices under the Federal Food, Drug, and Cosmetic Act. We firmly maintain that LDTs are not medical devices and regulating them as such would be harmful to patients and would severely hamper innovation in the next generation of diagnostics. Laboratories and the LDTs they develop have made – and continue to make – extraordinary contributions to patient care and public health. Every day, LDTs help physicians and patients to diagnose diseases and make informed health care choices. Rather than imposing a device framework that is inappropriate for LDTs, ACLA encourages FDA to work with Congress, ACLA, and other stakeholders to develop legislation that would establish a role for FDA in the regulation of LDTs aligned with their already robust oversight.”
Read ACLA’s full comment letter [here](https://www.acla.com/aclas-comments-on-fdas-proposed-regulation-of-laboratory-developed-tests-as-medical-devices/).
# 381 2024-03-21_FDA Website - ACLA President to Testify on Regulation of Diagnostic Tests.md
METADATA
last updated: 2025-12-17 BA
file_name: 2024-03-21_FDA Website - ACLA President to Testify on Regulation of Diagnostic Tests.md
file_date: 2024-03-21
title: FDA Website - ACLA President to Testify on Regulation of Diagnostic Tests
category: regulatory
subcategory: ldts
tags:
source_file_type: website
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gfile_url: NA
xfile_github_download_url: NA
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conversion: manual cut and paste
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tokens: 381
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notes: date converted 2024-06-03
web_url: https://www.acla.com/acla-president-to-testify-on-regulation-of-diagnostic-tests/
summary_short: The ACLA President to Testify on Regulation of Diagnostic Tests announcement previews Susan Van Meter’s March 21, 2024 testimony before the House Energy and Commerce Health Subcommittee on approaches to diagnostic test regulation and FDA’s proposed LDT rule. It summarizes ACLA’s argument that treating most lab testing services as medical devices would reduce access to critical tests, raise costs, and hinder innovation, and points to ACLA’s prior comments urging withdrawal of the rule and advocating for legislation to establish a diagnostics-specific framework.
CONTENT
Washington, D.C. – [American Clinical Laboratory Association](https://www.acla.com/) (ACLA) President Susan Van Meter will testify before the House Energy and Commerce Committee’s Subcommittee on Health for a hearing titled, “[Evaluating Approaches to Diagnostic Test Regulation and the Impact of the FDA’s Proposed Rule](https://energycommerce.house.gov/posts/chairs-rodgers-and-guthrie-announce-health-subcommittee-hearing-on-regulation-of-diagnostic-tests),” today at 10:00 a.m. E.T.
Laboratory developed test services are an indispensable pillar of the nation’s health care system. ACLA members provide high quality and innovative testing services to patients in every state across the country. However, the U.S. Food and Drug Administration’s (FDA) proposed rule would subject virtually all laboratory testing services to medical device regulation, which would limit or eliminate access to critical tests, increase health care costs, and undermine diagnostic and medical innovation.
ACLA previously [submitted comments](https://www.acla.com/fda-proposed-rule-to-regulate-ldts-as-medical-devices-would-slow-development-of-critical-lab-tests-and-should-be-withdrawn-acla-urges/) urging the FDA to withdraw its proposed rule to regulate laboratory developed tests as medical devices under the Federal Food, Drug, and Cosmetic Act. The association maintains that legislation is required for FDA to regulate laboratory developed tests and has committed to working with Congress, FDA, and other stakeholders to develop a diagnostic-specific regulatory framework.
The hearing can be watched via the committee’s website [here](https://energycommerce.house.gov/committees/subcommittee/health).
Van Meter’s written remarks, as submitted to Congress, are available [here](https://www.acla.com/statement-of-acla-president-to-the-health-subcommittee-of-the-house-energy-commerce-committee/).
# 475 2024-04-29_FDA Website - ACLAs Statement on the Final Rule.md
METADATA
last updated: 2025-12-17 BA
file_name: 2024-04-29_FDA Website - ACLAs Statement on the Final Rule.md
file_date: 2024-04-29
title: FDA Website - ACLAs Statement on the Final Rule
category: regulatory
subcategory: ldts
tags:
source_file_type: website
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: NA
pdf_github_url: NA
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conversion: manual cut and paste
license: Public Domain
tokens: 475
words: 308
notes: date converted 2024-06-03
web_url: https://www.acla.com/acla-statement-on-fda-final-rule-to-regulate-laboratory-developed-testing-services-as-medical-devices/
summary_short: ACLA’s Statement on the Final Rule responds to FDA’s April 29, 2024 Final Rule regulating laboratory developed testing services as medical devices and reiterates ACLA’s view that this approach will harm patient access and diagnostic innovation. It argues the rule will increase costs, limit availability of critical tests, and exceed FDA’s statutory authority, emphasizing that clinical labs are already robustly overseen and that any expanded FDA role should come through new legislation.
CONTENT
Washington, D.C. – In response to the U.S. Food & Drug Administration (FDA) releasing its [Final Rule](https://public-inspection.federalregister.gov/2024-08934.pdf) to regulate laboratory developed testing services as medical devices under the Federal Food, Drug, and Cosmetic Act, the following statement can be attributed to [American Clinical Laboratory Association](https://www.acla.com/) (ACLA) President Susan Van Meter:
“The FDA today released a final rule to regulate laboratory developed testing services as medical devices. While ACLA is currently reviewing the rule, our position has been clear and consistent: Laboratory developed testing services are not medical devices and subjecting them to medical device regulation will harm patient access to needed testing and compromise innovations that drive personalized medicine.
ACLA has grave concerns about this rule as a matter of both policy and law. The rule will limit access to scores of critical tests, increase health care costs, and undermine innovation in new diagnostics. The rule also exceeds FDA’s statutory authority, as Congress has never granted the agency authority to regulate laboratory developed testing services offered by laboratory professionals.
We are disappointed that FDA has continued down this path. That is not just ACLA’s view. At a recent [congressional hearing](https://energycommerce.house.gov/events/health-subcommittee-hearing-evaluating-approaches-to-diagnostic-test-regulation-and-the-impact-of-the-fda-s-proposed-rule), it was clear that there is little support for the agency’s approach among members of Congress and key stakeholders. Clinical laboratories are already subject to robust regulation and oversight, and ACLA maintains that new legislation would be required for the FDA to regulate laboratory developed testing services.
ACLA has committed to working with Congress, FDA, and other stakeholders on legislation that would create a regulatory framework tailored to the dynamic nature of laboratory diagnostics. We urge FDA to resume work on legislation rather than unilaterally imposing medical device authorities that Congress never intended for this purpose. The future of patient care depends on it.”
ACLA previously submitted comments addressing the many problems with FDA’s proposal. Learn more [here](https://www.acla.com/fda-proposed-rule-to-regulate-ldts-as-medical-devices-would-slow-development-of-critical-lab-tests-and-should-be-withdrawn-acla-urges/).
# 2,717 2024-05-06_FDA Guidance - Enforcement Policy under LDT Final Rule.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2024-05-06_FDA Guidance - Enforcement Policy under LDT Final Rule.md
file_date: 2024-05-06
title: FDA Guidance - Enforcement Policy under LDT Final Rule
category: regulatory
subcategory: ldts
tags:
source_file_type: pdf
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: https://drive.google.com/file/d/11doz6YRunX5Wh8_GGhFC04xgzdgdBv7k
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tokens: 2717
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notes:
summary_short: The FDA Federal Register notice (published May 6, 2024) announces a draft guidance on an enforcement policy allowing certain laboratory manufacturers to offer validated, unauthorized “immediate response” in vitro diagnostic tests for CBRN threats when no section 564 EUA declaration is in place. It explains the conditions for this enforcement discretion—validation, FDA notification, transparency, prescription-only labeling, and use during the emergent window between detection and resolution or issuance of a 564 declaration—against the backdrop of FDA’s phaseout of general LDT enforcement discretion under the LDT Final Rule.
CONTENT
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
21 CFR Part 809
[Docket No. FDA-2024-D-0083]
Enforcement Policy for Certain In Vitro Diagnostic Devices for Immediate Public Health Response in the Absence of a Declaration under Section 564; Draft Guidance for Laboratory Manufacturers and Food and Drug Administration Staff; Availability
**AGENCY:** Food and Drug Administration, HHS.
**ACTION:** Notice of availability.
**SUMMARY:** The Food and Drug Administration (FDA or Agency) is announcing the availability of the draft guidance entitled “Enforcement Policy for Certain In Vitro Diagnostic Devices for Immediate Public Health Response in the Absence of a Declaration under Section 564.” In the context of emergent situations involving chemical, biological, radiological, or nuclear (CBRN) threats, there may be a public health need for certain in vitro diagnostic devices (IVDs) to be available for immediate response purposes. When finalized, this guidance will describe the Agency’s enforcement policy for certain laboratory manufacturers offering certain unauthorized IVDs for immediate response to CBRN agents in the absence of a declaration applicable to IVDs under the Federal Food, Drug, and Cosmetic Act (FD&C Act). This draft guidance is not final nor is it for implementation at this time.
**DATES:** Submit either electronic or written comments on the draft guidance by [INSERT DATE 60 DAYS AFTER DATE OF PUBLICATION IN THE _FEDERAL REGISTER_] to ensure that the Agency considers your comment on this draft guidance before it begins work on the final version of the guidance.
**ADDRESSES:** You may submit comments on any guidance at any time as follows:
## Electronic Submissions
Submit electronic comments in the following way:
- Federal eRulemaking Portal: [https://www.regulations.gov](https://www.regulations.gov). Follow the instructions for submitting comments. Comments submitted electronically, including attachments, to [https://www.regulations.gov](https://www.regulations.gov) will be posted to the docket unchanged. Because your comment will be made public, you are solely responsible for ensuring that your comment does not include any confidential information that you or a third party may not wish to be posted, such as medical information, your or anyone else’s Social Security number, or confidential business information, such as a manufacturing process. Please note that if you include your name, contact information, or other information that identifies you in the body of your comments, that information will be posted on [https://www.regulations.gov](https://www.regulations.gov).
- If you want to submit a comment with confidential information that you do not wish to be made available to the public, submit the comment as a written/paper submission and in the manner detailed (see “Written/Paper Submissions” and “Instructions”).
## Written/Paper Submissions
Submit written/paper submissions as follows:
- Mail/Hand delivery/Courier (for written/paper submissions): Dockets Management Staff (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852.
- For written/paper comments submitted to the Dockets Management Staff, FDA will post your comment, as well as any attachments, except for information submitted, marked and identified, as confidential, if submitted as detailed in “Instructions.”
**Instructions:** All submissions received must include the Docket No. FDA-2024-D-0083 for “Enforcement Policy for Certain In Vitro Diagnostic Devices for Immediate Public Health Response in the Absence of a Declaration under Section 564.” Received comments will be placed in the docket and, except for those submitted as “Confidential Submissions,” publicly viewable at [https://www.regulations.gov](https://www.regulations.gov) or at the Dockets Management Staff between 9 a.m. and 4 p.m., Monday through Friday, 240-402-7500.
- **Confidential Submissions**—To submit a comment with confidential information that you do not wish to be made publicly available, submit your comments only as a written/paper submission. You should submit two copies total. One copy will include the information you claim to be confidential with a heading or cover note that states “THIS DOCUMENT CONTAINS CONFIDENTIAL INFORMATION.” The Agency will review this copy, including the claimed confidential information, in its consideration of comments. The second copy, which will have the claimed confidential information redacted/blacked out, will be available for public viewing and posted on [https://www.regulations.gov](https://www.regulations.gov). Submit both copies to the Dockets Management Staff. If you do not wish your name and contact information to be made publicly available, you can provide this information on the cover sheet and not in the body of your comments and you must identify this information as “confidential.” Any information marked as “confidential” will not be disclosed except in accordance with 21 CFR 10.20 and other applicable disclosure law. For more information about FDA’s posting of comments to public dockets, see 80 FR 56469, September 18, 2015, or access the information at: [https://www.govinfo.gov/content/pkg/FR-2015-09-18/pdf/2015-23389.pdf](https://www.govinfo.gov/content/pkg/FR-2015-09-18/pdf/2015-23389.pdf).
**Docket:** For access to the docket to read background documents or the electronic and written/paper comments received, go to [https://www.regulations.gov](https://www.regulations.gov) and insert the docket number, found in brackets in the heading of this document, into the “Search” box and follow the prompts and/or go to the Dockets Management Staff, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852, 240-402-7500.
You may submit comments on any guidance at any time (see 21 CFR 10.115(g)(5)).
An electronic copy of the guidance document is available for download from the internet. See the SUPPLEMENTARY INFORMATION section for information on electronic access to...
**FOR FURTHER INFORMATION CONTACT:** Toby Lowe, Center for Devices and Radiological Health, Food and Drug Administration, 10903 New Hampshire Ave., Bldg. 66, Rm. 3416, Silver Spring, MD 20993-0002, 301-796-6512.
**SUPPLEMENTARY INFORMATION:**
### I. Background
When finalized, this guidance will describe the Agency’s enforcement policy for certain laboratory manufacturers offering certain unauthorized IVDs for immediate response to CBRN agents in the absence of a declaration applicable to IVDs under section 564 of the Federal Food, Drug, and Cosmetic Act (FD&C Act) (hereafter referred to as an “applicable 564 declaration”).[^1] In the context of emergent situations involving CBRN threats, there may be a public health need for certain IVDs to be available for immediate response purposes. An emergent situation is, for purposes of this guidance, the period of time between detection of the exposure or outbreak and, either, resolution of the exposure or outbreak or issuance of an applicable 564 declaration. In the past, during this period of time, laboratory manufacturers offered laboratory developed tests (LDTs) for which FDA has had a general enforcement discretion approach. However, as discussed in the preamble to the final rule amending FDA regulations to make explicit that IVDs are devices under the FD&C Act including when the manufacturer of the IVD is a laboratory (LDT Final Rule)[^2], FDA is phasing out this general enforcement discretion approach for LDTs. Accordingly, FDA is issuing this guidance with our enforcement policy for “immediate response” tests.
This guidance, when finalized, will describe the Agency’s enforcement policy for certain laboratory manufacturers offering certain unauthorized IVDs for immediate response to CBRN agents in the absence of an applicable 564 declaration. FDA does not intend to object to the offering of “immediate response” tests, as defined in the guidance, when the test is manufactured and offered by certain laboratory manufacturers, the test has been appropriately validated, FDA is notified, appropriate transparency is provided, the test is labeled for prescription use only, and there is no applicable 564 declaration, as described in the guidance. Prior to an emergent situation and after an emergent situation has been resolved, when there might not be a critical need for a coordinated and immediate public health response and where the implications of false results may not have as serious implications for public health decision-making, such tests may fall within the enforcement discretion policies described in section V.B of the preamble to the LDT Final Rule.
This draft guidance is being issued consistent with FDA’s good guidance practices regulation (21 CFR 10.115). The draft guidance, when finalized, will represent the current thinking of FDA on “Enforcement Policy for Certain In Vitro Diagnostic Devices for Immediate Public Health Response in the Absence of a Declaration under Section 564.” It does not establish any rights for any person and is not binding on FDA or the public. You can use an alternative approach if it satisfies the requirements of the applicable statutes and regulations.
### II. Electronic Access
Persons interested in obtaining a copy of the draft guidance may do so by downloading an electronic copy from the internet. A search capability for all Center for Devices and Radiological Health guidance documents is available at [https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/guidance-documents-medical-devices-and-radiation-emitting-products](https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/guidance-documents-medical-devices-and-radiation-emitting-products). This guidance document is also available at [https://www.regulations.gov](https://www.regulations.gov) or [https://www.fda.gov/regulatory-information/search-fda-guidance-documents](https://www.fda.gov/regulatory-information/search-fda-guidance-documents). Persons unable to download an electronic copy of “Enforcement Policy for Certain In Vitro Diagnostic Devices for Immediate Public Health Response in the Absence of a Declaration under Section 564” may send an email request to CDRH-Guidance@fda.hhs.gov to receive an electronic copy of the document. Please use the document number GUI00007032 and complete title to identify the guidance you are requesting.
### III. Paperwork Reduction Act of 1995
While this guidance contains no new collection of information, it does refer to previously approved FDA collections of information. The previously approved collections of information are subject to review by the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3501-3521). The collections of information in the following table have been approved by OMB:
| 21 CFR Part or Guidance | Topic | OMB Control No. |
|-------------------------|----------------------------------------------------------------------------------|-----------------|
| “Emergency Use Authorization of Medical Products and Related Authorities” | Emergency Use Authorization | 0910-0595 |
| 807, subpart E | Premarket notification | 0910-0120 |
| 814, subparts A through E | Premarket approval | 0910-0231 |
| 814, subpart H | Humanitarian Use Devices; Humanitarian Device Exemption | 0910-0332 |
| 812 | Investigational Device Exemption | 0910-0078 |
| 860, subpart D | De Novo classification process | 0910-0844 |
| “Administrative Procedures for CLIA Categorization” and “Recommendations: Clinical Laboratory Improvement Amendments of 1988 (CLIA) Waiver Applications for Manufacturers of In Vitro Diagnostic Devices” | CLIA Administrative Procedures; CLIA Waivers | 0910-0607 |
| 800, 801, 809, and 830 | Medical Device Labeling Regulations; Unique Device Identification | 0910-0485 |
| 803 | Medical Device Reporting; | 0910-0437 |
| 810 | Recalls | 0910-0432 |
||
Dated: April 22, 2024.
Lauren K. Roth,
Associate Commissioner for Policy.
[FR Doc. 2024-08934 Filed: 4/29/2024 8:45 am; Publication Date: 5/6/2024]
---
[^1]: The Office of the Federal Register has published this document under the category “Proposed Rule” pursuant to its interpretation of 1 CFR 5.9(b). We note that the categorization as such for purposes of publication in the Federal Register does not affect the content or intent of the document. See 1 CFR 5.1(c).
[^2]: “Medical Devices: Laboratory Developed Tests” is issued elsewhere in this *Federal Register*.
# 142,259 2024-05-29_ACLA - LDT Complaint to FDA Court filing.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2024-05-29_ACLA - LDT Complaint to FDA Court filing.md
file_date: 2024-05-29
title: ACLA - LDT Complaint to FDA Court filing
category: regulatory
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tags:
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pdf_gdrive_url: https://drive.google.com/file/d/1IYnIE7-thqc7PAASkxy-L0YsyuQAp7en
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words: 94535
notes:
summary_short: The Complaint to FDA – ACLA LDT Complaint is a federal court filing by the American Clinical Laboratory Association and member laboratories challenging the FDA’s 2024 Final Rule that classifies laboratory-developed tests as medical devices under the FDCA. It argues the rule exceeds FDA’s statutory authority, conflicts with CLIA’s established regulatory framework for laboratory services, and is arbitrary and capricious under the Administrative Procedure Act. The complaint seeks declaratory and injunctive relief to vacate the rule and prevent FDA from enforcing device regulations on professional laboratory testing services.
CONTENT
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF TEXAS
SHERMAN DIVISION
AMERICAN CLINICAL LABORATORY ASSOCIATION; HEALTHTRACKRX INDIANA, INC.; and HEALTHTRACKRX, INC.,
Plaintiffs,
v.
U.S. FOOD AND DRUG ADMINISTRATION; U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; XAVIER BECERRA, in his official capacity as Secretary of Health and Human Services; and ROBERT M. CALIFF, M.D., in his official capacity as Commissioner of Food and Drugs, United States Food and Drug Administration,
Defendants.
Case No.: 4:24-cv-479
COMPLAINT
## TABLE OF CONTENTS
PRELIMINARY STATEMENT ................................................................................ 1
PARTIES ..................................................................................................................... 9
JURISDICTION AND VENUE ................................................................................ 10
GENERAL ALLEGATIONS .................................................................................... 12
- A. Laboratory-developed tests are services carried out by highly skilled and trained laboratory professionals ..................... 12
- B. FDA’s statutory authority to regulate medical devices does not extend to professional services ............................................... 15
- C. Congress created a separate and distinct framework for regulating laboratory testing services .......................................... 21
- D. FDA has never broadly regulated laboratory testing services as medical devices ............................................................. 26
1. FDA’s Many Years of Silence ..................................................... 27
2. FDA’s Never-Finalized 1992 Guidance .................................... 29
3. FDA’s Sporadic Claims of Authority in the 1990s and 2000s .................................................................................................... 30
4. FDA’s Never-Finalized 2014 Guidance .................................... 31
5. The 2020 Charrow Memo Questions FDA’s Authority to Regulate Laboratory Testing Services ............................ 35
6. Congress Chooses Not to Enact Legislation ............................. 37
- E. FDA now seeks for the first time to classify virtually all laboratory testing services as medical devices .............................. 38
1. The 2023 Proposed Rule .............................................................. 38
2. ACLA’s Comments on the Proposed Rule ................................ 40
3. The 2024 Final Rule .................................................................... 41
- F. HealthTrackRX and other ACLA members face irreparable harm from FDA’s final rule ............................................................ 50
CLAIMS FOR RELIEF ............................................................................................. 54
- COUNT 1 Violation of the Administrative Procedure Act—Contrary to Law, in Excess of Statutory Jurisdiction and Authority, and Contrary to Constitutional Right and Power 5 U.S.C. § 706(2) .......... 54
- COUNT 2 Violation of the Administrative Procedure Act—Arbitrary and Capricious and an Abuse of Discretion 5 U.S.C. § 706(2) ............ 57
PRAYER FOR RELIEF ........................................................................................... 58
## COMPLAINT FOR DECLARATORY AND INJUNCTIVE RELIEF
Plaintiffs American Clinical Laboratory Association (“ACLA”) and HealthTrackRX Indiana, Inc. and HealthTrackRX, Inc. (together “HealthTrackRX”) bring this action against the Food & Drug Administration (“FDA”), the Department of Health and Human Services, and the Secretary of Health and Human Services and the FDA Commissioner in their official capacities, challenging the final rule published on May 6, 2024, announcing FDA’s intent to regulate laboratory-developed tests as medical devices under the Federal, Food, Drug and Cosmetic Act. Because the final rule exceeds FDA’s lawful authority and is arbitrary and capricious and contrary to law, the rule should be set aside and vacated, and defendants should be enjoined from enforcing or implementing the rule. _See_ 5 U.S.C. § 706. Plaintiffs allege as follows:
### PRELIMINARY STATEMENT
1. The professional diagnostic testing services provided by clinical laboratories are an essential part of the nation’s healthcare system. These important testing services have long been relied on by healthcare providers to diagnose and develop appropriate treatments for patients who suffer from illness and disease. There are thousands of laboratories across the United States that offer tens of thousands of molecular and other types of high-quality diagnostic testing services to providers and patients. These testing services are a critical pillar of our nation’s health care system.
2. For decades, laboratory-developed testing services (often referred to as “LDTs”) have been regulated under a statutory and regulatory framework—the Clinical Laboratory Improvement Amendments Act of 1988 (“CLIA”)—that imposes numerous laboratory-specific standards to ensure the validity and reliability of laboratory diagnostic testing services, including the training and qualifications of the skilled professionals who perform, supervise, and interpret those tests. When creating and performing testing services, these laboratory professionals have not generally been required to comply also with the costly and burdensome pre-approval and clearance requirements that the Federal Food, Drug and Cosmetic Act (“FDCA”) authorizes FDA to apply to manufactured medical devices sold in interstate commerce. Nor has Congress ever granted FDA authority to regulate professional laboratory-developed testing services.
3. FDA’s final rule threatens to upend the nation’s entire laboratory profession by seeking to regulate all laboratory-developed tests as if they are medical devices under the FDCA. In asserting authority to transform the regulatory framework that has applied for decades, FDA cannot point to any new statutory authority granted by Congress. Nor can FDA contend that Congress has ever provided it with the resources that would be necessary to retain the personnel and build the expertise necessary to exercise sweeping authority over the thousands of testing services provided by the nation’s laboratories. To the contrary, Congress has recently entertained legislative proposals that would have granted FDA new authority to regulate laboratory-developed testing services, and it has declined to provide FDA that power.
4. FDA’s final rule relies on the extraordinary position that in 1976, when Congress expanded FDA’s authority to regulate medical devices, it also quietly intended to outlaw—and subject to substantial civil and criminal monetary penalties—any professional laboratory-developed testing services that were not first approved or cleared by FDA. The logic of FDA’s position is that tens of thousands of professionals across the country performing millions of diagnostic testing services every year, working with thousands of doctors and patients, have for decades done so in open and direct violation of the law. According to FDA, the only reason laboratories have not been civilly and criminally punished is because FDA has chosen to exercise unreviewable “enforcement discretion.” In short, FDA is taking the position that a “long-extant statute” grants it vast, “transformative” regulatory powers that it has not previously exercised—a position that courts have rightly approached with deep skepticism. _West Virginia v. EPA_, 597 U.S. 697, 724 (2022) (quoting _Util. Air Regul. Grp. v. EPA_, 573 U.S. 302, 324 (2014)).
5. If it is not vacated, FDA’s unprecedented final rule will have devastating and far-reaching consequences not only for the nation’s clinical
laboratories, but also for the nation’s entire healthcare system, including the millions of vulnerable patients who depend on the essential clinical testing services that laboratories provide. FDA’s final rule means that, in order to be _legally_ marketed, virtually all diagnostic laboratory tests will have to undergo costly and time-consuming administrative review through a regulatory process that was designed for evaluating manufactured medical devices, not professional testing services.
6. The final rule states that FDA intends to apply this onerous regulatory regime to new and modified laboratory-developed tests, which will dramatically increase research and development costs, hinder vital medical innovation, and hamper adaptation of existing tests to meet evolving patient needs. Indeed, FDA itself has recognized “significant regulatory changes” to the treatment of laboratory testing services “could have negative effects on the public health.” 62 Fed. Reg. 62,243, 62,249 (Nov. 21, 1997). With respect to unmodified existing tests, FDA states that as a matter of enforcement discretion it generally does not intend—at least not at this time—to enforce certain especially burdensome medical-device requirements, such as premarket review. But FDA’s final rule means that in the agency’s view all of those tests, including tests that physicians have relied on for decades, are being marketed illegally and are subject to FDA enforcement action at any time.
7. FDA does not have authority to regulate professional laboratory-developed testing services as medical devices. The text and structure of the FDCA make plain that FDA’s authority to regulate “devices,” which dates to 1938 and was expanded through the Medical Device Amendments of 1976, extends only to physical products that are sold and distributed by manufacturers in interstate commerce. The FDCA has never applied medical device regulation to laboratory testing services. And for good reason: Those tests are not physical products sold and distributed by manufacturers. Instead, they are professional healthcare services offered by highly skilled and trained laboratory professionals that are outside FDA’s regulatory expertise and are subject to different regulatory requirements. A laboratory-developed test is a process by which laboratory professionals use various tools—some of which may be individually regulated as devices—to derive diagnostic information that a patient and the patient’s physician may use in making health care decisions.
8. Nor has FDA provided any plausible interpretation of the statute that could support its approach. FDA’s assertion that laboratory testing services are devices just because the professionals performing those services _use_ devices is as unreasonable as calling a surgical procedure a “device” because the surgeon uses a scalpel, or calling a doctor’s physical examination a “device” because the doctor uses a stethoscope. The fact that a skilled professional may use physical tools, in addition to his or her professional expertise, training, and judgment, to perform a procedure does not mean that the procedure itself is a device.
9. Equally untenable is FDA’s contention that laboratory testing services are devices because they serve a similar function to in vitro diagnostic test kits, which FDA regulates as devices. An IVD test kit is a “device” because it is a packaged set of components manufactured and sold in interstate commerce as a single physical product, like an at-home COVID test. Such commercial test kits are fundamentally different from laboratory-developed tests, which are professional services performed by professional clinicians in a laboratory.
10. As noted above, the development and performance of laboratory-developed tests is regulated at the federal level under a separate statutory and regulatory framework—CLIA—that ensures the validity and reliability of laboratory tests and the training and qualifications of the skilled professionals who perform, supervise, and interpret those tests. Notably, when Congress enacted CLIA, it did not so much as hint that it had already granted FDA authority to regulate laboratory testing services as medical devices under the FDCA. If Congress had wanted to expand FDA’s authority so dramatically over an entire profession, it would have said so.
11. In its proposed rule, FDA initially contended that nearly all existing laboratory-developed tests would have to go through a burdensome
In the final rule, recognizing that its sweeping interpretation would be unworkable and have devastating consequences, FDA tried to rewrite the FDCA in the guise of dozens of pages of vague, non-binding “enforcement discretion policies” that are designed to mitigate (but not eliminate) those consequences. This “need to rewrite” the statute “should have alerted [FDA] that it had taken a wrong interpretive turn.” *Util. Air Regul. Grp.*, 573 U.S. at 328. “Agencies are not free to ‘adopt … unreasonable interpretations of statutory provisions and then edit other statutory provisions to mitigate the unreasonableness.’” *Id.* (quotation marks omitted).
12. The final rule repeatedly warns that FDA may change its enforcement discretion policy at any time and bring the hammer down on laboratories for unlawfully marketing existing tests. Even if FDA never takes that step, the rule creates enormous regulatory uncertainty for laboratories and places them in an impossible position: They must either (1) withdraw all their existing tests from the market (which FDA recognized would be devastating for patients and the public health); (2) incur massive costs to obtain FDA approval or clearance for their existing tests, which would divert resources from innovating and developing new tests and overwhelm FDA; or (3) continue serving patients by providing existing tests without FDA approval or clearance, even though FDA says that by doing so they are breaking the law and are subject to enforcement action at any time in the agency’s sole discretion.
13. In addition to casting a shadow over all existing tests, the final rule undermines innovation and threatens patient access to critical new diagnostic tests. FDA lacks the expertise or resources to timely and efficiently review and approve new and modified laboratory-developed testing services. Moreover, given the need for FDA approval or clearance, the rule will discourage laboratories from devoting scarce resources to research and development, which will impede the creation of new and improved tests for cancer, infectious disease, cardiovascular disease, and countless other diseases and conditions. Because many tests do not generate sufficient revenue to support the expense of seeking FDA approval or clearance, many important tests will never be developed—especially tests for rare diseases or that serve small patient populations, such as children or racial or ethnic minorities.
14. FDA has identified no genuine public-health justification for imposing these costs on laboratories and the physicians and patients who rely on them. The agency’s exercise of enforcement discretion for existing tests only underscores the lack of a valid public-health rationale for treating *any* laboratory-developed tests as medical devices.
15. For these reasons and those explained below, ACLA and HealthTrackRx seek declaratory and injunctive relief to vacate, set aside, and enjoin enforcement of the final rule.
### PARTIES
16. Plaintiff American Clinical Laboratory Association (“ACLA”) is a not-for-profit association with its principal place of business in Washington, D.C. ACLA is the national trade association representing leading laboratories that deliver essential diagnostic health information to patients and providers. ACLA’s members perform hundreds of millions of tests each year for patients across the country, and ACLA advocates for policies that expand access to the highest quality clinical laboratory services, improve patient outcomes, and advance the next generation of personalized care.
17. Plaintiff HealthTrackRx Indiana, Inc. is a corporation organized and existing under the laws of Indiana with its principal place of business in Denton, Texas. Plaintiff HealthTrackRX, Inc., is a corporation organized and existing under the laws of Texas with its principal place of business in Denton, Texas. HealthTrackRx is a leading national PCR-based infectious disease laboratory, providing services to over 10,000 clinicians nationwide. HealthTrackRx is also an ACLA member.
18. Defendant FDA, which has its principal office at 10903 New Hampshire Avenue, Silver Spring, Maryland 20993, is a federal agency headquartered in Maryland. It regulates drugs and medical devices under authority delegated by Congress and the Secretary of Health and Human Services.
19. Defendant U.S. Department of Health and Human Services, which has its principal office at 200 Independence Avenue, S.W., Washington, D.C. 20201, is a federal agency headquartered in the District of Columbia. It has authority over FDA.
20. Defendant Xavier Becerra is being sued in his official capacity as Secretary of Health and Human Services. As Secretary, Mr. Becerra has ultimate responsibility for the activities of the Department of Health and Human Services, including those actions complained of herein. Mr. Becerra maintains an office at 200 Independence Avenue, S.W., Washington, D.C. 20201.
21. Defendant Robert Califf, M.D., is being sued in his official capacity as Commissioner of Food and Drugs, FDA. As Commissioner, Dr. Califf is responsible for the activities of FDA, including those actions complained of herein. Dr. Califf maintains an office at 10903 New Hampshire Avenue, Silver Spring, Maryland 20993.
### JURISDICTION AND VENUE
22. This Court has original subject matter jurisdiction over this action pursuant to 28 U.S.C. § 1331 because it arises under the laws of the United States.
23. Plaintiffs have a right to bring this action pursuant to the Administrative Procedure Act (“APA”), 5 U.S.C. §§ 701–706, and the Declaratory Judgment Act, 28 U.S.C. § 2201.
24. Plaintiffs have standing because they or their members provide thousands of laboratory-developed tests that would be treated as devices under the final rule, making them direct objects of regulation under that rule. _See_ Dr. Reddy Decl. ¶¶ 6–7, 9–14, 24–37 (attached as Ex. A); Dr. Eisenberg Decl. ¶¶ 6, 8–10, 12, 18–20 (attached as Ex. B); Dr. Fesko Decl. ¶¶ 5–11 (attached as Ex. C); Dr. Genzen Decl. ¶¶ 12–13, 16–18, 22 (attached as Ex. D); Dr. Morice Decl. ¶¶ 19, 22, 25–30 (attached as Ex. E). Plaintiffs and their members also engage in research and development efforts to bring to market new and modified tests that would be treated as devices under the final rule. _See_ Dr. Reddy Decl. ¶¶ 20, 24, 32, 36–37; Dr. Eisenberg Decl. ¶¶ 6, 8, 9–10, 12, 18–19; Dr. Fesko Decl. ¶¶ 7, 9, 16, 19–21; Dr. Genzen Decl. ¶¶ 19–21, 25–42, 47–50, 58–59; Dr. Morice Decl. ¶¶ 9, 17–18, 22–26, 58.
25. There is currently an actual, justiciable controversy between the parties concerning whether FDA’s final rule is consistent with the requirements of the FDCA, 21 U.S.C. § 301 _et seq._, and the APA.
26. Venue is proper in this District pursuant to 28 U.S.C. § 1391(e) because this is a civil action in which the defendants are officers or agencies of the United States, plaintiff HealthTrackRx resides in this District, and no real property is involved in this action. _See_ Dr. Reddy Decl. ¶ 8.
### GENERAL ALLEGATIONS
#### A. Laboratory-developed tests are services carried out by highly skilled and trained laboratory professionals.
27. Laboratory-developed tests are procedures designed, developed, and performed by clinical laboratories certified to perform high-complexity testing to yield important clinical information about a patient that can be used to inform or guide patient care. _See_ Dr. Reddy Decl. ¶¶ 9–17, 23; Dr. Eisenberg Decl. ¶¶ 6–10, 15; Dr. Fesko Decl. ¶¶ 5–11; Dr. Genzen Decl. ¶¶ 11–13, 15–20, 23–26, 28; Dr. Morice Decl. ¶¶ 14. 27–28, 48–52.
28. Laboratories that develop and perform these tests are providing professional healthcare services; they are not acting as device manufacturers or distributing devices. _See_ Dr. Reddy Decl. ¶¶ 21–23; Dr. Eisenberg Decl. ¶¶ 14–15, 18; Dr. Fesko Decl. ¶¶ 14–15; Dr. Genzen Decl. ¶¶ 43–45; Dr. Morice Decl. ¶¶ 14, 48–56.
29. As an example, consider the steps associated with performing a mass spectrometry test offered by an ACLA member laboratory. Mass spectrometry is a chemical analysis technique with many uses, including helping manage hormonal disorders such as Cushing’s syndrome and measuring proteins with functions related to cancer and Alzheimer’s disease. After a physician orders the test, a blood specimen is obtained by a phlebotomist and sent to the laboratory. Laboratory staff then perform the
The following tasks:
a. *Pre-analytical steps.* The laboratory receives the blood sample and enters it into the laboratory information system. Laboratory staff then complete pre-analytical steps in accordance with the relevant standard operating procedures. That may include centrifuging the sample or aliquoting the sample into a separate tube for testing.
b. *Analytical steps.* A laboratory scientist prepares reagents, standards, and quality control materials, and retrieves the patient sample for testing. The scientist pipettes the applicable samples and reagents into a 96-well plate and extracts the analytes of interest using an automated liquid handling instrument. The scientist then enters relevant information into the instrument software and loads samples onto the testing system, which includes an automated sampler, liquid chromatography instrumentation, and a high-resolution mass spectrometer. When testing is complete, the scientist reviews the test both qualitatively and quantitatively (*e.g.,* reviewing chromatography and signal-to-noise ratios), including reviewing quality control to ensure the results are within parameters for acceptable performance. The scientist then reviews the patient results, uses software to determine the concentration of the analyte(s) being measured, and enters the results into the laboratory information system.
c. *Post-analytical steps.* A second laboratory scientist or lead scientist reviews the results to confirm they were accurately interpreted, quantitated, and entered into the laboratory information system. The reviewing scientist approves the results, sending them to the patient’s electronic medical record. The ordering physician then reviews the laboratory result produced by the test and uses it to inform patient care decisions.
30. This is a laboratory-developed testing service: a series of processes and tasks undertaken by trained laboratory professionals using instruments and other tools to derive information that may be useful to a treating physician. Under any reasonable interpretation, these procedures and the exercise of judgment that they require constitute a professional service, not a manufactured device. *See* Dr. Reddy Decl. ¶¶ 14, 22–23; Dr. Fesko Decl. ¶¶ 15, 20; Dr. Eisenberg Decl. ¶¶ 8, 14–15, Dr. Genzen Decl. ¶¶ 43–45; Dr. Morice Decl. ¶¶ 14, 48–56.
31. Laboratory-developed tests are a vital part of the U.S. healthcare system and make significant contributions to patient care. They have often been responsible for scientific innovations and breakthroughs—for example, testing for the BRCA1/BRCA2 genetic mutations that indicate susceptibility to breast and ovarian cancer—that have become part of the standard of care (and in some cases, have been incorporated into FDA-cleared or approved IVD test kits). They also play a critical role in responding to public health threats from rare or emerging pathogens and new synthetic drugs, such as fentanyl analogs.
32. Many important diagnostic tests are available *only* as laboratory-developed testing services because no FDA-cleared or approved test kit exists for a particular disease, condition, or patient population. And even when an approved or cleared test kit is available, laboratory-developed tests often perform better and are preferred by physicians. Unlike medical devices, which must always take their approved form, laboratory-developed tests can be updated and customized (under the supervision of a CLIA-qualified laboratory director) to take account of the latest scientific developments and the needs of particular patients and clinicians. *See* Dr. Reddy Decl. ¶¶ 17, 36–37; Dr. Genzen Decl. ¶¶ 26–27.
#### B. FDA’s statutory authority to regulate medical devices does not extend to professional services.
33. The FDCA was originally enacted by Congress in 1938. It authorized FDA to regulate “foods,” “drugs,” “devices,” and “cosmetics,” all of which were physical *products* that were mass-manufactured and commercially distributed. *See* Federal Food, Drug, and Cosmetic Act of 1938, Pub. L. No. 75-717, § 201(h), 52 Stat. 1040, 1041 (“The term ‘device’ … means instruments, apparatus, and contrivances, including their components, parts, and accessories, intended (1) for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or other animals; or (2) to affect the structure or any function of the body of man or other animals.”); *see also id.* §§ 201(f), (g),
34. Congress greatly expanded FDA’s authority over devices in the Medical Device Amendments of 1976 (“MDA”), Pub. L. No. 94-295, 90 Stat. 539, which amended the FDCA to “impose[] a regime of detailed federal oversight” on medical devices. *Riegel v. Medtronic, Inc.*, 552 U.S. 312, 316 (2008).
35. The FDCA’s Medical Device Amendments classify medical devices into three categories based on the level of risk they present. Class I devices are subject only to “general controls” such as labeling requirements. Class II devices are also subject to “special controls” such as performance standards and postmarket surveillance measures. Class III devices are subject to “a rigorous regime of premarket approval.” *Id.* at 316–17 (quotation marks omitted); see 21 U.S.C. § 360c(a)(1).
36. There are a few statutory exceptions to these general rules. Class III devices that were marketed before the statute’s effective date in 1976 were allowed to remain on the market unless and until FDA promulgates a regulation requiring the submission of premarket approval applications. *Riegel*, 55 U.S. at 316–17; see 21 U.S.C. §§ 360c(f)(1), 360e(b)(1). Moreover, a new Class III device need not go undergo full premarket approval if FDA finds that the new device is “substantially equivalent” to a grandfathered device. 21 U.S.C. § 360c(f)(1)(A).
37. While the three device categories differ by level of risk, they all comprise tangible, physical products. For example, Class I devices include “elastic bandages and examination gloves,” Class II devices include “powered wheelchairs and surgical drapes,” and Class III devices include “replacement heart valves, implanted cerebella stimulators, and pacemaker pulse generators.” *Riegel*, 552 U.S. at 316–17.
38. The statutory definition of “device” makes clear that FDA’s regulatory jurisdiction under the FDCA is limited to physical products and does not encompass professional services. The statute provides:
- The term “device” … means an *instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is—
- (A) recognized in the official National Formulary, or the United States Pharmacopeia, or any supplement to them,
- (B) intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals, or
- (C) intended to affect the structure or any function of the body of man or other animals, and
- which does not achieve its primary intended purposes through chemical action within or on the body of man or other animals and which is not dependent upon being metabolized for the achievement of its primary intended purposes.
21 U.S.C. § 321(h)(1) (emphasis added).
39. All of the terms used in the FDCA’s definition of “device”—“instrument,” “apparatus,” “implement,” “machine,” “contrivance,” “implant,” and “in vitro reagent”—refer to tangible, physical objects. Moreover, the statute uses the term “article” as a catch-all to encompass all “devices,” and the plain meaning of “article” does not include intangible services. An “article” is a “particular material thing, esp. one belonging to a specified class; a commodity; an item of goods or property.” *Article*, Oxford English Dictionary (2023), [https://www.oed.com/search/dictionary/?scope=Entries&q=article](https://www.oed.com/search/dictionary/?scope=Entries&q=article). Consistent with this common definition, courts have consistently construed the term “article” to mean a “material thing” or a “tangible item.” See, e.g., *ClearCorrect Operating, LLC v. ITC*, 810 F.3d 1283, 1290–94 (Fed. Cir. 2015) (construing the term “articles” in the Tariff Act), reh’g en banc denied, 819 F.3d 1334 (Fed. Cir. 2016) (mem.).
40. Other provisions of the FDCA confirm that a “device” is a physical product, not a service. Several key provisions are triggered only when a device is shipped or received in interstate commerce, commercially distributed, or held for sale—actions that, in ordinary parlance, can be performed on a tangible article but not on an intangible professional service.
41. For example, section 510(k) of the FDCA requires a device manufacturer to file a premarket notification report with FDA at least 90 days before “the introduction or delivery for introduction into interstate commerce for commercial distribution of a device.” 21 U.S.C. § 360(k). “Commercial
distribution” is defined in an FDA regulation to mean “any distribution of a device intended for human use which is held or offered for sale.” 21 C.F.R. § 807.3(b). Similarly, section 301(k) prohibits various acts “with respect to” a device “if such act is done while such article is held for sale (whether or not the first sale) after shipment in interstate commerce and results in such article being adulterated or misbranded.” 21 U.S.C. § 331(k). None of these provisions can reasonably be applied to an intangible professional service performed within a laboratory.
42. Still other provisions of the FDCA discuss devices in ways that make sense only if applied to physical products. For example, an application for premarket approval for a device must include, among other things: (i) a description of “the components, ingredients, and properties” of the device; (ii) a description of the methods, facilities and controls used in “the manufacture, processing, and, when relevant, packing and installation” of the device; and (iii) “such samples of such device and of components thereof as the Secretary may reasonably require” or “information concerning the location of one or more such devices readily available for examination and testing.” 21 U.S.C. § 360e(c)(1)(B), (C), (E). Intangible professional services do not have components, ingredients, or properties; the services are not manufactured, processed, packed, or installed (even if providing them might entail using a manufactured product or products); and samples of a service cannot be submitted to FDA or made readily available for inspection. *See* Dr. Reddy Decl. ¶¶ 22–23; Dr. Eisenberg Decl. ¶¶ 14–15; Dr. Fesko Decl. ¶ 15; Dr. Genzen Decl. ¶ 45; Dr. Morice Decl. ¶¶ 14, 48–56.
43. So too, the statute provides that in certain circumstances FDA may order the manufacturer, importer, or distributor of a device to “repair the device” or “replace the device with a like or equivalent device.” 21 U.S.C. § 360h(b). Unlike physical products, intangible professional services cannot be repaired or replaced.
44. Several of FDA’s promulgated regulations for devices can similarly be understood only as applied to a manufactured product. For example, an FDA regulation requires the “label of every medical device” and “[e]very device package” to bear a unique device identifier. 21 C.F.R. § 801.20(a). “Label” is defined as “a display of written, printed, or graphic matter upon the immediate container of any article,” and “device package” is defined as “a package that contains a fixed quantity of a particular version or model of a device.” *Id.* § 801.3 (incorporating 21 U.S.C. § 321(k)). These requirements make sense in the context of manufactured devices, where the primary and expected means of communication between the manufacturer and any purchaser is through a standardized label. In sharp contrast, a laboratory scientist’s performance of the tasks comprising a laboratory-developed test cannot be “labeled” or “packaged” in compliance with these regulations. Nor can those professional services be summarized in a standardized label; instead, clinical laboratory services entail the exercise of professional judgment when interpreting testing results and often a consultation process between professional laboratory clinicians and doctors and other healthcare providers. *See* Dr. Eisenberg Decl. ¶ 14; Dr. Fesko Decl. ¶¶ 9, 15; Dr. Genzen Decl. ¶ 19; Dr. Morice Decl. ¶¶ 27, 48–56.
45. Viewed collectively, these provisions confirm what the statutory definition of “device” makes clear: A “device” under the FDCA is a physical product or manufactured good, not an intangible professional service.
#### C. Congress created a separate and distinct framework for regulating laboratory testing services.
46. Congress created a separate statutory and regulatory framework to regulate laboratory testing services: the Clinical Laboratories Improvement Act of 1967, Pub. L. No. 90-174, § 5, 81 Stat. 533, 536, which was significantly expanded by the Clinical Laboratory Improvement Amendments of 1988, Pub. L. No. 100-578, 102 Stat. 2903, codified at 42 U.S.C. § 263a. This statutory framework is commonly referred to as “CLIA.”
47. Congress’s enactment and expansion of CLIA in 1967 and 1988 confirms that it did not understand the Medical Device Amendments in 1976 as authorizing FDA to regulate laboratory testing services as medical devices.
48. CLIA establishes a framework for the regulation of laboratories
49. CLIA and its implementing regulations reflect that performing and interpreting laboratory tests requires significant scientific and technical knowledge, training, experience, and judgment, and is fundamentally different from manufacturing physical devices. *See* Dr. Reddy Decl. ¶ 22; Dr. Genzen Decl. ¶ 27; Dr. Morice Decl. ¶¶ 12, 49, 52, 56–58, 62; Dr. Eisenberg Decl. ¶¶ 15–16; Dr. Fesko Decl. ¶ 15.
50. Under CLIA, all laboratories that perform clinical tests on human specimens must be certified by CMS or accredited through certain CMS-approved accreditation organizations. 42 U.S.C. § 263a(b); *see* Dr. Reddy Decl. ¶ 12; Dr. Genzen Decl. ¶ 15. Both CMS and accreditation organizations issue standards to assure that laboratories’ performance is “consistent” and their tests are “valid and reliable,” including quality-control standards and standards for the qualifications of the personnel directing, supervising, and performing the tests. 42 U.S.C. § 263a(f)(1). The standards must take into account, among other things, the type of tests performed, the “degree of independent judgment involved,” “the amount of interpretation involved,” “the difficulty of the calculations involved,” and “the type of training required.” § 263a(f)(2).
51. The College of American Pathologists is the most prominent example of a CMS-approved accreditation organization, and to be accredited by that organization, a laboratory must be inspected initially and then every two years and must demonstrate that it complies with approximately 3,000 specific requirements, including validation of any clinical claims made by the laboratory for any laboratory-developed testing service. *See* College of American Pathologists, *CAP Advances Quality in Laboratory Medicine and Safeguards Patient Testing with Annual Release of Laboratory Accreditation Program Checklists* (Sept. 23, 2021), https://newsroom.cap.org/cap-in-the-news/cap-advances-quality-in-laboratory-medicine-and-safeguards-patient-testing-with-annual-release-of-la/s/88c2ad6c-72b4-4641-aaa7-3edb4954aac8.
52. The CLIA regulations ensure that laboratory testing services are performed only by highly skilled and trained laboratory professionals. Laboratories that perform high-complexity tests must be overseen by a laboratory director, who must either be a licensed physician or hold a doctoral degree in a chemical, physical, biological, or clinical laboratory science. 42 C.F.R. § 493.1443. The laboratory director is responsible for ensuring that the laboratory’s test methodologies are “capab[le] of providing the quality of results required for patient care,” that “[l]aboratory personnel are performing the test methods as required for accurate and reliable results,” and that “consultation is available to the laboratory’s clients on matters relating to the quality of the test results reported and their interpretation concerning specific patient conditions.” *Id.* § 493.1407(e)(3), (9).
53. The laboratory must also have a technical supervisor with appropriate training or experience for the types of tests performed by the laboratory, *id.* § 493.1449, and a clinical consultant qualified to “consult with and render opinions to the laboratory’s clients concerning the diagnosis, treatment, and management of patient care,” *id.* § 493.1455. The clinical consultant is responsible for providing “consultation regarding the appropriateness of the testing ordered and interpretation of test results.” *Id.* § 493.1457. And all laboratory personnel who perform high-complexity tests must either be licensed physicians or have appropriate training and experience in laboratory science or medical technology. *Id.* § 493.1489.
54. Under CLIA, laboratory testing services are subject to strict quality controls. When a laboratory introduces a new diagnostic test “not subject to FDA clearance or approval” (or when it modifies an FDA-cleared or approved IVD test kit purchased from a device manufacturer), it must, “before reporting patient test results,” establish “performance specifications” for the test—including specifications for accuracy, precision, analytical sensitivity, and other characteristics “required for test performance.” *Id.* § 493.1253(b)(2). Performance of the test is also subject to the laboratory’s CLIA-mandated
quality control system, which requires, among other things, establishment and performance of calibration and control procedures; maintenance and function checks for equipment, instruments and test systems; and ongoing quality monitoring. *Id.* § 493.1200–1299.
55. CLIA further requires laboratories to demonstrate proficiency in their tests multiple times a year. 42 U.S.C. § 263a(f)(3). For many of their tests, laboratories must enroll and participate in approved proficiency testing programs, which serve as external quality control checks for every test the laboratory performs. Proficiency testing requires that the laboratory test blinded samples according to its typical procedures and report the results back to the testing program for evaluation. 42 C.F.R. § 493.801. A laboratory that fails to achieve satisfactory proficiency scores may face sanctions, including suspension, limitation, or revocation of its CLIA certificate. *Id.* §§ 493.803(b), 493.1806.
56. CLIA-certified laboratories are subject to inspections, by the Department of Health and Human Services, state agencies, and authorized accrediting bodies. *See, e.g.*, 42 U.S.C. § 263a(g); 42 C.F.R. Part 493, Subpart Q.
57. Although CLIA was enacted nine years before the Medical Device Amendments and significantly expanded twelve years after those Amendments, neither CLIA nor its legislative history acknowledges any authority of FDA to regulate laboratory testing services as medical devices.
58. The Senate Report on the 1967 bill addressed concerns about possible overlap between regulation of clinical laboratories under CLIA and under the Medicare statute, but it did not mention any role for FDA. *See* S. Rep. No. 90-724 (1967), *reprinted in* 1967 U.S.C.C.A.N. 2076, 2084.
59. Likewise, the House Report on the 1988 bill described “[t]he Current Regulatory System” as involving federal regulation of laboratories “under two programs”—the Clinical Laboratory Improvement Act of 1967 and the Medicare statute—and did not so much as mention regulation by FDA. H.R. Rep. No. 100-899, at 11 (1988). The Report also states that the purpose of CLIA was to replace a “confusing” system where laboratories were regulated under “two separate and distinct statutes” with a single “unified regulatory mechanism”—a purpose that is at odds with subjecting laboratory testing services to regulation under both CLIA and the FDCA. *Id.* at 12.
60. In short, there is no indication that Congress, when it enacted CLIA, believed that clinical laboratories’ provision of testing services was already subject to regulation under the FDCA.
#### D. FDA has never broadly regulated laboratory testing services as medical devices.
61. In the nearly half-century since Congress enacted the Medical Device Amendments of 1976—not to mention the 86 years since Congress first gave FDA authority over medical devices in 1938—FDA has never before acted to broadly regulate laboratory-developed tests as “devices” under the FDCA. This lengthy history confirms that FDA lacks statutory authority to do so now. *See Util. Air Regul. Grp.*, 573 U.S. at 324 (an agency’s reliance on “a long-extant statute” to bring about a dramatic “expansion in [its] regulatory authority” should be met with “skepticism”); *Christopher v. SmithKline Beecham Corp.*, 567 U.S. 142, 157–58 (2012) (when an agency has responded to an industry’s “decades-long practice” with a “lengthy period of conspicuous inaction,” the likely explanation is that the industry practice was lawful).
##### 1. FDA’s Many Years of Silence
62. In the first 16 years following Congress’s enactment of the Medical Device Amendments to the FDCA, from 1976 through 1992, FDA did not claim any authority to regulate laboratory testing services as “devices.” Nor had FDA ever claimed such authority under the FDCA as enacted in 1938, even though that statute contained a similar definition of “device.”
63. Clinical laboratories thus reasonably understood that their services were not subject to regulation under the FDCA. *See Dr. Reddy Decl.* ¶ 24; Dr. Eisenberg Decl. ¶¶ 15–17; Dr. Fesko Decl. ¶ 14; Dr. Genzen Decl. ¶ 46. Congress acted on the same understanding when it enacted CLIA to create a single, unified, comprehensive system for the federal regulation of laboratory testing.
64. The first time FDA suggested that it might possess authority to regulate laboratory-developed tests as devices was in 1992—16 years after Congress enacted the Medical Device Amendments and 54 years after it first enacted the FDCA. But when that suggestion drew immediate and strenuous objections, FDA essentially backed down and announced a “policy” of not exercising jurisdiction over laboratory testing services that it adhered to for the next 30 years.
65. In its final rule, FDA cites a 1973 rulemaking as purported evidence that FDA treated tests as devices before Congress enacted the Medical Device Amendments. 89 Fed. Reg. 37,286, 37,328 (May 6, 2024) (citing 38 Fed. Reg. 7096 (Mar. 15, 1973)). That rulemaking defined “[i]n vitro diagnostic products”—not services—as diagnostic “reagents, instruments and systems.” 38 Fed. Reg. at 7098. (emphasis added). Although FDA now suggests that the term “systems” was intended to include testing services, the context makes clear that the only “systems” subject to the rule were finished products, not laboratory tests. For example, the 1973 rule included labeling provisions requiring that certain information be affixed to the “retail package” of the “article.” 38 Fed. Reg. at 7098. The 1973 rule thus confirms that FDA originally sought to regulate only physical products, not professional laboratory procedures or techniques. Moreover, when Congress amended the definition of “device” in 1976, it did not include the term “system” or even the term “in vitro product,” but only the narrower term “in vitro reagent.”
##### 2. FDA’s Never-Finalized 1992 Guidance
66. Sixteen years following the enactment of the Medical Device Amendments, in 1992, in a draft Compliance Policy Guide, FDA made the novel claim that it could regulate laboratory-developed tests as medical devices. This claim was made in passing in a document that generally addressed the marketing and distribution of IVD test kits. In a brief aside, FDA stated that “laboratories have been manufacturing ‘home brew’ products, either from products already on the market, or from components, and utilizing these unapproved products for diagnostic purposes,” and added that “[t]hese products are subject to the same regulatory requirements as any unapproved medical device.” FDA, Draft Compliance Policy Guide: Commercialization of Unapproved In Vitro Diagnostic Devices Labeled for Research and Investigation at 4 (Aug. 3, 1992).
67. The laboratory profession immediately objected to this abrupt and unexplained assertion of jurisdiction over professional laboratory testing services. For example, a law firm that represented clinical laboratories filed a citizen petition asking FDA not to assert jurisdiction over laboratories’ “in-house assays” and noting, among other concerns, that FDA’s authority over medical devices “does not extend to test methods, protocols, or services.” Citizen Pet. at 9, Hyman, Phelps & McNamara, P.C., Docket No. FDA-92-P-0405 (Oct. 22, 1992) (“1992 Citizen Petition”).
68. FDA did not immediately respond to the 1992 Citizen Petition. But following controversy over the 1992 draft guidance, FDA did not finalize that guidance or attempt to actively regulate laboratory testing services. Instead, FDA sought to calm the waters by announcing that it did “not intend to routinely exercise its authority over home-brew tests.” *IVD Policy Will Not Include Exemptions for “Standard-of-Care” Tests*, The Gray Sheet (Oct. 11, 1993).
##### 3. FDA’s Sporadic Claims of Authority in the 1990s and 2000s
69. FDA next asserted that it had jurisdiction over laboratory testing services in the non-binding preamble to a 1996 proposed rule regarding device classification levels for certain “active ingredients used in preparing in-house developed [laboratory] tests.” 61 Fed. Reg. 10,484, 10,485 (Mar. 14, 1996). In the preamble, FDA noted that it had previously regulated as devices only (i) “diagnostic tests that are traditionally manufactured and commercially marketed as finished products” (i.e., test kits), and (ii) tangible articles used as test “ingredients,” such as “laboratory apparatus” and “chemicals or antibodies,” that laboratories “purchase from biological or chemical suppliers.” *Id.* at 10,484.
70. In response, ACLA and other stakeholders filed comments.
challenging FDA’s assumption that it had authority to regulate laboratory testing services as medical devices.
71. In the preamble to the final rule, FDA stated that it “believes that clinical laboratories that develop such [in-house] tests are acting as manufacturers of medical devices.” 62 Fed. Reg. at 62,249. FDA recognized, however, that “the use of in-house developed tests has contributed to enhanced standards of medical care in many circumstances and that significant regulatory changes to this area could have negative effects on the public health.” *Id.* FDA therefore stated that it would continue to focus on regulating “ingredients … that move in commerce” and other tangible articles, not laboratory testing services. *Id.; see id.* at 62,250 (concluding that “regulation of all in-house developed tests” was not “appropriate at this time”).
72. Over the next 12 years, FDA continued to assert periodically and in draft non-binding guidance that it had statutory authority to regulate professional laboratory testing services as manufactured devices but was choosing not to. But FDA never took any final regulatory action backing up its non-binding statements. And the agency’s consistent policy of *not* treating laboratory-developed tests as devices made these occasional claims nothing but empty posturing.
##### 4. FDA’s Never-Finalized 2014 Guidance
73. FDA’s first real suggestion that it might put its posturing into practice came in 2010, when the agency announced its intention to “reconsider its policy of enforcement discretion” with respect to laboratory-developed tests. 75 Fed. Reg. 34,463–64 (June 17, 2010). FDA said it intended to “develop a draft oversight framework for public comment” that would “phase in … over time based on the level of risk” presented by various tests. *Id.*
74. In response, ACLA submitted comments reiterating that “laboratories are providers of testing services; they are not medical device manufacturers.” ACLA Supp. Comments on Oversight of Lab’y Developed Tests at 4, Docket No. FDA-2010-N-0274 (Sept. 15, 2010). ACLA explained that, while it might be appropriate for FDA to regulate as devices “the products used by clinical laboratories to perform tests,” including “commercially distributed *in vitro* diagnostic test kits,” FDA should not and cannot recklessly impose device regulation on the provision of “laboratory services.” *Id.* at 4, 6 (emphases added).
75. Two years later, with FDA still not having published any proposed oversight framework, Congress prohibited the agency from issuing “any draft or final guidance on the regulation of laboratory-developed tests” for five years unless the details of FDA’s plan were disclosed to the relevant congressional committees at least 60 days prior to such issuance. Pub. L. No. 112-144, § 1143(a), 126 Stat. 993, 1130 (2012).
76. A year after that, ACLA submitted a citizen petition asking FDA to acknowledge that laboratory testing services are not devices. ACLA’s petition explained that text and legislative history make clear that “devices” are tangible articles and do not include services or procedures. *See* ACLA Citizen Pet. at 7–9, Docket No. FDA-2013-P-0667 (June 4, 2013). The petition acknowledged that performing a laboratory-developed test “might involve use of” physical devices, such as “reagents,” “laboratory equipment,” or “IVD test kits.” *Id.* at 1, 8. But it stressed that a clinical service does not become subject to regulation as a device “simply because the service involves the use of tangible articles which may be subject to FDA regulation.” *Id.* at 8–9. Otherwise, it noted, “every surgical procedure or physical examination that is performed on a patient using tangible devices” would itself be a “device.” *Id.*
77. FDA denied ACLA’s citizen petition in 2014 and asserted that laboratory-developed tests “are ‘devices’ as defined in the FDCA.” FDA Denial of ACLA Citizen Pet. at 3, Docket No. FDA-2013-P-0667 (July 31, 2014). Eliding the distinction between professional services and physical products, FDA claimed that laboratory testing services are devices because they *make use of* various physical “articles,” such as “reagents,” “instruments,” and “equipment”—even though the testing services themselves are plainly not “articles.” *Id.* at 3–5, 23.
78. On the same day it denied ACLA’s citizen petition, FDA made similar assertions in response to two other citizen petitions, which had been
pending since 2006 and 2008, respectively. *See* FDA Denial of Wash. Legal Found. Citizen Pet. at 3–4, Docket No. FDA-2006-P-0149 (July 31, 2014); FDA Denial of Genentech, Inc., Citizen Pet. at 5–6, Docket No. FDA-2008-P-0638 (July 31, 2014). Also on that day, FDA notified Congress of its intent to issue draft guidance documents regarding laboratory-developed tests.
79. On October 3, 2014, FDA released the draft guidance documents it had promised in 2010, proposing to phase in new regulation of laboratory-developed tests as devices over a nine-year period. In announcing the draft guidance documents, FDA described laboratory-developed tests as “a subset of in vitro diagnostic devices that are intended for clinical use and designed, manufactured, and used within a single laboratory.” 79 Fed. Reg. 59,776, 59,777 (Oct. 3, 2014); *see also* 79 Fed. Reg. 59,779, 59,780 (Oct. 3, 2014).
80. ACLA submitted comments on the draft guidance documents. Among other points, ACLA’s comments explained once again that “a ‘device’ is a physical article or product” and “[l]aboratory-developed testing services are processes and methodologies that are qualitatively and categorically different from the tangible goods that FDA may regulate as ‘devices.’” ACLA Comments on Oversight of Laboratory Developed Tests and Reporting at 5, Docket Nos. FDA-2011-D-0357 & -0360 (Feb. 2, 2015). ACLA also reiterated that “[l]aboratory-developed testing services do not become medical devices merely because they sometimes utilize other medical devices,” such as reagents and laboratory equipment. *Id.* at 6. As ACLA noted, “every time a radiologist reads an x-ray, she is providing a service that depends on a medical device—the x-ray machine. However, the radiologist is rendering a service and is not subject to regulation under the FDCA” as a device manufacturer. *Id.*
81. On November 18, 2016, FDA backed down, announcing that it would not finalize the 2014 draft guidance documents. In a white paper published in January 2017, FDA noted that it had made this decision “to allow for further public discussion on an appropriate oversight approach, and to give our congressional authorizing committees the opportunity to develop a legislative solution.” FDA, Discussion Paper on Laboratory Developed Tests (LDTs) at 1 (Jan. 13, 2017).
##### 5. The 2020 Charrow Memo Questions FDA’s Authority to Regulate Laboratory Testing Services
82. In 2020, Robert Charrow, then-General Counsel of the Department of Health and Human Services, issued a memorandum regarding “Federal Authority to Regulate Laboratory Developed Tests.”
83. The Charrow memorandum is significant because it addresses and undermines key premises upon which FDA now relies. For example, it recognized that laboratory-developed tests “were never mentioned in the [Medical Device Amendments], in the House Report accompanying it, or during the floor debates.” Mem. from Robert Charrow, Gen. Counsel, to Stephen Hahn, M.D., Comm’r of Food & Drugs, at 3 (June 22, 2020) (attached as Ex. F). It further noted that Congress’s enactment of CLIA in 1988, and the Secretary’s issuance of “comprehensive rules governing clinical laboratories” pursuant to CLIA, “appeared to have occupied the field for regulating [laboratory-developed tests].” *Id.* at 3–4.
84. Contrary to FDA’s claims that it regarded laboratory-developed tests to be devices as far back as 1976, the Charrow memorandum acknowledges that FDA had “first suggested that [laboratory-developed tests] are subject to its jurisdiction” in 1992—16 years after the Medical Device Amendments were enacted—and that from 1992 until 2014, “FDA did little to regulate LDTs.” *Id.* at 4. Moreover, although FDA had proposed altering that status quo in 2014 when it published the draft guidance documents, it had subsequently declined to finalize those documents. *Id.* at 5.
85. Acknowledging the argument that laboratory-developed tests “are not physical embodiments, e.g. ‘contraptions,’ but rather are processes or services, and therefore not devices,” the Charrow memorandum observed that while “in vitro reagents are devices, … that does not necessarily lead to the conclusion that [laboratory-developed tests] fall within FDA’s jurisdiction.” *Id.* at 6. The memorandum explained that Congress’s enactments do not “lead[] to the conclusion that [laboratory-developed tests] are devices” and “the Secretary has issued rules implementing Medicare and CLIA that strongly
suggest that [laboratory-developed tests] are not devices and not within FDA’s jurisdiction.” *Id.* at 14.
86. The memorandum also recognized that laboratory-developed tests are not “goods or commodities” but rather “clinical laboratory services,” and are treated as such by Medicare. *Id.* at 10. The memorandum analogized “the development and use of” laboratory-developed tests to a “doctor’s development and use of a medical procedure.” *Id.*
##### 6. Congress Chooses Not to Enact Legislation
87. Reflecting the lack of statutory authority for FDA to regulate laboratory testing services under the FDCA, Congress considered legislative proposals that would have given FDA such authority. On March 5, 2020, the VALID Act was introduced in both houses of Congress. *See* Verifying Accurate Leading-edge IVCT Development Act of 2020, H.R. 6102, 116th Cong. (2020) (companion bill S.3404). The Act would have created a new regulatory pathway, separate from both drugs and devices, for FDA premarket review and regulation of “in vitro clinical tests,” including laboratory-developed tests. *See id.* § 2(a).
88. Commentators noted that “[e]arlier versions of the proposed VALID Act had been circulating in Washington for several years” following FDA’s “abortive” attempt to regulate laboratory-developed tests in 2014, which FDA had “abandoned” in 2016 “amid questions about [its] jurisdiction to regulate laboratory services.” Barbara J. Evans & Ellen Wright Clayton, *Deadly Delay: The FDA’s Role in America’s COVID-Testing Debacle*, 130 Yale L.J. Forum 78, 83–84 (2020)).
89. The VALID Act did not pass during the 116th Congress. It was reintroduced in the 117th Congress, where it again failed to pass. *See* VALID Act of 2021, H.R. 4128, 117th Cong. (2021) (companion bill S.2209). It was introduced again in 118th Congress, and once again it failed to become law. *See* VALID Act of 2023, H.R. 2369, 118th Cong. (2023) (companion bill S.2496).
#### E. FDA now seeks for the first time to classify virtually all laboratory testing services as medical devices.
##### 1. The 2023 Proposed Rule
90. With no congressional authorization forthcoming, FDA once again announced its intent to move forward with regulating virtually all laboratory-developed testing services as medical devices. FDA published its proposed rule in October 2023. *See* 88 Fed. Reg. 68,006 (Oct. 3, 2023).
91. In the proposed rule, FDA stated that it would amend a regulatory definition of “in vitro diagnostic products” to add the underlined language:
- [In vitro diagnostic products] are defined as “those reagents, instruments, and systems intended for use in the diagnosis of disease or other conditions, including a determination of the state of health, in order to cure, mitigate, treat, or prevent disease or its sequelae. Such products are intended for use in the collection, preparation, and examination of specimens taken from the human body.” ... These products are devices as defined in section 201(h)(1) of the Federal Food, Drug, and Cosmetic Act (the act) and may also be biological products subject to section 351 of the Public Health Service Act, *including when the manufacturer of these products is a laboratory.*
*See id.* at 68,017, 68,031 (proposed amendment to 21 C.F.R. § 809.3(a)). In the preamble, FDA made clear that it intended this amendment to signify that all laboratory testing services are “devices” and that whenever a laboratory scientist or technician performs a clinical laboratory test, he or she is engaged in “manufacturing” a “device.” *Id.* at 68,007–09, 68,017–19.
92. In the preamble to the proposed rule, FDA also stated its intent to “phase out its general enforcement discretion approach” so that most laboratory-developed tests would “fall under the same enforcement approach as other” medical devices within a few years. *Id.* at 68,007.
93. FDA also recognized that its rule would impose vast costs on the clinical laboratory sector (although again, its projections were low). It estimated that the up-front cost of preparing and submitting premarket approval applications, premarket notifications, and de novo classification requests *for existing tests alone* would exceed $35 billion and could be as high as $113 billion. FDA, Docket No. FDA-2023-N-2177, Laboratory Developed Tests Proposed Rule: Preliminary Regulatory Impact Analysis at 85 (Oct. 3, 2023). It also estimated that going forward, the annual compliance for affected laboratories would be more than $4 billion and could be as high as $14 billion.
94. FDA acknowledged that these costs would cause some existing tests to “come off the market” because laboratories would not be able to justify the high costs of obtaining the necessary approval or clearance for those tests. 88 Fed. Reg. at 68,014.
##### 2. ACLA’s Comments on the Proposed Rule
95. FDA received more than 6,000 comments on its proposed rule, a volume of public input that reflects the radical and transformative nature of FDA’s proposal.
96. ACLA submitted its comments on December 4, 2023. Among other critical points, ACLA’s comments explained, yet again, that FDA does not have legal authority to regulate laboratory-developed tests as devices—including because “devices” under the FDCA are physical products that are sold and distributed by manufacturers, whereas laboratory-developed tests are services offered by trained laboratory professionals that are regulated under CLIA’s distinct statutory and regulatory framework. _See_ ACLA Comments on Proposed Rule “Medical Devices; Laboratory Developed Tests” at 59–71, Docket No. FDA-2023-N-2177 (Dec. 4, 2023) (attached as Ex. G). ACLA’s comments also explained that FDA’s unlawful assertion of jurisdiction over clinical laboratory services would seriously harm patients by undermining diagnostic and medical innovation and limiting or eliminating access to critical tests. _Id._ at 7–18.
97. In addition, ACLA’s comments demonstrated that FDA had vastly underestimated the costs of regulating laboratory-developed tests as devices—including by underestimating the number of affected laboratories, the number of currently available tests that would require costly and time-consuming premarket submissions, the cost of preparing those submissions, and the cost of complying with other device regulations. _Id._ at 46–54. And conversely, ACLA showed that FDA had vastly _overestimated_ the benefits of its novel regulatory approach, including by using cherry-picked, anecdotal, and unverified “evidence” to paint an unfairly disparaging picture of laboratory testing services, while ignoring studies showing that laboratory-developed tests perform at least as well as FDA-approved or cleared IVD test kits. _Id._ at 36–46, 54–59.
##### 3. The 2024 Final Rule
98. FDA published the final rule on May 6, 2024.
99. As contemplated in the proposed rule, FDA amended the regulatory definition of “in vitro diagnostic products” in 21 C.F.R. § 809.3(a) to add the language, “including when the manufacturer of these products is a laboratory.” 89 Fed. Reg. at 37,286–87. And, as in the proposed rule, FDA made clear that it considers the provision of laboratory-based testing services a form of device “manufacturing.” _See id._ at 37,286–87, 37,289, 37,293, 37,328–32, 37,344.
100. In a major departure from the proposed rule, however, the preamble to the final rule states that FDA intends—for now and until it changes its mind—to exercise “enforcement discretion” for some or all requirements with respect to broad categories of laboratory-developed tests, including nearly all existing tests. _Id._ at 37,294–95. These non-binding “enforcement discretion policies” include the following:
- FDA will generally not enforce premarket review and Quality System (“QS”) requirements for existing tests that are not modified or that are “modified in certain limited ways.”
- FDA will generally not enforce premarket review requirements for tests approved by the New York State Department of Health’s Clinical Laboratory Evaluation Program.
- FDA will generally not enforce premarket review and QS requirements (except certain recordkeeping requirements) for tests “manufactured and performed” by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system.
- FDA will generally not enforce premarket review and QS requirements (except certain recordkeeping requirements) for non-molecular antisera tests for rare red blood cell antigens where such tests are “manufactured and performed” in blood establishments, including transfusion services and immunohematology laboratories, and where there is no alternative available to meet the patient’s need for a compatible blood transfusion.
- FDA will generally not enforce any requirements for “1976-Type LDTs” (tests with certain characteristics that FDA says were common among laboratory-developed tests offered in 1976).
- FDA will generally not enforce any requirements for Human Leukocyte Antigen tests that meet certain specified characteristics.
- FDA will generally not enforce any requirements for tests intended solely for forensic (law enforcement) purposes.
- FDA will generally not enforce any requirements for tests “manufactured and performed” within the Department of Defense or the Veterans Health Administration.
*Id.*
101. These extensive carveouts are necessary, the final rule acknowledges, because “expecting compliance with full [quality system] and premarket review requirements for all currently marketed” laboratory-developed tests “could lead to the loss of access to safe and effective” tests “on which patients currently rely.” *Id.* at 37,293; see Dr. Reddy. Decl. ¶ 6; Dr. Genzen Decl. ¶¶ 47, 56; Dr. Morice Decl. ¶¶ 15–16, 59–65.
102. In other words, faced with the impracticality and catastrophic impact of its novel interpretation of the law, FDA did not take that unworkability as a hint that its interpretation might be mistaken. Instead, to try to contain the damage, FDA effectively used a non-binding regulatory preamble to write a new statute on the fly, under the guise of “enforcement discretion policies.”
103. These broad carveouts undermine FDA’s legal rationale for the rule, which classifies all laboratory-developed tests as manufactured “devices” subject to the full suite of medical-device requirements regardless of whether the tests fall into the categories outlined in the enforcement discretion policies. For example, FDA does not identify any textual basis in the statute for subjecting new tests to a different regime than existing tests.
104. The broad carveouts are also inconsistent with FDA’s public-health rationale for the rule. For example, FDA cannot explain why, on the one hand, more limited regulation is sufficient for the tens of thousands of laboratory-developed tests in existence at the time of the final rule, but on the other hand, virtually every test developed *after* May 6, 2024, must run the full gauntlet of the medical-device requirements.
105. The final rule states that FDA will phase out its “general enforcement discretion approach” within a four-year period. 89 Fed. Reg. at 37,294. As a result, excepting the “enforcement discretion policies” described above, FDA will begin enforcing medical-device requirements with respect to laboratory-developed tests in five stages measured from the date of publication of the final rule:
- *After 1 year,* FDA will expect compliance with medical device reporting (“MDR”) requirements, correction and removal reporting requirements, and some QS requirements under 21 C.F.R. § 820.198.
- *After 2 years,* FDA will expect compliance with requirements not covered during other stages of the phaseout policy, including registration and listing requirements, labeling requirements, and investigational use requirements.
- *After 3 years,* FDA will expect compliance with other QS requirements under 21 C.F.R. § 820.198.
- *After 3½ years,* FDA will expect compliance with premarket review requirements for “high-risk IVDs offered as LDTs.”
- *After 4 years,* FDA will expect compliance with premarket review requirements for “moderate-risk and low-risk IVDs offered as LDTs.”
*Id.*
106. At the same time, the final rule emphasizes that both the “enforcement discretion policies” and the phased-in approach are merely matters of prosecutorial discretion and that laboratories are legally required to comply with all medical-device regulations *immediately.* The rule states that “the phaseout policy does not in any way alter the fact that it is illegal to offer” laboratory-developed tests “without complying with applicable requirements” and stresses that “[r]egardless of the phaseout timeline and enforcement discretion policies … FDA retains discretion to pursue enforcement action for violations of the FD&C Act at any time, and intends to do so when appropriate.” *Id.* at 37,295.
107. With respect to the “enforcement discretion policies,” FDA further cautions that “[a]s with any enforcement discretion policy, FDA may update any of these policies as circumstances warrant or if the circumstances that inform these policies change.” *Id.* at 37,297. FDA again emphasizes that “these enforcement discretion policies do not confer lawful marketing status on any [laboratory-developed tests] being marketed as described in the policies” and “do not in any way alter the fact that it is illegal to market [a laboratory-developed test] without complying with applicable requirements.”
The final rule also warns that FDA “intends to take action to enforce applicable requirements for [laboratory-developed tests] … as appropriate, taking into account any public health concerns as evaluated on a case-by-case basis.” *Id.* For example, “if FDA receives reports, or otherwise learns of information, that raise safety or effectiveness concerns with [a laboratory-developed test] that falls within an enforcement discretion policy, FDA generally intends to take action with respect to requirements applicable to that specific [test].” *Id.*
Again and again throughout the final rule, FDA declares that no laboratory is safe from enforcement merely because its conduct is consistent with FDA’s stated enforcement discretion policies. *See id.* at 37,301 (“[A]s noted elsewhere in this preamble, regardless of this or any other enforcement discretion policy, FDA retains discretion to pursue enforcement action at any time against violative [laboratory-developed tests] when appropriate.”); *id.* at 37,304 (same); *id.* at 37,307 (same).
As to existing tests, the final rule also states that FDA will expect compliance with premarket review and quality system requirements whenever the test is “changed in certain, more significant ways that could affect its basic safety and effectiveness profile,” such as “includ[ing] significantly different technology” in the test. *Id.* at 37,305. FDA does not explain how a laboratory might determine when a difference in technology is so “significant” as to trigger an expectation of compliance.
Under the final rule, FDA thus continues to assert comprehensive authority to regulate virtually all laboratory-developed tests as medical devices. FDA then tries to mitigate the fallout from that regulatory sea change by announcing vague, non-binding enforcement discretion policies in a 150-plus-page preamble to its final rule. But FDA takes the position that even laboratories acting within the scope of those vaguely defined policies are violating federal law and that FDA can decide to prosecute them at any time, leaving laboratories “at the mercy of [FDA’s] noblesse oblige.” *FCC v. Fox Television Stations, Inc.*, 567 U.S. 239, 255 (2012) (quoting *United States v. Stevens*, 559 U.S. 460, 480 (2010)).
In response to comments questioning FDA’s legal authority, FDA doubles down on its theory that professional laboratory testing services are medical “devices” just like pacemakers or test kits. “As an initial matter,” FDA says, “FDA does not read the definition of device to encompass only physical objects.” 89 Fed. Reg. at 37,331. And “[r]egardless” of that reading (i.e., even assuming the “device” definition is limited to tangible products), FDA explains, “a test system” developed by a laboratory “is a physical product and a material thing” because it involves “a set of components—such as reagents, instruments, and other articles—that function together to produce a test result.” *Id.* In other words, FDA’s position is that whenever laboratory professionals use multiple tangible articles together to perform a test, they are “manufacturing” a “device.” While FDA superficially disclaims that view, stating that its “position is not that laboratory services are articles but that in vitro diagnostic products used in laboratories (such as test systems) are articles,” FDA has effectively adopted a definition of “test systems” that conflates professional laboratory services with the articles used to perform those services.
Whereas the statutory definition of “device” refers to discrete objects or fixed assemblages of objects, which can typically be packaged and shipped, FDA’s approach treats as a “device” even a set of transient relationships between physical articles used by a skilled professional. For example, under FDA’s reductionist approach, if a surgeon uses multiple objects to perform a procedure, such as a scalpel and a set of sutures, the surgeon has “manufactured” a “device” by using those objects in combination.
In the final rule’s preamble, FDA also asserts that the statutory term “article” cannot be limited to tangible goods because, in FDA’s view, computer software can qualify as a medical device despite being “an intangible thing.” 89 Fed. Reg. at 37,331–32. Even assuming FDA is correct that software may sometimes qualify as a device, that does not support FDA’s assertion that
the “device” definition can be stretched to cover the intangible professional services provided by laboratory medical professionals, which are different from manufactured medical devices. As the Supreme Court has explained, while it is possible to conceive of “software in the abstract: the instructions themselves detached from any medium,” “[w]hat retailers sell, and consumers buy,” are “tangible,” “physical cop[ies] of the software” that, whether “delivered by CD-ROM” or “downloaded from the Internet,” are ultimately “contained in and continuously performed by” a piece of physical hardware such as a computer.
*Microsoft Corp. v. AT&T Corp.*, 550 U.S. 437, 446–48, 449–51 (2007).
115. FDA acknowledges that the final rule will impose major burdens on laboratories, but as with the proposed rule, FDA underestimates the impact. FDA projects that the requirements in the final rule will initially affect about 79,114 existing tests offered by 1,181 existing laboratories, and that it will also affect about 10,013 new tests offered every year going forward. *See* FDA, Laboratory Developed Tests Final Rule: Final Regulatory Impact Analysis at 36, 54–55 (May 6, 2024) (“Final Impact Analysis”) (attached as Ex. H). As FDA notes, “most facilities that will be affected by this rule are defined as small businesses and the final rule is likely to impose a substantial burden on the affected small entities.” *Id.* at 6–7; 89 Fed. Reg. at 37,433.
116. Even under the generous assumption that FDA will adhere to its non-binding enforcement discretion policies, *see* Final Impact Analysis at 37–38, FDA estimates that it will need to review an additional 103 premarket applications, 1,090 premarket notifications, and 267 de novo classification requests each year—a vast increase in each category compared to the average from 2017 to 2021, including more than a doubling of the number of premarket applications, *see id.* at 57.
117. FDA estimates that the compliance costs for laboratories will total well over $1 billion per year. *See id.* at 2, 135, 178. Over the next two decades, FDA projects that total costs associated with the final rule will range from $12.57 billion to $78.99 billion, with a primary estimate of $28.61 billion. *Id.* at 125.
118. FDA acknowledges that the huge “increased cost to laboratories” may cause price increases for customers and “reduce the amount of revenue a laboratory can invest in creating and/or modifying” tests. *Id.* at 127.
#### F. HealthTrackRX and other ACLA members face irreparable harm from FDA’s final rule.
119. Under Fifth Circuit precedent, “the nonrecoverable costs of complying with a putatively invalid regulation typically constitute irreparable harm.” *Rest. L. Ctr. v. U.S. Dep’t of Lab.*, 66 F.4th 593, 597 (5th Cir. 2023) (collecting cases).
120. By FDA’s own admission, the final rule will impose significant nonrecoverable compliance costs on regulated laboratories, including HealthTrackRX and other ACLA members. *See* Final Impact Analysis at 125 (estimating compliance costs of about $101 million in year 1, $113 million in year 2, $386 million in year 3, and more than $1.6 billion every following year). These costs will be unrecoverable because FDA, like other federal agencies, enjoys sovereign immunity from monetary damages. *See* *Rest. L. Ctr.*, 66 F.4th at 598.
121. HealthTrackRX and other ACLA members will need to begin incurring these costs immediately. FDA has made clear that despite the “phaseout” timeline and “enforcement discretion” policies in the final rule, it “retains the authority to enforce any applicable requirements and pursue enforcement action *at any time*” against laboratories that offer laboratory-developed tests without complying with regulatory requirements applicable to medical devices. 89 Fed. Reg. at 37,372 (emphasis added). And even if FDA were to commit to not taking enforcement action before the dates set forth in the policy (and FDA has expressly disclaimed such a commitment), laboratories would still have to begin incurring compliance costs well in advance of those dates to ensure full compliance by the relevant deadline.
122. Although FDA greatly underestimates both the magnitude of unrecoverable compliance costs and how quickly laboratories will begin incurring those costs, even FDA suggests that laboratories’ costs of compliance in the first year after publication of the final rule will range from $47.85 million
to $216.75 million, with a primary estimate of $101.46 million. *See* Final Impact Analysis at 125. Those unrecoverable costs alone are sufficient to establish that laboratories face irreparable harm from the final rule.
123. Moreover, FDA wrongly assumes that laboratories will be able to defer certain compliance costs for several years. For example, FDA predicts that costs associated with preparing and submitting premarket approval applications, premarket notifications, and de novo classification requests for laboratory-developed tests—costs that FDA acknowledges will easily run to billions of dollars—will not occur until the third year after publication of the final rule. *See id.* at 124–25.
124. Contrary to FDA’s assumptions, laboratories cannot delay incurring these costs until just six to eighteen months before FDA says it will begin enforcing premarket review requirements. Indeed, to support premarket applications, laboratories will need to begin preparatory work immediately, including meeting with FDA reviewers to agree on analytical and clinical validation study protocols, running such validation studies, and otherwise compiling the voluminous material required to support FDA approval or clearance.
125. HealthTrackRx and other ACLA members have made substantial financial investments to maintain and expand their business—including opening new laboratories, acquiring assets, and hiring employees—in reliance on the understanding that laboratory testing services are not subject to FDA regulation as medical devices and are instead regulated under CLIA and applicable state law. Dr. Reddy Decl. ¶ 24; Dr. Eisenberg Decl. ¶ 18; Dr. Fesko Decl. ¶ 16; Dr. Genzen Decl. ¶ 22; Dr. Morice Decl. ¶ 66.
126. FDA’s final rule puts HealthTrackRx and other ACLA members in an untenable situation of regulatory uncertainty, which creates a serious risk of chilling investment in the maintenance of existing testing services and the development of new or modified testing services. Dr. Reddy Decl. ¶ 27; Dr. Eisenberg Decl. ¶ 17; Dr. Fesko Decl. ¶¶ 18–21; Dr. Genzen Decl. ¶¶ 47, 52; Dr. Morice Decl. ¶¶ 15–16, 58–65, 68.
127. ACLA members have already expended substantial time and capital to prepare for, and ensure that they are able to comply with, FDA’s final rule. *See* Dr. Reddy Decl. ¶ 26.
128. If FDA’s final rule is permitted to take effect, ACLA members will face even greater unrecoverable costs, often in the hundreds of thousands of dollars or more per test, in order to ensure that they can remain in compliance with federal law. *See id.* ¶ 29; Dr. Fesko Decl. ¶ 19; Dr. Genzen Decl. ¶¶ 50, 56.
129. If the final rule is allowed to remain in place, there is a substantial risk that some tests will no longer be available to help providers and patients because of the prohibitive costs of seeking FDA approval and clearance, especially for tests that are not high-volume. *See* Dr. Reddy Decl. ¶ 31; Dr. Genzen Decl. ¶¶ 56, 58; Dr. Morice Decl. ¶¶ 16, 59–61.
130. Given the unrecoverable costs of complying with the FDA’s medical device requirements, and the likelihood that device regulation will exacerbate an FDA-review bottleneck, the final rule will hinder innovation by making it more difficult for ACLA members to develop, and for patients to access, new and modified tests. *See* Dr. Reddy Decl. ¶¶ 32–37; Dr. Genzen Decl. ¶¶ 47–51; Dr. Morice Decl. ¶¶ 15–16, 59–65, 68; Dr. Fesko Decl. ¶ 21.
### CLAIMS FOR RELIEF
#### COUNT 1 Violation of the Administrative Procedure Act—Contrary to Law, in Excess of Statutory Jurisdiction and Authority, and Contrary to Constitutional Right and Power 5 U.S.C. § 706(2)
131. Plaintiffs reallege and incorporate by reference each of the preceding paragraphs as if set forth fully herein.
132. Under the Administrative Procedure Act, a court must set aside agency action that is not in accordance with law or in excess of statutory authority. *See* 5 U.S.C. § 706. An agency action is invalid and must be vacated if it exceeds the power conferred upon the agency by the statute. *See Perez v. Mortg. Bankers Ass’n*, 575 U.S. 92, 104–05 (2015).
133. FDA’s final rule is contrary to law and in excess of FDA’s statutory jurisdiction and authority because it treats laboratory testing services as medical devices that are subject to regulation under the FDCA, when in fact...
they are services performed by highly skilled healthcare professionals.
134. The text, structure, and history of the FDCA make clear that a device is a physical product, not a professional service. Treating laboratory testing services as devices would not only do violence to the statutory definition of “device,” but would also require distorting numerous other statutory and regulatory provisions that confirm that FDA’s device authority is limited to physical goods.
135. The text and history of CLIA provide further confirmation that laboratory services are not devices subject to regulation under the FDCA. In CLIA, Congress created a comprehensive framework for the regulation of professional laboratory testing services—including extensive personnel qualification requirements, quality controls, and proficiency testing—that is separate and distinct from the framework for regulation of manufactured medical devices under the FDCA. Congress first enacted CLIA in 1967, nine years before the Medical Device Amendments, and significantly expanded CLIA in 1988, twelve years after those Amendments. In doing so, Congress never so much as hinted at any existing authority of FDA to regulate laboratory testing services under the FDCA. And when Congress acted to create a distinct and uniform system of regulation for clinical laboratories, it clearly indicated that FDA had no such authority.
136. Although the clarity of the statutory text should put an end to the inquiry, FDA’s attempt to regulate laboratory testing services as devices also implicates the major questions doctrine. *See West Virginia, 597 U.S. at 724.* FDA’s rule would mean that the entire clinical laboratory sector, which is a significant part of the U.S. healthcare system, has been breaking the law for nearly 50 years, and possibly much longer. And it would mean that going forward, the entire profession is operating unlawfully and can be subject to civil and criminal penalties at any time, with its only protection coming from a policy of enforcement discretion that FDA insists it is free to revoke at any time. The rule would also wreak havoc on clinical laboratories and the doctors and patients they serve, imposing billions of dollars in immediate, unnecessary costs and preventing countless new tests from ever being developed. And it would produce a vast increase in the number of medical-device applications FDA must review every year.
137. An agency cannot impose massive costs and place an entire profession under its thumb in this manner without, at minimum, a clear statement from Congress. The Supreme Court has repeatedly warned that agencies should not attempt, and courts should not abide, such drastic expansions of the agency’s authority under a “‘long-extant statute”’—especially where, as here, Congress has “conspicuously and repeatedly declined to enact” such an expansion itself. *West Virginia, 597 U.S. at 724 (quoting Util. Air Regul. Grp., 573 U.S. at 324).*
#### COUNT 2 Violation of the Administrative Procedure Act—Arbitrary and Capricious and an Abuse of Discretion 5 U.S.C. § 706(2)
138. Plaintiffs reallege and incorporate by reference each of the preceding paragraphs as if set forth fully herein.
139. Under the Administrative Procedure Act, a court must set aside agency action that is arbitrary and capricious, an abuse of discretion, or inconsistent with the requirements of reasoned decision-making. *See* 5 U.S.C. § 706. An action is arbitrary and capricious if agency acts outside the reasonable scope of its lawful authority, fails to articulate a satisfactory explanation for its actions, or fails to respond adequately and reasonably to comments and objections.
140. FDA has not acted consistent with the requirements of reasoned decision-making because it has not adequately responded to objections, provided a reasoned justification for its rule, or reasonably explained its sweeping assertion of new regulatory authority. FDA’s decision to exercise enforcement discretion through the use of non-binding guidance in a preamble only underscores how unreasonable it is for FDA to outlaw an entire sector of professional services, especially given the reliance interests at stake.
141. Accordingly, even if Congress had granted FDA authority under the FDCA to regulate certain types of laboratory-developed tests as medical
devices, the agency has not exercised that authority consistent with the requirements of reasoned decision-making under the Administrative Procedure Act and the Constitution’s separation of powers.
142. FDA’s final rule cannot be allowed to stand because it is ultra vires, arbitrary and capricious, and an abuse of discretion.
### PRAYER FOR RELIEF
WHEREFORE, Plaintiffs request that the Court:
A. Enter a declaratory judgment that FDA’s final rule is contrary to law; in excess of statutory jurisdiction, authority, or limitations; and arbitrary or capricious, and that FDA is not authorized to regulate laboratory testing services as medical devices under the FDCA.
B. Enter an order that vacates FDA’s final rule and enjoins FDA from enforcing the final rule and regulating laboratory testing services as medical devices under the FDCA.
C. Order such other and further relief as the Court deems just and proper.
Dated: May 29, 2024
Respectfully submitted,
**/s/ Edward F. Fernandes**
Edward F. Fernandes
Texas Bar No. 06932700
Christopher H. Taylor
Texas Bar No. 24013606
KING & SPALDING LLP
500 W. 2nd Street
Suite 1800
Austin, TX 78701
Tel: (512) 457-2000
Fax: (512) 457-2100
efernandes@kslaw.com
ctaylor@kslaw.com
Ashley C. Parrish*
D.C. Bar No. 464683
Paul Alessio Mezzina*
D.C. Bar No. 999325
Alexander Kazam*
D.C. Bar No. 1708188
KING & SPALDING LLP
1700 Pennsylvania Avenue NW
Suite 900
Washington, DC 20006
Tel: (202) 737-0500
Fax: (202) 626-3737
aparrish@kslaw.com
pmezzina@kslaw.com
akazam@kslaw.com
Scott D. Danzis*
D.C. Bar No. 481426
COVINGTON & BURLING
One CityCenter
850 Tenth Street, NW
Washington, DC 20001-4956
Tel: (202) 662-6000
sdanzis@cov.com
*Counsel for Plaintiffs*
*pro hac vice applications forthcoming*
## EXHIBIT A
AMERICAN CLINICAL LABORATORY ASSOCIATION;
HEALTHTRACKRX INDIANA, INC.; and HEALTHTRACKRX, INC.,
Plaintiffs,
v.
U.S. FOOD AND DRUG ADMINISTRATION; U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; XAVIER BECERRA, in his official capacity as Secretary of Health and Human Services; and ROBERT M. CALIFF, M.D., in his official capacity as Commissioner of Food and Drugs, United States Food and Drug Administration,
Defendants.
**DECLARATION**
### DECLARATION OF JAY REDDY, Ph.D.
I, Jay Reddy, Ph.D., declare as follows:
1. I am a resident of Denton, Texas. I am over the age of eighteen, and I am competent to provide this declaration.
2. I am the Senior Vice President of Laboratory and Clinical Strategy at HealthTrackRx. I have held that position for a little more than 2 years. I was previously the company’s Vice President of Laboratory Operations.
3. I have worked at HealthTrackRx for more than 9 years.
4. I received my Ph.D. in Molecular Biology at Texas Women’s University.
5. As a result of my professional experiences and background, I am familiar with the laboratory testing services and procedures that HealthTrackRx offers. I am also familiar with the legal and regulatory requirements that apply to laboratory-developed tests.
6. I am deeply concerned about the final rule issued by the Food and Drug Administration (“FDA”) on May 6, 2024, and the enormous costs it will impose on clinical laboratories, such as HealthTrackRx. FDA’s final rule also creates serious risks for patients by threatening to reduce their access to important and safe testing services.
#### HealthTrackRx
7. HealthTrackRx is one of the nation’s premier infectious disease laboratories.
8. HealthTrackRx has its principal place of business in Denton, Texas.
9. For more than twenty years, HealthTrackRx has helped providers make informed clinical decisions by offering next-morning testing results to healthcare providers throughout the nation using accurate and targeted molecular diagnostic testing processes and procedures.
10. HealthTrackRx specializes in a particular type of testing service that employs a pathogen assay referred to as Real-Time Transcription Polymerase Chain Reaction (“RT-PCR”). The RT-PCR technology is used to detect bacteria and viruses on a molecular level. PCR testing services, which can be performed overnight, allow for faster and more accurate results than traditional culture assays, which can take 3 to 14 days (or even longer) to obtain results. By using advanced PCR testing, HealthTrackRx is able to help providers make better and more informed patient treatment decisions.
11. The company’s testing services cover a wide variety of different specialties, such as otolaryngology and ophthalmology, and target viral, bacterial, and fungal pathogens that cause a range of everyday infections, including respiratory infections, urinary tract infections, genitourinary infections, gastrointestinal infections, wound infections, and onychomycosis.
12. All of HealthTrackRx’s laboratories are certified by the United States Department of Health and Human Services under the federal Clinical Laboratory Improvement Amendments (“CLIA”) to perform clinical tests on human specimens. All HealthTrackRx laboratories are enrolled in proficiency
13. All of HealthTrackRx’s laboratories also participate in the rigorous accreditation program overseen by CAP, which is the “gold standard” accreditation program for molecular diagnostic laboratories.
14. HealthTrackRx has more than 300 employees and operates laboratories in Denton, Texas; Clarksville, Indiana; Marietta, Georgia; and Sherman Oaks, California. All testing personnel meet CLIA/CAP requirements, and HealthTrackRx employees in California are certified by the California Department of Public Health to perform testing. HealthTrackRx also employs professional “Certifying Scientists” to review quality control and raw data before releasing patient reports to providers. These professional scientists have a minimum of a Master’s degree in a biological or chemical science, and most also have certification by the American Society of Clinical Pathology (MB (ASCP) or MLS (ASCP)).
15. The testing services provided by HealthTrackRx are carefully validated according to federal guidelines before those services are offered to healthcare providers. Analytical and clinical performance evaluations are concluded before the launch of any new testing service, and tests are continuously re-evaluated throughout each year to ensure patient data integrity.
16. HealthTrackRx has assumed an active leadership role in educating the healthcare community about Antimicrobial Resistance, which is recognized by the Centers for Disease Control as one of the greatest threats to public health worldwide. Antimicrobial Resistance occurs when bacteria mutate over time and no longer respond to antibiotics, making infections more challenging to treat and increasing the risk of contagion, severe illness, and death.
17. HealthTrackRx helps providers by detecting antibiotic resistant genes and identifying pathogens that are difficult to culture. Because our best-in-class PCR tests meet demanding sensitivity and specificity standards, and because we are able to offer next-morning results that provide a personalized, patient-specific antibiotic summary, we are able to help providers identify appropriate antibiotics that work for their patients.
18. HealthTrackRx promotes antibiotic stewardship through active training on diagnostic stewardship. All new and existing accounts have ongoing training to help identify the appropriate tests for their patient population. Appropriate test ordering is key to reducing unnecessary prescribing of antibiotics.
19. HealthTrackRx has an Advisory Board that is made up of leaders in the healthcare industry. Members of the Board include:
- **Barbara Alexander, M.D., FACP, FIDSA**, the company’s Chief Medical Advisor and Chair of the Advisory Board. Dr. Alexander is a Professor of Medicine and Pathology at Duke University, where she serves as Director of the Transplant/Immunocompromised Infectious Diseases Services.
- **Josh M. Berlin, J.D.**, Chief Executive Officer of rule of three, LLC (“ro3”).
- **Leah Binder**, President and Chief Executive Officer of Leapfrog Group.
- **Elizabeth Canis**, former Vice President for Emerging Business and Partnerships at Anthem.
- **Eric D. Hargan**, former Acting Secretary for the U.S. Department of Health and Human Services.
- **David B. Nash, M.D., MBA**, Founding Dean Emeritus at the Jefferson College of Population Health.
20. HealthTrackRx also has a Clinical Advisory Board, composed of leading experts in infectious disease and antimicrobial resistance. Our Clinical Advisory Board helps guide the company’s development of new testing services and menus, seeking to improve patient outcomes and combat antimicrobial resistance. The members of our Clinical Advisory Board include:
- **Barbara Alexander, M.D., FACP, FIDSA**.
- **Cornelius J. Clancy, M.D.**, Director of the Mycology Program at the University of Pittsburgh, Associate Chief of the VA Pittsburgh Health System and Chief of Infectious Diseases, and a Member of the Infectious Diseases Society of America’s Committee on Antimicrobial Resistance.
- **Barry Eisenstein, M.D.**, Chief Medical Officer and former Chair of the Scientific and Business Advisory Board of CARB-X.
- **Thomas M. File, Jr., M.D., MSC, MACP, FIDSA, FCCP**, Professor of Medicine and Chair of the Infectious Disease Section at Northeast Ohio Medical University.
- **Kimberly E. Hanson, M.D., MHS, FIDSA**, Professor of Medicine and Director of Transplant Infectious Diseases and Immunocompromised Host Service, and Section Head of Clinical Microbiology at the University of Utah.
- **Robin Patel, M.D.**, Elizabeth P. and Robert E. Allen Professor of Individualized Medicine, Professor of Microbiology and Medicine, Director of the Infectious Diseases Research Laboratory, and Co-Director of the Clinical Bacteriology Laboratory at the Mayo Clinic.
- **Adriana E. Rosato, SM (ASCP), MSC, Ph.D.**, Director of the Center for Molecular Medicine at the MaineHealth Institute for Research and Visiting Professor of Medicine at Tufts University.
#### The Consequences of FDA’s Final Rule
21. In treating laboratory-developed tests the same as medical devices, FDA’s final rule fundamentally misunderstands how laboratories, such as HealthTrackRx, perform professional testing services for the benefit of patients.
22. HealthTrackRx is not a manufacturer, and it does not manufacture products or articles of equipment. Its PCR testing services are not medical devices.
23. The molecular diagnostic services that HealthTrackRx’s professionals perform at its laboratories at the request of healthcare providers involve medical procedures, protocols, and processes that are used to analyze at the molecular level tissue, blood, and other patient specimens as part of the practice of laboratory medicine.
24. HealthTrackRx has made substantial financial investments — opening new laboratories, hiring employees, developing additional testing services, and expanding its business — in reliance on the understanding that laboratory testing services are not subject to FDA regulation as medical devices and are instead carefully regulated under CLIA and applicable state regulatory regimes.
25. I am concerned about the substantial costs that FDA’s final rule poses both for HealthTrackRx and for patients.
26. HealthTrackRx has already made substantial investments in order to prepare for, and ensure that it is able to comply with, FDA’s final rule. Because there is no ready ability to recover money damages from FDA, it is unlikely that HealthTrackRx will ever be able to recover those investments.
27. If FDA’s final rule is allowed to take effect, HealthTrackRx will face even greater unrecoverable costs and financial burdens in order to ensure that it is able to remain in compliance with federal law. Although FDA has announced carveouts that are supposed to reduce the consequences of FDA’s decision to regulate laboratory-developed tests as medical devices, the carveouts create intolerable regulatory uncertainty, as FDA’s rule states that the agency could change its mind at any time.
28. Notwithstanding the carveouts that FDA says it will observe as a matter of enforcement discretion, FDA’s position appears to be that all laboratory developed tests are illegal under federal law — and subject to civil and criminal penalties — unless they have been approved and cleared by FDA.
29. FDA’s own estimates recognize that obtaining FDA approval and clearance could cost hundreds of thousands of dollars for each separate test — even if there is a predicate FDA-approved medical device that can be used as a reference product to compare to any specific test service for which a manufacturer seeks approval or clearance. If there is no predicate device, the costs are likely to be substantially larger, as professional laboratories will be required to make significant investments and undertake substantial efforts to demonstrate to FDA’s satisfaction the safety and efficacy of tests.
30. FDA lacks the resources needed to oversee the prompt approval of potentially tens of thousands of laboratory-developed tests. I am therefore...
concerned that when HealthTrackRx submits a test for FDA approval and clearance, the company will be forced to wait many months (if not longer) for approval or clearance. Any delay in providing approval or clearance could cause substantial harm by making it more difficult for HealthTrackRx to provide the essential testing services that healthcare providers rely on in order to make appropriate treatment decisions.
31. Moreover, there are tests that HealthTrackRx includes on its testing menu that, because they are not high-volume tests, may not justify the costs associated with seeking FDA approval and clearance. If FDA’s final rule is allowed to remain in place, there are significant risks that some of these tests will no longer be available to help providers and patients.
32. FDA’s final rule will create significant disincentives for financial investment by laboratories in new testing protocols and processes. The impact will be especially significant for specialized testing services.
33. For example, at the request of a group of expert ophthalmologists, HealthTrackRx worked to develop a cutting-edge PCR test that quickly diagnoses whether a corneal ulcer — also known as infectious keratitis — is caused by a virus, bacterium, or fungus. There is no FDA-approved device that ophthalmologists are able to use for this purpose. Infectious keratitis is a major cause of visual impairment and blindness, often affecting marginalized populations. Because the proper treatment of keratitis differs depending on whether it is caused by a virus, bacterium, or fungus, quick and accurate diagnosis is important. With the right diagnosis, treatment can often cure the patient; a wrong diagnosis can often be debilitating. The PCR test that HealthTrackRx developed is critical because it allows providers to confirm quickly the source of a corneal ulcer and to identify appropriate treatment options.
34. Because this type of test is not used frequently or in large volumes, it is unlikely that it would ever have been developed if FDA’s final rule were in place. Given the substantial costs of seeking FDA approval and clearance, no laboratory would invest the months of effort to develop and validate a new test for the benefit of patients with corneal ulcers.
35. As another example, HealthTrackRx has stepped up during the last two public health emergencies to help with the testing burden for both COVID-19 and Monkeypox. The Centers for Disease Control needed laboratory professionals to validate high throughput tests to help with the increased testing burden. Because the FDA-approved tests for both diseases were low throughput and could not meet testing demands, professional laboratories, including HealthTrackRx, were essential in providing services and addressing unmet needs that manufactured medical devices could not address. The FDA’s final rule will stifle the very innovation that helped with testing demands in two public health emergencies in the last four years.
36. I am also concerned that FDA’s final rule will prevent laboratories from innovating and customizing tests when necessary. One of the important features of laboratory-developed testing services is the ability of individual laboratories to modify their testing protocols and procedures to adapt to specific requests made by providers (and their patients). If FDA’s final rule remains in place, however, I am concerned that the threat of FDA fines may discourage laboratories from customizing their professional testing services when needed by patients.
37. I have additional concerns that FDA’s final rule will negatively impact both ordering providers and patients. HealthTrackRx has moved away from “static” panels to customizable menus. That approach allows the physician to request targeted testing based on the symptoms presented by the patient as opposed to relying on a “one size fits all” approach, which is how medical devices work. FDA’s final rule could make customizable menus too expensive to pursue. That would force physicians to move back to relying on broad syndromic menus, which increase costs to patients. Increased costs reduce access to testing to those who cannot afford it, and in many cases, for those who need testing the most.
In accordance with 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.
Executed on this **23rd** day of May, 2024.
By:
________________________
Jay Reddy, Ph.D.
## EXHIBIT B
AMERICAN CLINICAL LABORATORY ASSOCIATION;
HEALTHTRACKRX INDIANA, INC.; and HEALTHTRACKRX, INC.,
Plaintiffs,
v.
U.S. FOOD AND DRUG ADMINISTRATION; U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; XAVIER BECERRA, in his official capacity as Secretary of Health and Human Services; and ROBERT M. CALIFF, M.D., in his official capacity as Commissioner of Food and Drugs, United States Food and Drug Administration,
Defendants.
**DECLARATION**
### DECLARATION OF MARCIA EISENBERG, Ph.D.
I, Marcia Eisenberg, Ph.D., declare as follows:
1. I am a resident of Apex, North Carolina. I am over the age of eighteen, and I am competent to provide this declaration.
2. I have worked for Labcorp for more than 30 years, including in a variety of leadership positions. I am currently a Senior Vice President and the Enterprise Chief Scientific Officer at Labcorp.
3. I oversee research and development and science and technology for the company, which includes test development, optimization, and automation. I have been recognized and honored for my contributions to the advancement of forensic DNA testing, and I have been involved with the development and validation of hundreds of clinical assays used for patient care.
4. I earned a B.S. in biology, a B.A. in psychology, and an M.S. in molecular biology from the State University of New York at Albany. I earned a Ph.D. in molecular biology from the University of Kentucky.
5. My experience includes work with the National Institute of Environmental Health Sciences. I have been a member of the FBI’s Technical Working Group on DNA Analysis Methods, and I was an appointed member of the National DNA Advisory Board during its lifespan.
#### Labcorp
6. Labcorp is a global life sciences and healthcare company. With nearly 100 laboratories in dozens of countries, Labcorp performs professional testing services for providers and patients across the world. Our services include doctor-requested testing, consumer-initiated testing, research and development laboratory testing, and clinical trial laboratory testing.
7. In 2019, Labcorp celebrated its 50th anniversary and the company’s transformation from a local laboratory operating in a former hospital to a leading global life sciences company that is deeply integrated in guiding patient care.
8. Labcorp prides itself on leveraging cutting-edge science, technology, and innovations to find healthcare answers for patients. We pursue scientific advancements in clinical diagnostic testing and breakthrough treatments, relying on a professional team of more than 2,500 M.D.s and Ph.D.s.
9. Labcorp works to provide healthcare providers and patients with the highest quality and most comprehensive menu of testing services available. We have a growing list of more than 6,000 different routine and esoteric tests.
10. Our scientific experts and specialists focus on helping patients in areas of pressing need, including oncology, Alzheimer’s, liver, and autoimmune diseases, as well as helping people prevent serious illness and remain healthy. The world-class diagnostic testing services that we provide help enable and accelerate patient care and access to innovative treatments, medicines, and new technologies that can change outcomes and lives.
11. The Labcorp Charitable Foundation, which was founded in 2020, has given out more than 341 grants to promote greater access to healthcare and education. These grants have focused on supporting food pantries and summer meal programs for children, providing access to healthcare and patient support services for the underserved, broadening access to STEM education programming, and providing ongoing support for medical research, screenings, and programs that promote a healthy lifestyle.
12. Labcorp is constantly innovating and developing new testing services and updating older tests. In April and May 2024 alone, we developed numerous new LDTs, including for early Sjogren’s Syndrome, Candida auris colonization screening, and others. We also updated dozens of other existing LDTs.
#### FDA’s Final Rule
13. The new final rule issued by the Food & Drug Administration (“FDA”) poses a significant threat to the nation’s healthcare system and the longstanding practices and regulatory requirements that Labcorp has relied on to build and expand its business.
14. FDA is wrong to suggest that laboratory developed tests are equivalent to manufactured medical devices sold in interstate commerce. The professional testing services that laboratories provide are not instruments, machines, or physical objects that qualify as medical devices subject to FDA approval and clearance. Instead, they are an essential healthcare service that involves the exercise of professional medical expertise and judgment to provide clinical information to physicians and patients. Laboratory developed testing
The professionals at Labcorp are expert technicians, M.D.s, and Ph.Ds; they are not manufacturers.
15. During my decades in the clinical laboratory industry, professional laboratory testing services have been regulated under the federal Clinical Laboratory Improvement Amendments Act of 1988 and by individual states under state law, not the FDA. Those regulations are designed to take account of the processes and procedures that are involved when professional clinicians engage in laboratory testing. In contrast, the requirements that apply to medical devices are a poor fit for regulating professional services. If the government wants to change the regulatory requirements that apply to clinical laboratories, that should be accomplished through legislation, not by re-tooling a statute that was never designed for that purpose.
16. The suggestion made by FDA in its final rule that Congress in 1976 somehow banned laboratory developed testing services unless and until they are approved and cleared by FDA would mean that thousands of laboratories have violated the law for more than half a century. That makes no sense.
17. It is also unfair. In its final rule, FDA has said that it does not intend to enforce the rules that apply to medical devices to existing laboratory developed tests, and it has suggested that it intends to limit when the agency will exercise its enforcement discretion against laboratories. But FDA has made clear that it believes those testing services are subject to the medical-device requirements. FDA has suggested that it could change its mind about enforcement at any time. That creates an untenable situation of regulatory uncertainty.
18. Labcorp has made substantial investments to expand its professional testing capabilities in reliance on the existing regulatory system and the understanding that our large team of M.D.s and Ph.Ds provide professional testing services that are not subject to the same regulatory requirements as manufactured medical devices. Since the early 2000s, Labcorp has acquired assets and made substantial investments that have allowed the company to expand its testing capabilities and expertise in the following areas: (1) ultra-sensitive hepatis C testing, (2) molecular microbial testing, (3) anatomic pathology, (4) esoteric oncology, (5) genetic and oncology services, (6) forensics, (7) specialized toxicology, and (8) cardiovascular and metabolic disorders.
19. Under FDA’s rule, for laboratories to avoid the risk of FDA changing its position and bringing future enforcement actions, they will need to seek FDA clearance or approval for the many tests that are already on the market and for every new testing protocol they might develop in the future. FDA does not have the personnel or financial resources necessary to review and approve all those testing protocols, which could take decades to complete.
Nor would it make sense for laboratories to undertake the cost and expense of seeking approval for all the different types of testing services they provide.
20. FDA’s rule threatens either to force laboratories to provide services with an uncertain risk of future enforcement or to deprive patients of essential testing services. Neither option is in the interests of laboratories or the nation’s healthcare system.
In accordance with 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.
Executed on this 24th day of May, 2024.
By:
Marcia Eisenberg, Ph.D.
## EXHIBIT C
AMERICAN CLINICAL
LABORATORY ASSOCIATION;
HEALTHTRACKRX INDIANA,
INC.; and HEALTHTRACKRX,
INC.,
Plaintiffs,
v.
U.S. FOOD AND DRUG
ADMINISTRATION; U.S.
DEPARTMENT OF HEALTH AND
HUMAN SERVICES; XAVIER
BECERRA, in his official capacity as
Secretary of Health and Human
Services; and ROBERT M. CALIFF,
M.D., in his official capacity as
Commissioner of Food and Drugs,
United States Food and Drug
Administration,
Defendants.
**DECLARATION**
### DECLARATION OF YURI A. FESKO, M.D.
I, Yuri A. Fesko, M.D., declare as follows:
1. I am a resident of North Carolina. I am over the age of eighteen, and I am competent to provide this declaration.
2. I have worked for Quest Diagnostics (“Quest”) for more than seven years. I currently serve as Quest’s Chief Medical Officer.
3. I am a board-certified physician in the areas of oncology, hematology, and internal medicine. In my current role, I lead Quest’s medical affairs organization and oversee the Company’s medical team of approximately 700 MDs and PhDs. Prior to joining Quest, I was medical director of oncology for Duke Cancer Center of Wake County, where I was a member of the oncology faculty.
4. Because of my experience with Quest, I have a keen understanding of how laboratory testing services are developed and provided and of the meaningful differences between professional laboratory services and manufactured medical devices.
#### Quest Diagnostics
5. Quest is one of the world’s leading providers of professional diagnostic testing services. It serves customers globally, and each year it provides testing services to approximately 1 in 3 adults and half the physicians and hospitals in the United States.
6. Quest’s diagnostic testing portfolio is focused on three areas:
- **General Diagnostics**: Routine and non-routine testing and consultation services essential to healthcare delivery.
- **Advanced Diagnostics**: Genetic and advanced molecular testing and consultation services based on rich clinical, scientific, and medical expertise and innovation.
- **Diagnostic Services.** A wide range of capabilities that efficiently provide healthcare insights to individuals, employers, and institutions to support population health.
7. Quest is a leader in developing laboratory testing services, with clinical experts, resources, and other professional services all focused on helping to meet the needs of providers and patients. Its broad and deep menu of testing services includes 3,500 routine, esoteric, and genetic tests.
8. Quest maintains a nationwide network of clinical laboratories, including advanced laboratories as well as rapid response laboratories (smaller facilities where we can quickly perform an abbreviated menu of routine tests for customers who require rapid turnaround times). The company operates 24 hours a day, 365 days a year, with a nationwide network of patient service centers, phlebotomists in physician offices, and a range of connectivity resources, including call centers and mobile paramedics, nurses, and other health and wellness professionals.
9. Quest employs approximately 700 MDs and PhDs and approximately 23,000 phlebotomists, paramedics, nurses, and health and wellness professionals. It has a large in-house staff of medical and scientific experts, including medical directors, scientific directors, genetic counselors, and board-certified geneticists. These professionals provide medical and scientific consultation to healthcare providers and patients regarding the company’s testing services, helping to improve health outcomes. The company’s professionals also publish original research in peer-reviewed publications, at medical and scientific conferences, and as a public service.
10. Quest is a leading provider of diagnostic information services for infectious disease, such as COVID-19 (including molecular diagnostic and serology antibody offerings), tuberculosis, and tick-borne disease. It also provides diagnostic solutions for emerging infectious diseases, such as Zika, West Nile Virus, SARS, and Influenza A H1N1. It has leading positions in drug monitoring and toxicology, in neurology diagnostics, in advanced cardiovascular diagnostic services, and in cancer diagnostics.
11. Quest is also a leading provider of workplace drug testing. It is certified by the U.S. Department of Health and Human Services to perform federally mandated drug testing using electronic custody and control forms for safety-sensitive workers. In addition, Quest is a leading provider of employer population health services, including biometric screenings, flu shots, and related preventative services that leverage clinical data to improve population health outcomes and reduce healthcare costs. The solutions provided by Quest enable employers to leverage screening insights to identify chronic disease risks, connect employees to needed in-network care, and empower better health.
12. As an organization dedicated to improving our patients’ health, Quest aims to support a culture that is guided by “the 5Cs”:
- **Customers first:** Every decision made by Quest Diagnostics starts with a patient or customer in mind. The quality of work is vital because the answers it delivers are a matter of life.
- **Care:** Quest is in the healthcare business, with care at the core of everything it does. Its professionals do the right thing with empathy, integrity, and respect to show each patient, customer, and colleague they matter.
- **Collaboration:** Creating a healthier world is a monumental task. The professionals at Quest work as a team, internally across departments and externally throughout the healthcare ecosystem and in the communities where its professionals work and live.
- **Continuous improvement:** Quest recognizes that delivering superior quality requires intention and innovation. It is committed to being better today than yesterday and even better tomorrow.
- **Curiosity:** The professionals at Quest are constant learners. To do their jobs, they must be relentlessly curious, because that is what it takes to move healthcare forward.
#### FDA’s Final Rule
13. The final rule issued by the Food & Drug Administration (“FDA”) on May 6, 2024, seeks to treat professional laboratory testing services as if they are manufactured medical devices and asserts sweeping authority to subject those professional services to the same regulatory requirements as medical devices under the Food, Drug and Cosmetic Act.
14. FDA’s final rule is premised on the extraordinary view that in 1976, Congress prohibited the development and use of any laboratory tests that were not approved and cleared by FDA, and that in the ensuing five
decades, thousands of professional laboratory clinicians across the nation have been violating federal law by offering tests to physicians and patients without first seeking FDA approval and clearance. That makes no sense and is unfair to the thousands of Quest employees who are dedicated to helping patients by providing essential testing services.
15. FDA’s final rule ignores the fundamental differences between professional laboratory testing services and manufactured medical devices. Quest is not a manufacturer. It is a healthcare organization dedicated to and focused on providing empathetic, high-quality, and individualized patient care. The professional diagnostic services that Quest provides are not physical objects or articles that qualify as medical devices. Instead, the information and consultation services that Quest provides require the exercise of medical expertise and professional judgment.
16. Quest has made substantial investments in reliance on the understanding that Congress has never granted FDA authority to treat professional diagnostic testing services the same as manufactured medical devices. Those services are instead regulated under a specialized, laboratory-specific framework set forth in the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”). That framework was carefully designed and tailored by Congress to ensure the validity and appropriateness of the processes and procedures that are followed when laboratory professionals develop and perform testing services.
17. Congress has recently considered legislation that would change the regulatory requirements for laboratory testing services. Congress has so far rejected calls to grant FDA authority to regulate laboratory developed testing services and has instead decided to keep the existing regulatory framework in place.
18. Even though Congress has never granted FDA authority to regulate laboratory professional services, FDA takes the position that all laboratory developed tests are subject to the statutory requirements that apply to manufactured medical devices (in addition to the laboratory-specific requirements that apply under CLIA). In an attempt to reduce some of the immediate negative consequences that this position would otherwise have on the nation’s healthcare system, FDA has said that, at least for now, it does not intend to enforce certain regulatory requirements with respect to existing testing menus, and it has said that the agency will exercise its “enforcement discretion” not to enforce the statute in a variety of contexts. This attempt to soften the blow of its final rule does not solve the rule’s many problems and only creates more regulatory uncertainty.
19. Most notably, FDA has emphasized that it could change its mind and end its supposed “enforcement discretion” at any time. That puts Quest (and other laboratories) in an impossible position — either (1) expend substantial resources to go through FDA’s costly approval and clearance process and have fewer resources available to invest in continued innovation and development, or (2) continue to provide the essential testing services relied on by one third of the nation’s adult population and risk being subject to future enforcement action by FDA. No company should be put in that impossible position.
20. It is also unclear how the nation’s laboratories are likely to respond to the uncertainty created by FDA’s new rule. FDA’s attempt to assert authority over an entire profession is a massive undertaking, and when laboratories start seeking FDA approval and clearance for their testing services the problems are only likely to increase. The costly requirements imposed by the medical device regulations are not calibrated to account for the professional and expert judgments made by laboratory professionals when developing and performing diagnostic testing services.
21. Moreover, FDA lacks the resources and experience to review and approve the many thousands of different laboratory tests that are available today and the many more tests that are likely to be developed in the future. It would take years (if not decades) for FDA to review, approve, and clear all of the laboratory tests that are offered by Quest and other laboratories. But no one knows how long FDA will continue to exercise enforcement discretion or how it will respond if laboratories start seeking FDA approval and clearance. The risk of regulatory delay is significant, which could chill the incentives for laboratories to innovate and develop new testing processes and procedures needed to keep up with the pace of change in multiple medical specialties.
In accordance with 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.
Executed on this 24th day of May, 2024.
By:
Yuri A. Fesko, M.D.
## EXHIBIT D
AMERICAN CLINICAL
LABORATORY ASSOCIATION;
HEALTHTRACKRX INDIANA,
INC.; and HEALTHTRACKRX,
INC.,
Plaintiffs,
v.
U.S. FOOD AND DRUG
ADMINISTRATION; U.S.
DEPARTMENT OF HEALTH AND
HUMAN SERVICES; XAVIER
BECERRA, in his official capacity as
Secretary of Health and Human
Services; and ROBERT M. CALIFF,
M.D., in his official capacity as
Commissioner of Food and Drugs,
United States Food and Drug
Administration,
Defendants.
**DECLARATION**
### DECLARATION OF JONATHAN GENZEN, M.D., Ph.D.
I, Jonathan Genzen, M.D., Ph.D., declare as follows:
1. I am a resident of Salt Lake City, Utah. I am over the age of eighteen, and I am competent to provide this declaration.
2. I am the Chief Medical Officer and Senior Director of Government Affairs at ARUP Laboratories and have served in these roles since July 2022. I am also the Medical Director of Laboratory Automation for ARUP Laboratories and a Co-Medical Director of Automated Core Laboratory at ARUP Laboratories.
3. I have worked at ARUP Laboratories for more than 11 years.
4. In addition to my work at ARUP Laboratories, I am a clinical Professor in the Department of Pathology at the University of Utah School of Medicine. I am licensed to practice medicine in both Utah and New York.
5. I received my Ph.D. in Biological Sciences at the University of Chicago and my M.D. in Medicine at the University of Chicago Pritzker School of Medicine.
6. I completed my clinical pathology residency training at Yale University / Yale New Haven Hospital, and I was a post-doctoral Research Fellow at Yale University in the Department of Laboratory Medicine.
7. I specialize in clinical pathology, laboratory medicine, clinical chemistry, medical diagnostics, in vitro diagnostics, and laboratory automation.
8. I am a fellow of the American Society for Clinical Pathology and the College of American Pathologists. I am also a member of the Association for Diagnostics and Laboratory Medicine and the Academy of Clinical Laboratory Physicians and Scientists.
9. As a result of my professional experiences and background, I have significant knowledge of clinical diagnostic laboratory services. I am familiar with the legal and regulatory requirements that have long applied to laboratory-developed tests, including the regulations that apply to the conduct of laboratories and the validation of diagnostic testing services.
10. I am also familiar with the final rule issued by the Food and Drug Administration ("FDA") on May 6, 2024, and the analysis that the FDA has relied on to justify its new rule. I was directly involved in preparing the comments submitted on the FDA’s proposed rule by ARUP Laboratories.
11. As described in greater detail below, I am deeply concerned about the FDA’s final rule, the enormous costs it will impose on clinical laboratories, and the harm it will cause to patients across the nation. The FDA’s final rule is based on a flawed understanding of how laboratories develop and provide professional testing services to help healthcare providers treat and diagnose patients. The rule poses serious risks to patients by threatening to reduce access to safe testing services over time, which will disproportionately harm patients with rare diseases, underserved patient populations, patients with cancer, and children.
#### ARUP Laboratories
12. ARUP Laboratories was founded 40 years ago in 1984 as an enterprise of the University of Utah’s Department of Pathology. ARUP Laboratories operates the hospital and outpatient clinical laboratories for one of the nation’s most respected academic medical centers — University of Utah Health.
13. ARUP Laboratories is an academic, non-profit institution dedicated to providing hospitals and health systems with unparalleled quality testing services, particularly for otherwise unmet needs, while continuously adapting to the ever-changing needs of the healthcare industry.
14. ARUP Laboratories is a member of the American Clinical Laboratory Association ("ACLA"). Our Chief Executive Officer, Andy Theurer, is a member of the ACLA's Board of Directors.
15. ARUP Laboratories participates in the leading certification programs for clinical laboratories. It is accredited by the College of American Pathologists ("CAP-accredited") and certified by the International Organization for Standardization, which establishes the international standards for quality and competence in medical laboratory environments ("ISO 15189-certified"). It has also received certification by the Centers for Medicare and Medicaid Services under the requirements of the Clinical Laboratory Improvement Amendments of 1988 ("CLIA") ("CLIA-certified").
16. ARUP Laboratories is focused on providing hospitals and healthcare systems with unmatched professional clinical laboratory testing services, helping them to remain cost-effective and improve patient care. We believe in...
collaborating, sharing knowledge, and contributing to laboratory science in ways that provide the best value for patients.
17. **ARUP Laboratories** is the nation’s largest non-profit clinical reference laboratory. With more than 70 laboratory sections jointly located on its 700,000-square-foot main campus in Salt Lake City, Utah, ARUP Laboratories provides all types of comprehensive laboratory testing services, from routine screening tests to esoteric molecular and genetic assays. We provide professional services to more than 2,000 community hospitals and academic medical centers across the nation.
18. ARUP Laboratories has more than 4,000 employees, with a testing menu that offers hospitals and health centers access to more than 3,000 tests and test combinations. It processes an average of 70,000 specimens of blood, body fluid, and tissue per day, impacting more than 8 million patients each year.
19. ARUP Laboratories has more than 100 nationally and internationally recognized board-certified medical directors — including pathologists, subspecialty-qualified clinicians, and board-certified clinical scientists. Our MD and PhD certified professionals have extensive medical and scientific expertise to ensure that our testing services meet the ongoing clinical needs of health care providers and patients, while also providing clinical consulting services by telephone and secure email communications.
The expertise of our medical directors and scientists ensures an exceptionally high standard of quality, with each assay that ARUP Laboratories develops undergoing a rigorous and scientific validation process before it is added to the menu of testing services that ARUP Laboratories provides.
20. The **ARUP Institute for Clinical and Experimental Pathology** is the research and development arm of the organization, with over 60 scientists actively engaged in test development and optimization in collaboration with experts in the University’s medical facilities. Over several decades, the Institute has developed, validated, verified, improved, and maintained at least 1,500 laboratory-developed tests.
21. Consistent with ARUP’s academic foundations and its commitment to sharing knowledge with the clinical laboratory community, ARUP scientists and medical directors publish over 130 peer-reviewed articles each year. Collectively, we have published more than 3,400 scientific and clinical manuscripts in peer-reviewed journals to date.
22. In 2021, ARUP Laboratories completed a new, state-of-the-art 220,000-square-foot laboratory facility that spans four floors — the result of a substantial investment that ARUP Laboratories made, in reliance on the existing regulatory framework, to expand its ability to provide the highest quality services. The facility is designed to optimize quality laboratory testing, featuring world-class automation to provide efficient, large-scale laboratory operations with the ability to reconfigure quickly. In addition to other improvements, the facility includes new space for ARUP’s mass spectrometry laboratory, its automated core chemistry and immunology laboratories, and its specimen processing teams.
#### Professional Laboratory-Developed Testing Services
23. Professional laboratory-developed testing services are used by licensed practitioners in making health care decisions with their patients by providing diagnostic and other information that is used to monitor patients; influence medical, surgical, dietary, and other potential patient interventions; and inform future clinical advancements.
24. The testing services developed and performed by clinical laboratories have played a critical role in helping to diagnose and treat patients and are often at the forefront of innovation, particularly in academic and university clinical laboratory settings. For example, testing services that employ molecular diagnostics are routinely used in the diagnosis of malignancy, in the identification of genetic variants that suggest additional therapeutic interventions, in the characterization of genetic variants found in inheritable diseases, and in the diagnosis and treatment of infectious diseases. In many of these cases, no FDA-cleared or -approved medical devices are available, and physicians and patients rely on the professional testing services provided by laboratories to meet otherwise unmet needs, commonly when that
25. Laboratory-developed tests are frequently developed in academic clinical laboratories and in reference (e.g., referral) laboratories. For reference laboratories, requests for access to esoteric tests and services to diagnose rare disorders are relatively common, as specimens are received from clinics and hospital facilities extending over wider geographic areas or networks. Given the high costs of obtaining premarket approval or clearance from the FDA, as well as the limited financial incentives for medical device manufacturers to develop esoteric tests or tests for rare diseases, reference laboratories address unmet clinical needs by developing and offering professional testing services that are performed by clinical laboratory professionals in a single laboratory location.
26. As experts in clinical laboratory testing operations, clinical pathologists, doctoral-level clinical laboratory scientists, and laboratory personnel become aware of the strengths and limitations of different assays and testing platforms. This awareness comes from direct experience with assay and instrument operation, as well as peer-to-peer information sharing within the clinical laboratory community, scientific literature, and national and international conferences. When needed and appropriate, experts exercise their professional judgment in seeking to modify, update, and validate testing procedures to address specialty care needs.
27. Test modifications are particularly important in clinical laboratory settings. For example, important issues include alternative specimen types (e.g., when the specimen type listed in an FDA-approved test is not the appropriate matrix for clinical evaluation), extension of specimen stability parameters, or automation of otherwise manual tests to improve throughput, quality, and efficiency of testing and to minimize risks of repetitive motion injuries to laboratory professionals. There are also times when modifying a test is necessary to adapt to specific patient needs or to adapt to urgent reagent shortages. Under CLIA’s regulatory framework, the medical director of each laboratory is responsible for exercising professional judgment in deciding when to modify testing procedures to ensure that clinical testing is conducted appropriately, including validating the acceptability of the specimen used for testing. Under the FDA’s final rule, many such modifications would require FDA premarket review, thus delaying and/or preventing service improvements to meet clinical and public health needs.
28. ARUP Laboratories provides a wide range of professional testing services to assist hospitals and health centers in deciding how best to diagnose and treat patients.
29. **Genetic testing.** ARUP’s Institute for Clinical and Experimental Pathology was founded to foster the academic research of ARUP’s medical directors, while also advancing the science of diagnostic laboratory medicine to improve patient care.
30. Under the leadership of its professional medical directors, ARUP Laboratories was one of the first laboratories to use DNA sequencing as part of the routine testing services provided to hospitals and health centers. ARUP Laboratories leveraged DNA sequencing technologies developed by Frederick Sanger that emerged in the 1980s and ’90s and, more recently, ARUP has relied on next generation sequencing (known as massively parallel sequencing) technologies, which can be used to rapidly sequence whole genomes.
31. Building on these technological advances, many of ARUP’s laboratory-developed genetic tests have resulted in successful innovations in the diagnosis and treatment of diseases.
32. One of ARUP’s first genetic sequencing tests was a quantitative hepatitis C virus assay. Another notable test is ARUP’s genetic panel for myeloid malignancy variants, which at the time it was developed in 2014, was one of the first tests available to detect and treat patients with diseases resulting from stem cell variants. In addition, ARUP Laboratories has developed rapid molecular tests for certain immunodeficiency disorders that use state of the art tools, such as next generation DNA sequencing, to find new
causes of primary immunodeficiencies, which can present from the newborn period until mid-to-late adulthood. ARUP Laboratories was also the first clinical reference laboratory to offer unique assays that measure the ability of a drug to inhibit tumor necrosis factor ("TNF") and detect the presence of antibodies that neutralize TNF antagonist drug activity which can lead to treatment failure.
33. **Clinical toxicology.** More than a decade ago, ARUP Laboratories introduced a new and innovative approach to panel-based drug testing that focused on improving efficiency and specificity of results, and at the same time, reducing costs. Instead of using exclusively immunoassays to screen specimens, ARUP Laboratories developed testing procedures that take advantage of the benefits of mass spectrometry. An immunoassay screen detects the presence of a targeted compound or similar compound by the signal that changes when the compound (or compounds) react with specifically formulated reagents. In contrast, mass spectrometry identifies each targeted compound that is present in a specimen individually based on mass-to-charge ratio, in combination with other unique chemical and physical characteristics. Tests that employ mass spectrometry can yield results with higher specificity than immunoassays, which translates to a lower risk of false-negative and false-positive results.
34. ARUP Laboratories is proud of the work that it does to support clients across the nation in cases of unknown drug exposures. For example, ARUP Laboratories developed a mass spectrometry test that targets detection of over 100 different compounds cited in data from the American Association of Poison Control Centers on the most common accidental exposures.
35. There are many ways clinical toxicology testing and therapeutic drug monitoring can be used to help patients. For example, laboratory-developed tests are often used to help cancer patients who are receiving different forms of chemotherapy. Similarly, laboratory testing is important when a patient receives a kidney transplant and is required to take immunosuppressant drugs to reduce the risk of rejecting the new organ. Therapeutic drug monitoring allows the physician to calibrate dosing correctly and help the patient avoid harmful side effects, such as infection. Laboratory-developed testing is also important when identifying and monitoring trace and toxic elements with industrial exposures.
36. **Pharmacogenomics.** ARUP Laboratories has made significant advances in the field of pharmacogenomics, an emerging medical specialty that employs genetic and phenotype testing to predict or explain patient response to certain medications. Laboratory-developed testing in this area can be used to guide selection of drug options and doses for individual patients while avoiding adverse drug effects.
37. As with many laboratory testing services, choosing the appropriate test and interpreting the results can be complicated and requires professional expertise. As a result, ARUP Laboratories often assists physicians in understanding the complexities associated with testing, including pharmacogenomics.
38. **Maternal / pediatric health.** Another area where ARUP Laboratories has advanced healthcare is in the areas of maternal and pediatric health. In parallel with the opioid epidemic, there has been a significant increase in newborns experiencing neonatal abstinence syndrome. The professionals at ARUP Laboratories spent years developing a new mass spectrometry test, using either meconium or umbilical cord tissue as the specimen type, that identifies almost 50 different types of compounds and can be used to assess in utero drug exposure.
39. ARUP Laboratories has collaborated with hospital delivery units as well as representatives from children and family services agencies across the nation to understand when new drugs should be added to its screening panels. For example, collaboration with clinicians and caregivers led ARUP to be among the first clinical laboratories to add gabapentin to its umbilical cord drug screening panel. That drug is often prescribed as an alternative to opioids or in combination with opioids for pain management but has been increasingly
40. **ARUP Laboratories’ expertise in newborn drug testing** is having a positive impact on the development of public health programs. The close collaboration between ARUP’s medical directors and professors at the University of Utah Department of Obstetrics and Gynecology has allowed researchers to identify the prevalence and trends in drug exposures. From a public health standpoint, this research has allowed more targeted interventions, including educating clinicians to talk with patients about substance use and pregnancy in affected regions and finding ways to link patients to multidisciplinary care and addiction services. Data collected has also been used in a successful grant application for resources to reduce morbidity and mortality from substance use disorders during pregnancy in Utah.
41. **The Penelope Program.** ARUP Laboratories is a key partner in the “Penelope Program” at University of Utah Health, which is a collaboration between ARUP Laboratories, the Department of Pediatrics, the Department of Human Genetics, the Utah Center for Genetic Discovery, the Center for Genomic Medicine, and the Primary Children’s Hospital.
42. The program was launched in 2015 to address the challenge of undiagnosed diseases, recognizing that families often spend years — if not decades — searching for answers to the unidentified illnesses affecting their children. The program brings together a team of experienced clinicians from multiple specialties, molecular geneticists, data scientists, and researchers who pool their knowledge and expertise to help evaluate pediatric patients from different angles and perspectives, to identify potential diagnoses, and to develop an appropriate diagnostic plan. The team has access to advanced technologies and diagnostic tools to look for diagnoses that may have been missed. New testing, such as whole genome sequencing and RNA sequencing, can unmask genetic causes hidden in the depths of a complex genome. The program is also actively engaged in reducing disparities in access to advanced diagnostics.
#### FDA’s Final Rule Threatens Patient Health
43. The FDA’s final rule improperly treats laboratory-developed tests as if they are manufactured medical devices. The rule reveals the FDA’s fundamental misunderstanding of how laboratories perform professional testing services.
44. Laboratories are not manufacturers. And the tests they perform are not medical devices or other types of equipment. Instead, a laboratory-developed test is a professional service that reflects a series of procedures, medical protocols, and processes involved in analyzing tissue, blood, and other specimens as part of the practice of laboratory medicine. Those processes are validated and overseen by experts who must exercise informed clinical judgment in assembling the technical steps involved in conducting a test, understand how those steps interact, and determine how data should be interpreted.
45. Mass spectrometers and other manufactured equipment used by healthcare professionals are only tools used in performing a laboratory-developed test. The test itself entails procedures, methodologies, and processes that do not qualify as instruments, apparatuses, machines, contrivances, implants, in vitro reagents, or other related articles subject to FDA regulation. When laboratory clinicians develop the processes and procedures necessary to perform laboratory-developed testing services, they are no different than other health care professionals who develop protocols or methodologies for treating patients or diagnosing diseases.
46. I am concerned that FDA’s final rule takes the position that laboratory tests not cleared or approved by FDA are illegal and that laboratories have been violating the law for decades. Although the preamble to FDA’s final rule says that the agency intends to exercise enforcement discretion — to allow laboratory-developed tests to remain on the market until it decides otherwise — the notion that laboratories and the professionals who run them are all engaged in unlawful conduct is absurd and, in my mind, shows...
that the FDA itself is not acting reasonably and within the scope of any lawful authority granted by Congress.
47. I am also deeply concerned that, because the FDA lacks the resources to oversee tens of thousands of laboratory-developed tests, laboratories will face significant regulatory uncertainty and patients will face the risk of being denied access to the essential medical services they depend on clinical laboratories to provide. In short, the FDA’s attempt to regulate laboratory testing services as medical device products will undermine the provision of health care and stifle innovation in a critical sector of our health care ecosystem.
48. FDA clearance and/or approval requirements will also have significant negative consequences for the innovation that occurs when professional laboratory clinicians modify existing testing procedures, or tailor them to address unmet patient needs.
49. Laboratory-developed tests can be modified to address a patient’s specific circumstances, which can lead to the discovery of new and improved diagnostic approaches and testing protocols. This ability to innovate is likely to be curtailed under the FDA’s new rule, which is likely to result in treating many of these modifications as creating a new “test” subject to separate FDA premarket review. This appears to also apply to minor modifications, such as adding manual immunoassays or PCR-based assays to simple liquid handlers, for example. Through these requirements, quality improvements through automation are paradoxically disincentivized by the FDA.
50. Under the final rule, ARUP Laboratories and other clinical laboratories will have to devote significant resources to developing FDA-centric quality system processes and adhering to device submission requirements, including premarket submissions for modified and new laboratory-developed tests. But there are not enough laboratory professionals to support compliance with FDA’s final rule while maintaining current testing levels.
51. Patient access to innovative tests will also be harmed because device regulation is likely to cause an FDA-review bottleneck going forward. That can only slow patient access to innovative tests as a result of extended review times, inadequate FDA resources to engage with applicants and developers, and clinically beneficial tests that are discontinued by laboratories due to excessive compliance costs over time.
52. FDA’s final rule appears to recognize this concern by suggesting that it will not enforce certain requirements of federal law against laboratories that comply with New York requirements for laboratory testing. But that does not change the reality that tests not approved or cleared by FDA will be considered unlawful, and that FDA has made clear that it could change its enforcement guidelines at any time.
53. Even with the enforcement discretion announced in the final rule, the number of future premarket approval applications for laboratory-developed testing services will likely increase significantly. The FDA lacks the resources to deal effectively with these submissions, and, even if the FDA had more resources, there are not enough trained scientists and regulatory professionals for it to hire. The FDA will be competing with laboratories that also would need to increase hiring of the same professionals to deal with the new regulatory system.
54. The FDA’s final rule also vastly overestimates the benefits of regulating professional testing services as the equivalent of medical devices. In suggesting that a large percentage of errors are attributable to laboratory tests, the FDA misapplies a study and reaches conclusions that are inconsistent with the diagnostic literature. A review of that literature suggests that only one to four percent of diagnostic errors may be attributable to faulty test results. As a result, and as explained in more detail in ARUP’s public comment letter, it appears that in its initial regulatory impact analysis the “FDA has made, at a minimum, an approximately 250-fold overestimate in its assessment of financial benefit,” failing to consider relevant data and applying only superficial assumptions. Unfortunately, it carries erroneous assumptions into calculations used in its final regulatory impact analysis, therefore still overestimating the purported financial benefits to society in the final rule. For
example, while the FDA cited our 2023 research manuscript [Rychert et al. Am J Clin Pathol. 2023. 160(3):297-302] in its final regulatory impact analysis when describing the percentage of clinician test orders that are laboratory-developed tests (3.9%), it more than doubled this percentage in its revised calculations of financial benefit, claiming that our data was based on "information for one single laboratory." This arbitrary increase in percentage, however, is in direct contradiction to the discussion of results in our manuscript, which states that "the presence of a national reference laboratory as part of the university health system may also have contributed to more LDTs being available for ordering than at other institutions. If this were the case, the present study’s finding may overrepresent LDT orders vs those placed at other institutions." I therefore believe that the FDA has misapplied our study findings in its final regulatory impact analysis in a manner that overestimates the financial benefit to society.
55. The FDA’s final rule understates the costs of treating professional laboratory services the same as medical devices. The rule is particularly problematic because it assumes — without sufficient or adequate analysis — that added FDA oversight would improve the safety and effectiveness of laboratory-developed tests, and yet it fails to take into account the reductions in access to safe testing that will occur if FDA’s final rule remains in place.
56. The FDA’s final rule will reduce access to safe testing because the staggering costs of seeking FDA approval threatens to force clinical laboratories over time to reduce the range of testing services they provide. In turn, that will disproportionally affect patients with rare diseases, underserved populations, patients with cancer, and children. For many laboratory-developed tests, market prices would increase due to reduced competition, and patients might lose timely access to diagnostic and treatment.
57. Hospitals and health centers trust the testing services provided by ARUP Laboratories because of our decades of experience in developing and performing tests, using them in our laboratories, and using them in consultation with expert clinicians for the care of their patients. Nearly all of our customer health systems are under different corporate ownership than ARUP Laboratories. Therefore, as written, the FDA’s unmet needs exemptions in the final rule do not apply in our setting, and ongoing development of testing for unmet needs for the patients we serve will be more difficult under the final rule.
58. Under the FDA’s final rule, new, and many modified existing, laboratory-developed tests would need to be submitted to the FDA for premarket review. But it is unrealistic to expect laboratories to be able to afford the massive costs involved in obtaining FDA clearance or approval of every test that they might develop in the future. Many laboratory-developed tests are low-volume tests that are used infrequently. These are clinically essential tests for patients suffering from rare diseases or difficult-to-diagnose conditions, and they are often essential in developing effective treatment for patients who have unmet medical needs. But these types of tests often fail to generate sufficient revenues to justify going through the very expensive FDA-clearance or approval process, which is why testing is often performed in reference settings.
59. ARUP Laboratories is concerned about the negative impact of new regulatory requirements and premarket reviews on the clinical laboratory industry. ARUP Laboratories is also concerned that it may not be cost effective for many clinical laboratories to continue to develop new, low-volume tests that can be used to diagnose or monitor rare diseases, particularly given the restrictions on testing for unmet needs in patients seen in facilities outside a laboratory’s corporate ownership.
60. Diverting resources away from helping patients and toward seeking FDA clearance or approval of testing services that FDA lacks the resources and expertise to evaluate would not benefit patients or the public interest. Indeed, the most alarming consequence of FDA’s rule is to declare all existing laboratory-developed tests to be unlawful and to make it more difficult for patients to continue to obtain the essential testing services they need.
In accordance with 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.
Executed on this ___23___ day of May, 2024.
By:
Jonathan Genzen, M.D., Ph.D.
## Exhibit E
AMERICAN CLINICAL
LABORATORY ASSOCIATION;
HEALTHTRACKRX INDIANA,
INC.; and HEALTHTRACKRX,
INC.,
Plaintiffs,
v.
U.S. FOOD AND DRUG
ADMINISTRATION; U.S.
DEPARTMENT OF HEALTH AND
HUMAN SERVICES; XAVIER
BECERRA, in his official capacity as
Secretary of Health and Human
Services; and ROBERT M. CALIFF,
M.D., in his official capacity as
Commissioner of Food and Drugs,
United States Food and Drug
Administration,
Defendants.
**DECLARATION**
### DECLARATION OF WILLIAM MORICE II, M.D., Ph.D.
I, William Morice II, M.D., Ph.D., declare as follows:
1. I am a resident of Rochester, Minnesota. I am over the age of eighteen, and I am competent to provide this declaration.
2. I have worked for Mayo Clinic for more than 24 years, including in a variety of leadership positions.
3. Since 2015, I have served as the President of Mayo Clinic Laboratories. Since 2023, I have served as the Chief Executive Officer and President of Mayo Collaborative Services, which includes Mayo Clinic Laboratories. Mayo Clinic Laboratories is Mayo Clinic’s outreach reference laboratory service for external customers.
4. From 2015 to 2022, I served as the Chair of Mayo Clinic’s Department of Laboratory Medicine and Pathology, Rochester, Minnesota, and I have long been affiliated with the Department’s Division of Hematopathology, serving as a physician consultant on Mayo Clinic medical staff since 2000.
5. I am a Professor of Laboratory Medicine & Pathology at the Mayo Clinic College of Medicine.
6. I also serve on the College of American Pathologists, the leading accreditation organization for clinical laboratories under the program established by the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”).
7. Since 2017, I have served as a member of the Research and Innovation Board for the Brussels Academic Hospitals Laboratory, which is an international group of experts from different institutions dedicated to identifying areas of worldwide need for diagnostic services. I am also a founding member of the Bone Marrow Pathology Group, which is a group of academic pathologists focused on clinical and laboratory research to identify and address diagnostic issues associated with bone cancer.
8. I earned my Bachelor of Science degree in biochemistry from Indiana University, Bloomington, as well as combined medical and doctoral degrees in biomedical sciences and immunology from the Mayo Clinic College of Medicine.
9. As a Mayo Clinic faculty member, my research has focused on the diagnoses of blood and bone marrow-derived cancers, including lymphoproliferative disorders of T cells and natural killer (NK) cells, plasma cells, and B cells. I have studied these disorders using a variety of methods, with a particular emphasis on flow cytometry, and with the aim to develop practical applications for clinical diagnosis.
10. I am a member of the Board of Directors of the American Clinical Laboratory Association (“ACLA”), and I am currently serving as the Board’s Chair. ACLA is the national trade association representing leading laboratories that deliver essential diagnostic health information to patients and providers by advocating for policies that expand access to the highest quality clinical laboratory services, improve patient outcomes, and advance the next generation of personalized healthcare.
11. As a result of my professional experiences and leadership roles, I have significant knowledge of clinical diagnostic laboratory services. I engage frequently with medical device manufacturers, including manufacturers of in vitro diagnostic (“IVD”) test kits, and understand the substantial and meaningful differences between medical device products and laboratory-developed testing services. I am also familiar with the significant time and expense involved in seeking federal approval to market and sell medical devices to third parties.
12. I am generally familiar with the legal and regulatory requirements that have long applied to laboratory-developed tests, including the CLIA requirements that regulate the conduct of laboratories and the validation of laboratory diagnostic testing services. I am familiar with the state regulations for all states in which Mayo Clinic Laboratories does business. I am also familiar with the final rule issued by the Food and Drug Administration (“FDA”) on May 6, 2024.
13. As described below, I am deeply concerned about FDA’s final rule. FDA’s position — that laboratory-developed tests are and have always been subject to all of the requirements of the federal Food, Drug, and Cosmetic Act, including premarket approval requirements for medical devices — is an implausible position that is contrary to decades of settled expectations in the healthcare profession.
14. FDA’s final rule fails to appreciate that laboratory-developed tests are not manufactured products or devices; instead, they are services provided.
by trained laboratory and medical professionals. When laboratorians develop a methodology to perform laboratory-developed testing services, they are no different from other health care professionals that develop protocols or methodologies for treating patients or diagnosing diseases.
15. FDA lacks the expertise to regulate the important professional healthcare services that clinical laboratories provide, and the radical change in regulation that the agency seeks to impose will stymie innovation and undermine laboratories’ ability to help diagnose and treat diseases, especially those that are rare.
16. I am also deeply concerned that, because FDA lacks the resources to oversee the prompt approval of laboratory-developed tests, laboratories will face significant regulatory uncertainty and patients may be denied access to the essential medical services they depend on clinical laboratories to provide. In short, FDA’s choice to regulate laboratory testing services as medical device products will undermine the provision of health care and stifle innovation in a critical sector of our health care ecosystem.
#### Mayo Clinic Laboratories
17. Mayo Clinic is the largest integrated, not-for-profit medical group practice in the world. It is committed to clinical practice, education, and research, and its experts work together to diagnose and treat the toughest medical challenges and unmet needs of patients. It has more top rankings for high-quality patient care than any other healthcare organization.
18. Mayo Clinic’s unwavering drive to create better medical care and its relentless pursuit of research helps patients by making earlier diagnoses possible and developing new cures. More than 1.3 million patients, from nearly 130 counties, visit Mayo Clinic campuses each year.
19. Mayo Clinic physicians are supported by the Department of Laboratory Medicine and Pathology, which performs testing services for diagnostic and therapeutic evaluations. More than 2,350 employees, working in numerous specialty laboratories, staff the Department. They form one of the largest clinical laboratories in the world, which performs more than 26 million tests annually. The laboratory’s professional teams consist of highly experienced physicians, scientists, medical technologists, medical technicians, histotechnologists, cytology technologists, pathologist’s assistants, phlebotomists, lab assistants, biologists, chemists, microbiologists, geneticists, genetic counselors, and other specialists.
20. Mayo Clinic’s most extensive laboratory service facilities are located in Minnesota and are provided by more than 190 physicians and Ph.D. scientists. Besides serving Mayo Clinic patients, the laboratories also undertake testing for clinics and hospitals, both in the United States and in more than 50 countries worldwide.
21. Mayo Clinic’s laboratory specialty areas include anatomic pathology, clinical biochemistry and immunology, clinical core laboratory services, clinical microbiology, community laboratory medicine and pathology, dermatopathology, experimental pathology and laboratory medicine, hematopathology, laboratory genetics, and transfusion medicine.
22. Mayo Clinic Laboratories is a reference laboratory that specializes in esoteric laboratory testing — testing for the most unusual, complex, and difficult cases. The laboratory was launched more than 50 years ago, in March 1971 and has always operated as a highly specialized laboratory housed within an academic medical center.
23. As part of providing medical diagnostic services to patients, Mayo Clinic Laboratories has always reflected Mayo Clinic’s core mission — what are referred to as the “three shields”: (1) integrated clinical practice, (2) research, and (3) education.
24. Mayo Clinic Laboratories has partnered since its inception with Mayo Clinic and its high-caliber faculty and state-of-the-art laboratories to help patients. For example, Mayo Clinic Laboratories has long provided second opinions on surgical pathology. When a pathologist or physician at another hospital, health system, or practice has a difficult diagnosis, they call Mayo Clinic Laboratories, which works with them and connects them to a physician or surgeon from Mayo Clinic to discuss the case. Research has also long been
a distinguishing mark of Mayo Clinic Laboratories, particularly in the context of developing new diagnostic tests and other groundbreaking medical services. In addition, Mayo Clinic Laboratories is well known for its educational programs offered to other healthcare providers on topics such as endocrine diseases, infectious diseases, surgical pathology, and liver pathology.
25. Fueled by the caliber of Mayo Clinic’s academic medical faculty and its state-of-the-art laboratories, Mayo Clinic Laboratories is an internationally respected laboratory that provides important and cutting-edge testing services to help diagnose and treat patients with some of the most complex conditions.
26. Mayo Clinic Laboratories currently serves more than 3,400 national and international clients and, in ordinary circumstances, performs approximately 35,000 testing services per day. Together with Mayo Clinic, Mayo Clinic Laboratories relentlessly innovates on behalf of patients, building the diagnostics ecosystem of the future to help physicians save and improve more lives.
#### Laboratory-Developed Testing Services
27. When a patient visits Mayo Clinic with a difficult or complex medical challenge, or when its physicians and scientists are asked to consult with physicians outside of Mayo Clinic, the patient’s caregivers will turn to Mayo Clinic Laboratories and its expert laboratorians to help diagnose and evaluate the patient. In these situations, existing or routine tests — including available FDA-cleared or approved tests may be incapable of providing the information required. Instead, Mayo Clinic physicians and scientists have to rely on combining medical expertise with research and diagnostic expertise to ensure that it can properly evaluate and analyze the patient’s condition and then use that evaluation to diagnose the patient and develop effective treatment options.
28. Mayo Clinic Laboratories follows a rigorous process when developing new testing services. Laboratory teams focus on developing new tests when there is an unmet patient need and when it appears that new testing services could improve patient diagnosis, treatment, or care. Because the laboratory that develops a test must be knowledgeable about how the test will be used and understand the specimen type, range of detection, turnaround time requirements, and potential complementary tests, Mayo Clinic Laboratories has a large team of highly experienced physicians, scientists, medical technologists, medical technicians, histotechnologists, cytology technologists, pathologist’s assistants, phlebotomists, lab assistants, biologists, chemists, microbiologists, geneticists, genetic counselors, and others.
29. When developing the necessary protocols and methodologies for a new test, interdisciplinary experts and specialists consult with other medical experts, educators, and researchers at Mayo Clinic. Developing a new test requires a research and development process that documents standard operating procedures for each assay and includes basic analytical validation studies to show that assays satisfy clinical requirements. In addition, a variety of quality and process controls must be in place to verify that all steps of the assay are working appropriately, including extraction controls, controls to assess clinical accuracy, hybridization controls, external analyte controls, and/or internal controls for analytes expected to be presented in each test sample.
30. There are many examples of areas where Mayo Clinic Laboratories has developed groundbreaking approaches to providing the types of professional diagnostic services that are essential to helping patients. A few examples follow:
31. **Cardiovascular testing.** Mayo Clinic Laboratories has for more than two decades been at the forefront of cardiovascular genetic testing. The Laboratory’s current test menu features 24 different panels that collectively include more than 300 genes linked to inherited cardiovascular disorders, many of which are rare and challenging to diagnose. Disorders can involve multiple genes and may present similarly to other disorders with distinct genetic causes.
32. When providing genetic specimen or similar testing services, Mayo Clinic Laboratories takes an expansive approach. A team of technicians, genetic counselors, Ph.D. geneticists, and physicians work together to analyze the genetic data and determine how the data correlates with the clinical picture of each individual patient. This correlation entails both review of each patient’s family history and medical records and discussions with the treating clinicians.
33. There is significant professional medical expertise involved in developing well-thought-out gene panels to ensure that they are clinically useful and valid. In addition, professional expertise is required to interpret the results to ensure that the findings are accurate and consistent with the patient’s overall clinical presentation. Mayo Clinic Laboratories’ testing is part of Mayo Clinic’s integrated clinical practice.
34. For example, I am aware of the services Mayo Clinic Laboratories provided to a Mayo Clinic patient who was under the care of a preventative cardiologist. The patient had both high cholesterol and stage 1 hypertension, but current risk calculators and traditional blood tests were not helpful in reaching an appropriate diagnosis because they did not take into account the patient’s family history and because coronary artery disease and endothelial plaque formation are complex and multifactorial processes. As a result, the patient’s treating cardiologist recommended to the patient that a sample be sent to Mayo Clinic Laboratories for specialized ceramide testing. Ceramide testing uses liquid chromatography-mass spectrometry technology, which sorts through complex molecular compounds. By testing patients, the Laboratory is able to reveal more about heart disease and stroke risk than standard lipid tests, as ceramides are involved in plaque formation and can reflect inflammation, bad cholesterol, or coagulation and thickening of the blood. By evaluating the results of these tests, the treating physician was able to develop a tailored treatment plan for the patient that was appropriate to his risk level.
35. **Cancer testing.** Another important area where Mayo Clinic Laboratories is a leader is in the area of cancer diagnosis and treatment, where laboratory testing services are relied on to provide crucial information to guide appropriate care in real time. Because cancer is such a complex disease about which our medical understanding continues to evolve, it is important to be able to account for emerging new medical information on discoveries and technological advancements.
36. Mayo Clinic has one of the most robust laboratory and pathology practices for cancer care in the world, offering testing services that span diagnostic, theranostic, and prognostic approaches. The comprehensive test menu at Mayo Clinic Laboratories includes numerous laboratory-developed tests that aid in providing both diagnostic and prognostic information and treatment selection guidance across the full spectrum of malignancies.
37. Mayo Clinic Laboratories has developed a suite of hematology and oncology, next-generation sequencing panels that are used to help diagnose patients depending on the genetic associations of an individual patient’s cancer. Mayo Clinic Laboratories uses these panels to evaluate several gene mutations, rearrangements, and amplifications. The results of these analyses provide information that, along with correlation with the patient’s clinical features, inform clinicians regarding the appropriate diagnosis and are used to guide treatment. This all helps to ensure that patients receive the best cancer care and are able to follow the best treatment strategies.
38. The laboratory-developed tests developed by Mayo Clinic Laboratories include those used to diagnose sarcoma, melanoma, lung, and colorectal cancers, including gastrointestinal stromal tumors. New panels have recently been developed to help evaluate patients for renal cell carcinoma, bladder and prostate cancer, gynecological cancer, endometrial cancer, and ovarian, fallopian tube, and peritoneal cancer. In addition, panels have been developed to test for B-cell lymphoma, chronic lymphocytic leukemia, T-cell lymphoma, plasma cell myeloma, and histiocytic neoplasms.
39. These tests are not just a question of chemistry. They involve analyzing actionable genes that are carefully selected by a multi-disciplinary team of professional clinicians, geneticists, genetic counselors, and laboratory testing experts. The genes included on the testing panels are recognized as
clinically significant and are included in consensus group testing guidelines put forth by the World Health Organization, the National Comprehensive Cancer Network, the Intercultural Cancer Council, and European LeukemiaNet, among other governing bodies.
40. Because the experts who design the hematology panels are themselves hematopathologists, they are intimately familiar with the underlying disease. When questions arise, testing specialists collaborate with Mayo Clinic physicians to obtain their expert assistance with accurately interpreting the results. Moreover, each and every case is reviewed by a team of genetic experts, including technical experts, genetic counselors, and physician scientists, all of whom help to interpret the test results and ensure that they are accurate.
41. The interpretive report that accompanies the testing results describes in detail the gene variant detected and contextualizes the clinical significance from a diagnostic, prognostic, and/or therapeutic perspective. The report also may include information concerning relevant clinical trials. Even after the clinical report is provided to the treating physician(s), ongoing consultation between the laboratory professionals and the treatment team is common.
42. I was personally involved in developing standards for classifying and identifying different types of leukemia and, in particular, T cell, large granular, lymphocytic leukemia and NK-cell, large granular, lymphocytic leukemia, which are rare blood cancers of cytotoxic effector lymphocytes. Diagnosis involves evaluating blood and bone marrow samples for clonal abnormal T- and NK-cells through a variety of methods, all of which are synthesized by the pathologist and correlated with the clinical features to render the correct diagnosis.
43. Early diagnosis of this rare disease is often crucial for appropriate management and optimizing the outcomes for patients. That is especially true because patients with T cell and NK cell disorders often present with symptoms that are similar to other diseases and other types of leukemia. Early detection can ensure that the disease is properly treated and allow patients to live long and fulfilling lives.
44. The standards I helped develop to support the practice of medicine in this important area of pathology are reported in guidelines published by the World Health Organization and are part of the standard of care for classification of patients with this rare disease. _See_ Rita Alaggio, et al., _The 5th Edition of the World Health Organization Classification of Haematolymphoid Tumours: Lymphoid Neoplasms_. Leukemia. 2022 Jul;36(7) 1720-1748. doi: 10.1038/s41375-022-01620-2. Epub 2022 Jun 22. Erratum in: Leukemia. 2023 Sep;37(9):1944-1951. PMID: 35732829; PMCID: PMC9214472.
45. As this publication recognizes, evidence-based classification of disease is fundamental for the treatment of individual patients, monitoring global disease incidence, and investigating all aspects of disease causation, prevention, and therapy.
46. **Infectious diseases.** Mayo Clinic Laboratories is also internationally renowned for offering a broad selection of laboratory-developed tests designed for the rapid identification and in-depth characterization of the causative agents of infectious diseases. The Laboratory has developed culture techniques, immunoassays, antimicrobial susceptibility testing, and molecular methods for rapid detection, identification, and characterization, as well as providing treatment guidance for microbial pathogens.
47. For example, Mayo Clinic Laboratories has developed a test that assists with identifying nervous system infections. The assay uses shotgun metagenomic sequencing to apply complex bioinformatic analysis to all DNA and RNA sequences in a cerebrospinal fluid specimen. The sequences deriving from humans are removed, and the remaining sequences are then analyzed by expert technicians for a potentially pathogenic microorganism.
#### The Material Differences Between Laboratory-Developed Testing Services and FDA-Approved Medical Devices
48. Laboratory-developed testing services are materially different from the types of instruments, machines, or physical objects that qualify as and are properly considered to be medical devices.
49. Laboratory-developed testing services are essential professional healthcare services that are provided in connection with the practice of medicine. The types of tests developed by federally-certified CLIA laboratories reflect unique assays that yield important clinical information about a patient that can be used by physicians and other medical professionals to inform and guide that patient’s care and treatment.
50. When Mayo Clinic Laboratories develops and performs laboratory-developed testing services, it is not acting as a device manufacturer. Mayo Clinic Laboratories are managed by professional physicians and scientists with expert knowledge regarding the clinical implications of each test result and how those results can impact patient care. The type of interaction and collaboration between a clinical laboratory and the care team that I describe above is completely at odds with the idea of a laboratory as a device manufacturer. Medical device manufacturers do not perform patient care using their medical devices; medical device manufacturers do not collaborate with treating physicians; medical device manufacturers are not considered part of the care team for a patient.
51. By subjecting laboratories to regulation as device manufacturers, FDA’s final rule will significantly undermine the relationship between laboratory professionals and the care teams that rely on the diagnostic services of clinical laboratories.
52. Performing a test in a CLIA-certified laboratory involves (1) collecting and appropriately preparing a tissue, blood, or other patient specimen that is sent to the laboratory for testing and analysis; (2) conducting an analysis of the sample by using reagents, instrumentation and other equipment to evaluate the specimen quantitatively and/or qualitatively; and (3) preparing a report that reflects the results of the analysis, the expert medical judgment used in conducting the analysis, and patient-specific information that is shared with a physician or team of physicians to assist in patient diagnosis and treatment.
53. FDA-approved medical devices, including reagents, instrumentation, microscopes, spectrometers, and other sophisticated types of medical equipment, are routinely used by laboratory technicians when providing diagnostic testing services. Medical devices are appropriately subject to FDA’s clearance and pre-approval oversight because they are instruments, machines, or other physical objects that are packaged, labeled, and produced by manufacturers to be used and sold to third parties.
54. Unlike medical devices, laboratory testing services are not a type of equipment, machine, or physical object. They instead reflect medical protocols, information, procedures, and techniques that are used by healthcare professionals to evaluate and diagnose patients. Whereas medical devices are typically sold to healthcare providers or patients for their own use, laboratory-developed tests are not sold or shipped to third-party purchasers. Instead, these testing services are performed by the laboratory itself, and the material to be tested — human blood, tissue, or other specimen samples — is sent to the laboratory for its expert medical analysis. Professional laboratory-developed testing services are performed by expert laboratory technicians in consultation with medical experts and are integral to the broader practice of medicine.
55. To provide a simple analogy: When a patient visits his doctor, the doctor may use certain devices to perform medical procedures. The doctor might, for example, use a biopsy needle to obtain a tissue sample for subsequent analysis. The biopsy needle is an FDA-regulated medical device and must be cleared or approved by FDA before it can be obtained and used by the doctor. In contrast, the technique the doctor follows in performing the biopsy procedure and the information she deems relevant to evaluating her patient — for example, deciding where to place the needle to avoid sensitive
tissue and whether or how to use anesthetics or ultrasound guidance — is a healthcare service that is provided to the patient by a trained professional in connection with the traditional practice of medicine. The fact that the biopsy procedure uses a device does not transform the procedure itself into a medical device.
56. The same is true for professional laboratory-developed testing services. The equipment, machines, and other instruments used to analyze a blood, tissue, or other sample from a patient are medical devices — like an ultrasound or biopsy needle — that must be approved or cleared by FDA and qualified and validated for use by the laboratory pursuant to the requirements of CLIA. But the sophisticated protocols that laboratories develop and use to test and evaluate the samples received from patients are not themselves instruments, machines, or pieces of equipment.
57. Laboratory-developed testing services have long been subject to regulation under CLIA, a specific statutory and regulatory framework tailored for clinical laboratories. In addition, several states have their own requirements relating to laboratory testing services and the practice of medicine. Most significantly, New York has developed an extensive set of diagnostic-specific, risk-based requirements that apply to laboratory-developed tests offered to New York state residents.
58. One key aspect of the existing regulatory requirements is the flexibility provided to the professionals at clinical laboratories to develop new testing protocols and modify existing ones for the purpose of diagnosing and guiding innovative treatment for patients. When individual patients present unexpected or unusual challenges, laboratory-developed tests are used in combination and may be modified to address the patient’s specific circumstances, which can lead to discovering new diagnostic approaches and new testing protocols.
59. I am deeply concerned about the consequences of FDA’s new rule for patients and for the ability of Mayo Clinic physician specialists to treat patients effectively. The most significant consequence of FDA’s rule will be to make it more difficult for patients to continue to obtain the essential testing services they need. Seeking FDA clearance and approval for medical devices is very expensive and time-consuming. According to FDA, laboratories will face enforcement action if they fail to obtain such clearance or approval for most new testing services and most significant modifications of existing testing services. And even where FDA says it will exercise enforcement discretion (such as for some existing services), the agency insists it can change that policy at any time.
60. If FDA’s final rule is allowed to take effect, clinical laboratories that want to protect themselves — and not rely on FDA’s open-ended exercise of enforcement discretion — will need to seek FDA clearance or approval for the tens of thousands of tests that are already on the market and for every new testing protocol they might develop in the future. That is unrealistic. Many laboratory-developed tests are low-volume tests that are used infrequently. These types of tests do not generate sufficient revenue to justify going through the very expensive FDA clearance or approval process.
61. Moreover, FDA lacks the personnel and financial resources necessary to efficiently review all of the testing services provided by professional laboratories and grant the necessary clearances and approvals. On average, it takes FDA months — and sometimes years — to clear or approve a new medical device. There are tens of thousands of different types of tests provided by laboratories across the United States, and there is no practical way for FDA to review, approve, and clear all of them.
62. It is also unclear how FDA intends to apply its new rule to modifications that are made to existing tests, which are critical to improving laboratory-developed tests and ensuring that they reflect the latest scientific advances. Under existing law, when FDA approves a medical device, the device must be manufactured to the approved specifications, and modifications to the device may need to be separately approved by FDA. As noted above, making modifications to existing testing protocols for particular patients is an essential part of the diagnostic testing process. Clinical laboratories, such as
Mayo Clinic Laboratories frequently make adjustments to tests to respond to the specific circumstances of individual patients or to incorporate new biomarkers to reflect the latest scientific advances. Preventing laboratories from making these modifications without first going through the time-consuming and expensive FDA clearance or approval process would harm both patient care and innovation.
63. The consequences of not having laboratory-developed testing services available would be particularly devastating to the quality of care for patients suffering from rare diseases, many of whom come to Mayo Clinic. One of the particular advantages of laboratory-developed tests is the ability to determine — through a process of elimination — whether a patient has biomarkers for a particular disease.
64. To the uninitiated, it may seem to be only a minor consequence if certain tests are not developed, as only a small number of patients may suffer from any particular rare disease. But that misunderstands how tests are used. Tests are often most useful not for determining that a patient has or may have a particular disease (“ruling in” that disease), but for determining what diseases the patient does not have (“ruling out” diseases). Furthermore, tests developed within the laboratory in response to clinical need often provide new insights into previously identified diseases. Through the implementation of laboratory-developed tests, patients with more or less aggressive forms of a disease are often identified, significantly impacting both their care and the psycho-social response to their diagnosis.
65. Eliminating diseases is often the best way to design an appropriate treatment regimen for a patient, even if no existing test is available to determine precisely what disease the patient does have. As a result, even tests that are used to diagnose especially rare diseases are an extremely valuable tool when diagnosing patients with unknown conditions.
66. Mayo Clinic has invested substantial resources into research and medical care — and into Mayo Clinic Laboratories — in reliance on the existing regulatory regime and on the understanding that Congress has never granted FDA authority to regulate professional laboratory testing services. These settled expectations would be undermined if FDA is permitted, for the first time ever, to take control over all the services provided by clinical laboratories by treating those services as equivalent to medical devices.
67. On several occasions, Congress has evaluated legislation that would change the regulatory requirements for laboratory testing services. But Congress has not enacted legislation and has instead declined to empower FDA with authority to regulate laboratory-developed tests. For many of us who are aware of those legislative debates, FDA’s new rule appears to be an attempt to circumvent the political process and exercise sweeping authority that has never been granted to the agency by Congress.
68. In any event, as a practical matter, Mayo Clinic Laboratories will have less money to invest in developing new and innovative testing services if its resources have to be dedicated to obtaining FDA clearance or approval. Moving resources away from helping patients and in the direction of seeking FDA clearance or approval of testing services that FDA lacks the resources and expertise to evaluate would not benefit patients or the public interest.
In accordance with 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.
Executed on this 28th day of May, 2024.
By:
William Morice II, M.D., Ph.D.
## EXHIBIT F
**Privileged & Confidential**
**Attorney Client Communication**
**Pre-Decisional**
### MEMORANDUM
**TO:**
Stephen Hahn, M.D., Commissioner of Food and Drugs
**CC:**
Eric D. Hargan, Deputy Secretary
Brian Harrison, Chief of Staff
Stacy Amin, Deputy General Counsel & Chief Counsel
Anand Shah, M.D., Deputy Commissioner of Food and Drugs
Keagan Lenihan, Chief of Staff FDA
Danielle Steele, Counselor to the Secretary
**FROM:**
Robert Charrow, General Counsel
**SUBJECT:**
Federal Authority to Regulate Laboratory Developed Tests
**DATE:**
June 22, 2020
#### Introduction
We have been asked by departmental leadership to review the legal bases—both substantive and procedural—for FDA's regulation of laboratory developed tests ("LDT").[^1] This memorandum summarizes the results of our analyses.
Since 1992, FDA has taken the position in draft guidances, manuals, and web postings that LDTs are devices within the meaning of the Food, Drug, and Cosmetic Act ("FDCA" or "Act") § 201(h) and subject to the Agency’s jurisdiction. Most recently, FDA announced on its website that
- FDA generally has not enforced premarket review and other legal requirements [with respect to LDTs]. However, LDTs for which an HHS [Emergency Use Authorization] declaration justifies a need (and that potentially meet the EUA criteria) present a higher risk. This is because they are developed to diagnose serious or life-threatening diseases or conditions that not only have serious implications for individual patient care, but also for analyses of disease progression and public health decision-making. Thus, FDA requests that developers of such LDTs submit information about their tests to help FDA better understand their design, validation, and performance characteristics.
https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/information-laboratories-implementing-ivd-tests-under-eua (March 1, 2020) (last viewed June 15, 2020). We understand that some stakeholders, including many state university laboratories, have complained that this policy hindered their ability to develop and use LDTs to detect the virus that causes COVID-19.
We have undertaken a review of the relevant legal authorities and regulatory processes so as to advise departmental leadership, FDA, and other policymakers of FDA's authority in this area, especially in light of COVID-19. Specifically this memorandum addresses: (i) whether an LDT is a medical device; (ii) if so, under what circumstances, if any, does FDA have the jurisdiction to regulate LDTs; and (iii) whether FDA can properly regulate in this area without notice and comment rulemaking. We also discuss a potential re-assessment of relevant delegations in light of the foregoing analysis.
#### Summary of Conclusions
We believe that the Medical Device Amendments of 1976 ("MDA"), Pub. L. No. 94-295, may be broad enough, in certain settings, to accommodate FDA’s view that LDTs, as opposed to the procedures used to run those tests, are "devices," within the meaning of section 201(h) of the FDCA.[^2] However, the Agency’s jurisdiction to regulate these devices is not uniform and not as plenary as it is for a traditional device; this lack of jurisdictional uniformity is dictated by the FDCA itself. FDA relies on FDCA section 301(k) and the premarket review regime in sections 510(k) and 515 as the primary means of exercising authority over LDTs. This theory has several potential weaknesses. First, it appears likely that LDTs, even if they satisfy the "interstate commerce" requirement of the FDCA, would likely not satisfy the separate "commercial distribution" requirement of the premarket review provisions at sections 510(k) and 515. Section 301(k), the primary provision dealing with prohibited acts, turns on whether the device is "held for sale." While courts in the past have given that term a broad reading to include devices that never leave a physician’s office, a plain meaning assessment may not be as agency-friendly. Second, many first-line sophisticated laboratories are operated by state public health departments or academic medical centers at large state universities. These laboratories, by definition, are not "persons," within the meaning of the Act, and not subject to many of the Act’s requirements, including registration (§ 510(o)), premarket review (§§ 510(k), 515), and adverse event reporting (21 C.F.R. pt. 803).
Third, the process that FDA used to ordain that LDTs are devices subject to the usual breadth and depth of FDA regulation is, in my view, inconsistent with the rulemaking provisions of the Administrative Procedure Act ("APA"), 5 U.S.C. § 553. Although the FDCA does not mention laboratory tests, FDA’s various issuances have sought to fill this gap. However, where that gap-filling binds the Agency and has significant legal, regulatory and financial implications for those outside of the Agency, it is a legislative rule. This is especially the case here, where, as recently as last year, FDA has taken quasi-enforcement action on the basis of its determination that an LDT is a device, and where the FDA determination is inconsistent with the Secretary’s existing regulations. The APA requires that legislative rules be issued through notice and comment rulemaking coupled with a Regulatory Flexibility Act ("RFA") analysis. See 5 U.S.C. § 601 et seq. Here, FDA did neither.³
All of this is not to say that during a national public health emergency, FDA would lack authority to seize or take other appropriate action against fraudulent or dangerous LDTs. Its authority, though, would not derive from the FDCA. Under the Public Health Service Act § 361(a), 42 U.S.C. § 264(a), the Public Health Service agencies, including FDA and CDC, have authority "to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the States or possessions, or from one State or possession into any other State or possession." FDA has used this authority to enjoin facilities that transplant stem cells and it could be used in those rare cases when an LDT poses undue risk. There may also be other federal agencies with authority to take action in such circumstances.
#### Background
When the MDA amended the FDCA, Congress authorized the then-Secretary of Health, Education, and Welfare to regulate medical devices through, among other things, premarket review—notification and approval—and the imposition of sanctions on those that failed to heed FDA's regulations or orders. The MDA broadly defined "device" to include, among other things, an "in vitro reagent . . . intended for use in the diagnosis of disease." MDA § 3(a)(1)(A). Laboratory developed tests—tests developed in a single clinical laboratory and used exclusively in that laboratory—were never mentioned in the MDA, in the House Report accompanying it, or during the floor debates.
In 1988, though, Congress addressed clinical laboratory testing when it enacted CLIA, codified at 42 U.S.C. § 263a, which among other things, instructed the Secretary of Health and Human Services to "issue standards to assure consistent performance by laboratories issued a certificate under this section of valid and reliable laboratory examinations and other procedures." 42 U.S.C. § 263a(f)(1). CLIA also required the Secretary to conduct inspections of laboratories to ensure compliance with established standards. See 42 U.S.C. § 263a(g). Since CLIA certification is a prerequisite to receiving Medicare payment, it was viewed primarily as Spending Clause legislation and delegated to CMS for enforcement. Thereafter, the Secretary issued comprehensive rules governing clinical laboratories. See 42 C.F.R. pt. 493. With respect to laboratory developed tests, those regulations provide as follows:
Each laboratory that modifies an FDA-cleared or approved test system, or introduces a test system not subject to FDA clearance or approval (including methods developed in-house and standardized methods such as textbook procedures), or uses a test system in which performance specifications are not provided by the manufacturer must, before reporting patient test results, establish for each test system the performance specifications for the following performance characteristics, as applicable:
(i) Accuracy.
(ii) Precision.
(iii) Analytical sensitivity.
(iv) Analytical specificity to include interfering substances.
(v) Reportable range of test results for the test system.
(vi) Reference intervals (normal values).
(vii) Any other performance characteristic
42 C.F.R. § 493.1253(b)(2) (2019) (emphasis added). To perform LDTs, laboratories have to be certified under CLIA to perform highly complex tests. See id. § 493.17(c)(4). These tests can usually only be performed under the supervision of a board certified pathologist. See id. § 493.1443(b)(3) (noting that some with Ph.Ds may be grandfathered and medical doctors may satisfy the certification requirement in other ways). CLIA appeared to have occupied the field for regulating LDTs.⁴
FDA seems to have first suggested that LDTs are subject to its jurisdiction in a 1992 draft compliance policy guide aimed at regulating products sold to laboratories for research use only. The draft compliance guide stated that "laboratories have been manufacturing 'home brew' products, either from products already on the market, or from components, and utilizing these unapproved products for diagnostic purposes" and asserted that "[t]hese products are subject to the same regulatory requirements as any unapproved medical device." FDA, *Draft Compliance Policy Guide: Commercialization of Unapproved In Vitro Diagnostic Devices Labeled for Research and Investigation* at 4 (Aug. 1992).
In 1997, FDA issued a final rule regulating analyte specific reagents ("ASR"), the type frequently sold to commercial laboratories. In the preamble to the final ASR rule, FDA expressly stated that LDTs were devices subject to FDA jurisdiction: "FDA believes that clinical laboratories develop [LDTs] are acting as manufacturers of medical devices and are subject to FDA jurisdiction under the act."⁵ 62 Fed. Reg. 62,243, 62,249 (col. b) (Nov. 21, 1997).
During the intervening seventeen years, FDA did little to regulate LDTs, although it did issue a draft guidance for certain high-risk LDTs known as "in vitro diagnostic multivariate index assays" in 2007.⁶ Things changed, though, in 2014, when FDA issued two draft guidances.⁷ Not only did the Agency continue to assert its authority under the FDCA to regulate LDTs, but it noted that, as part of that authority, it was going to require registration for all LDTs, to classify LDTs under section 513, and to require premarket notification or approval under sections 510(k) or 515, respectively, for certain LDTs.
The draft guidances' legal justification for treating LDTs as devices subject to FDA jurisdiction relied on the FDCA definitions of "device" and "manufacturer." A "device" under FDCA § 201(h) is defined as:
- an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is—(1) recognized in the official National Formulary, or the United States Pharmacopeia, or any supplement to them, (2) intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals, or (3) intended to affect the structure or any function of the body of man or other animals, and which does not achieve its primary intended purposes through chemical action within or on the body of man or other animals and which is not dependent upon being metabolized for the achievement of its primary intended purposes. (emphasis added)
A "manufacturer" is defined as any person who owns or operates any establishment engaged in the "manufacture, preparation, propagation, compounding, assembly, or processing of a device" is required to register that establishment with FDA. FDCA § 510(b), (c).⁸ Under FDA's logic, because an LDT is system using one or more in vitro reagents, and hence a "device," that is assembled or prepared in the clinical laboratory, and hence "manufactured," it is, in the Agency's view, subject to its regulatory jurisdiction. Most of the draft guidance is a lengthy justification as to why regulation is warranted and how that regulation would be implemented.
FDA received more than 50 comments in response to the draft guidances. Some were supportive, but many questioned the Agency's legal authority, questioned the absence of any documentation to support its claim that LDTs posed a risk, and questioned whether agency action of this magnitude could be undertaken without going through notice and comment rulemaking. On November 18, 2016, following the Presidential election, FDA announced that it would not finalize the two guidance documents. Notwithstanding this decision, FDA's position—announced initially in a compliance policy guide, later in a preamble to a regulation, and most recently in the web posting—that LDTs are medical devices within its jurisdiction remains in place. At issue is whether that decision is legally viable.
#### Analysis
##### I. Many LDTs Are Likely Medical Devices, But Even Those That Are May Fall Outside of FDA's Full Regulatory Regime
FDA maintains that LDTs are systems that include *in vitro* reagents intended to diagnose disease in humans and are therefore medical devices subject to FDA jurisdiction. Those opposing this position argue that LDTs are not physical embodiments, e.g., "contraptions," but rather are processes or services, and therefore not devices. FDA is correct that, by definition, *in vitro* reagents are devices, but that does not necessarily lead to the conclusion that LDTs fall within FDA’s jurisdiction. For purposes of this memorandum, we assume that had FDA made that determination through notice and comment rulemaking, it would be entitled to *Chevron* deference and would likely withstand scrutiny under that standard. However, even assuming that LDTs are medical devices, three additional requirements must be satisfied before FDA can implement its most significant regulatory authorities: (i) the “device” must satisfy the constitutional and statutory “interstate commerce” requirements; (ii) the device itself must be in commercial distribution or held for sale; and (iii) the laboratory must be a “person.” We believe that the first requirement may be easy to establish with respect to certain authorities; the second more difficult to establish; and the third one cannot be established, as a matter of law, in many significant instances.
###### A. Statutory Interstate Commerce Requirement
The Constitution grants Congress power “[t]o regulate commerce with foreign nations, and among the several States, and with the Indian tribes.” U.S. Const., art. I, § 8, cl. 3. Since the 1940s, the Supreme Court has construed the Commerce Clause broadly. *See, e.g., Wickard v. Filburn*, 317 U.S. 111 (1942). In addition to regulating the channels of interstate commerce, and persons and things therein, Congress has authority to regulate activities that “substantially affect” interstate commerce. *Nat’l Fed’n of Indep. Bus. v. Sebelius*, 132 S. Ct. 2566, 2578 (2012). The Court’s consistent rulings that Congress intended to regulate local, noncommercial activities that have only a nominal or indirect connection to interstate commerce. *See, e.g., Gonzales v. Raich*, 545 U.S. 1, 22 (2005); *Katzenbach v. McClung*, 379 U.S. 294, 300-01 (1964); *United States v. Wrightwood Dairy Co.*, 315 U.S. 110, 121 (1942); *Wickard*, 317 U.S. at 128-29. Given the breadth of the Court’s interpretation, the Commerce Clause poses no barrier to FDA’s theory of jurisdiction.
In the years since *Wickard*, Congress also expanded FDA’s statutory jurisdiction to cover some intrastate activities. Congress revised the FDCA in 1948 to clarify that its prohibitions against adulteration and misbranding apply to articles that are held for sale within a state after being shipped in interstate commerce. Amendments in 1976 authorized FDA to seize misbranded or adulterated medical devices without proof that they have traveled in interstate commerce. *See FDCA § 304(a)(2)*. FDA also has authority under the Public Health Service Act (“PHSA”) to prohibit false labeling of biological products whether or not they move in interstate commerce, and section 361 of the PHSA authorizes FDA regulation to prevent the spread of communicable disease without any interstate commerce limitations. However, despite these extensions of FDA jurisdiction, the Agency still lacks statutory authority to regulate a large segment of wholly intrastate conduct. Nonetheless, as those regulated by FDA have generally engaged in interstate commerce in some fashion, courts have tended to make statements regarding FDA’s statutory jurisdiction as broad as the Commerce Clause, and the Agency prevails in the overwhelming majority of cases where its jurisdiction is challenged because a component of the drug or device was transmitted in interstate commerce. We offer below, in case a litigant were to assert that their conduct is wholly intrastate, advice regarding how FDA can successfully assert that its regulation of LDTs satisfies the statutory interstate commerce requirement in section 301(k) and otherwise consider its litigation position or reviews its regulations in light thereof.
1. Section 301(k)
Section 301(k) of the FDCA (21 U.S.C. § 331(k)) prohibits:
- The alteration, mutilation, destruction, obliteration, or removal of the whole or any part of the labeling of, or the doing of any other act with respect to, a food, drug, device, tobacco product, or cosmetic, if such act is done while such article is held for sale (whether or not the first sale) *after shipment in interstate commerce* and results in such article being adulterated or misbranded. (emphasis added).
The ability of the Agency to satisfy the statutory interstate commerce requirement in section 301(k) hinges on whether a laboratory can show that everything used in its tests came from within the state. In *United States v. Regenerative Sciences, LLC*, 878 F. Supp. 2d 248 (D.D.C. 2012), *aff’d*, 741 F.3d 1314, 1326 (D.C. Cir. 2014), two Colorado physicians developed a cellular therapy for orthopedic patients that involved harvesting stem cells from a patient’s bone marrow or synovial fluid, culturing those cells for several weeks in a laboratory with growth factors from the patient’s blood, placing the cultured cells into a syringe along with the antibiotic doxycycline and other additives, and injecting the contents of the syringe into the patient’s injured area. The doctors formed Regenerative Sciences LLC (“Regenerative”) to commercialize this practice. FDA officials inspected Regenerative’s facilities in 2009 and 2010 and found that its laboratory operations did not conform to FDA manufacturing regulations. When FDA charged Regenerative with manufacturing and distributing adulterated and misbranded biological drug products in violation of section 301(k) of the FDCA and section 351(k) of the PHSA, the defendant physicians responded that they were lawfully practicing medicine within the state of Colorado and that their procedure fell outside FDA’s regulatory purview.
The district court focused on whether defendants’ actions were directly connected to interstate commerce. FDCA section 301(k) prohibits any act “with respect to, a . . . drug . . . if such act is done while such article is held for sale (whether or not the first sale) after shipment in interstate commerce and results in such article being adulterated or misbranded.” The court held that the manipulated cellular brew was “held for sale,” a fact not contested by defendants. The court further went on to hold that
[d]efendants do not dispute that the doxycycline is shipped from out of state to their facilities in Colorado. Id. Therefore, because a component of the drug in this case is shipped through interstate commerce prior to its administration to the patient, the “interstate commerce” requirement [of section 301(k)] is also met.
878 F. Supp. 2d at 259.
The defendants’ conduct satisfied the statutory interstate commerce requirement only because the doxycycline was shipped into Colorado from out of state and added to the stem cells prior to the mixture’s administration to patients. Had the doxycycline been manufactured in Colorado and shipped intrastate, FDA would have lacked a jurisdictional hook. Alternatively, suppose the defendants had administered the doxycycline separately rather than mixing it with the stem cells in a single syringe. If the procedure were modified to comprise two separate injections—a first syringe of stem cells and a second syringe of doxycycline—FDA presumably would lose its regulatory authority under the FDCA, even if the doxycycline were shipped from out of state. In this case, the defendants would be prescribing doxycycline for off-label use, an activity that FDA lacks power to regulate regardless of its connection to interstate commerce. It was the mixing of the doxycycline, an approved drug, with other material that created FDA’s jurisdictional hook.
Thus, under the terms of *U.S. v. Regenerative Sciences, LLC*, in order for FDA to satisfy the statutory interstate commerce requirement in section 301(k), at least one element of an LDT must come from outside the state. With the exception of some academic medical centers, most laboratories use LDTs that have at least one component that came from out-of-state, so we believe FDA can usually successfully defend its jurisdiction in this regard.
2. Section 510(k)
Premarket review, which is set out in section 510(k), was central to the 2014 guidances and is the primary difference between regulation under CLIA and regulation under the FDCA. FDCA section 510(k) (21 U.S.C. § 360(k)) provides:
- Each person who is required to register under this section and who proposes to begin the *introduction or delivery for introduction into interstate commerce for commercial distribution of a device intended for human use* shall, at least ninety days before making such introduction or delivery, report to the Secretary . . . action taken by such person to comply with requirements under section 514 [related to performance standards] or 515 [related to premarket approval] which are applicable to the device. (emphasis added).
Section 510(k) has a meaningful grammatical difference from section 301(k). Section 301(k) prohibits the sale in interstate commerce of a component or other aspect of a device that is then altered or manipulated. Hence, if a laboratory were to purchase in interstate commerce any of its reagents, which it then modified or used to modify other reagents, it would satisfy the jurisdictional prerequisite in section 301(k). However, under section 510(k), the premarket review requirements are only triggered when one proposes to introduce or deliver the device into interstate commerce, even if the reagents were purchased from another state. The typical LDT, though, never physically leaves the laboratory. There is no “introduction” and no “delivery.”
Thus, while the actions of the laboratory operator may have been sufficient to support regulation under the Commerce Clause, as having a substantial effect on interstate commerce, those actions may not be sufficient, if challenged by a savvy litigant, to satisfy the statutory requirements of section 510(k) or section 515 (premarket approval), which uses identical language.
###### B. “Held for Sale” or “Commercial Distribution” Requirement
1. Section 301(k)
Section 301(k) only applies if an article is “held for sale . . . after shipment.” Courts have tended to interpret section 301(k)’s “held for sale” requirement very broadly—far broader than the plain meaning of the statutory text. But it is unclear whether the current Supreme Court would ignore the plain meaning of the text and affirm these expansive readings.
Case law supports the assertion that the “held for sale” standard of section 301(k) has long been afforded a liberal reading, encompassing “[a]ll articles, compound or single, not intended for consumption by the producer.” *United States v. Cassaro, Inc.*, 443 F.2d 153, 156 (1st Cir. 1971) (citing *Hipolite Egg Company v. United States*, 220 U.S. 45, 54 (1911)). The Supreme Court has explained that that 301(k)’s “held for sale” requirement is “designed . . . to extend the [FDCA’s] coverage to every article that had gone through interstate commerce until it finally reached the ultimate consumer.” *United States v. Sullivan*, 332 U.S. 689, 697 (1948). The United States government has repeatedly advocated for this expansive reading of “held for sale,” and stated that the requirement is satisfied if the product can be shown to have been used for any purpose other than personal consumption. See, e.g., *United States v. Rhody Dairy, L.L.C.*, 812 F. Supp. 2d 1239 (E.D. Wash. 2011); *United States v. Scenic Dairy, L.L.C.*, 2011 WL 3879490 at *14 (W.D. Mich. Sep. 1, 2011); *United States v. Torigian Labs., Inc.*, 577 F. Supp. 1514, 1521 (E.D.N.Y. 1984); *Articles of Animal Drug Containing Diethylstilbestrol*, 528 F. Supp. 202, 205 (D. Neb. 1981); *United States v. Articles of Device (Acuflex; Pro-Med)*, 426 F. Supp. 366, 368 n.3 (W.D. Penn. 1977).
Several courts have held that the phrase “held for sale” extends to physicians using devices in the treatment of patients. See, e.g., *United States v. Kaplan*, 836 F.3d 1199, 1208 (9th Cir. 2016). In *Kaplan*, the Ninth Circuit held that a doctor’s use of a device (in that case, single-use plastic needle guides used during prostate biopsy exams) in the course of treating a patient is considered a “sale” within the meaning of “held for sale” in section 301(k). 836 F.3d at 1208. This makes sense—the single-use medical device is being consumed (i.e., sold) when used by the doctor, because the doctor is using the item with the patient during the course of a service. In contrast, LDTs usually involve the development of technologies and processes to conduct testing activities. For example, Medicare does not pay for the physical embodiment of any LDT or any other laboratory test. LDTs are more analogous to a doctor who creates and develops a replicable procedure, rather than a doctor who uses a medical device during an ordinary course of treatment. Just as the doctor’s development and use of a medical procedure would not be considered to be “held for sale,” the development and use of LDTs would also not be considered “held for sale” under the common meaning of that term.
In short, even though courts have given a liberal reading to the “held for sale” requirement, it is unclear whether that reading is sufficient to support liability under section 301(k) with respect to LDTs. Even in light of this uncertainty, we assume for purposes of our analysis that courts would adopt a liberal reading and apply that section to LDTs such that FDA could defend its current position.
2. Sections 510(k), 513(f), and 515
Similar to section 301(k)’s “held for sale” requirement, section 510(k) requires that persons subject to it “begin the introduction or delivery for introduction into interstate commerce for commercial distribution of a device . . . .” Similar language is used in section 513(f) and 515(b). There do not appear to be any judicial interpretations of “commercial distribution” as used in these classification and premarket review sections. But this phrase is used in the grandfathering provision of the FDCA, and with respect to that provision, FDA has interpreted “commercial distribution” to mean “on the market” or “actively promoted” for a specific purpose. See, e.g., *United States v. An Article of Device Consisting of 1,217 Cardboard Boxes*, 607 F. Supp. 990, 994 (W.D. Mich. 1985); see also *Northwest Tissue Center v. Shalala*, 1 F.3d 522, 535 (7th Cir. 1993).
The plain meaning of this phrase makes it much narrower than section 301(k)’s “held for sale” requirement. First, the term “commercial” relates to “commerce” which means the “buying or selling of commodities on a large scale involving transportation from place to place.” *Webster’s New Collegiate Dictionary* 223-24 (1980). Second, the term “distribution” means to “supply.” *Id.* at 330. This means that if LDTs are to satisfy the “commercial distribution” standard, they must be viewed as goods or commodities that are sold and dispersed beyond the laboratory. This, of course, does not occur. Each LDT remains in situ, and is not treated as merchandise by the Secretary for payment purposes, but rather as a service. For example, under Medicare part B, the Secretary only pays for clinical laboratory services. See Social Security Act § 1861(s) (defining “medical and other health services” as including diagnostic laboratory tests); § 1834A (referring to the information generated by laboratory tests). Thus, the Secretary does not purchase the physical embodiment of any LDT or any other laboratory test, for that matter.
The FDA definition of “commercial distribution” appears to be to be in keeping with the phrase’s plain meaning, namely, “any distribution of a device intended for human use which is held or offered for sale but does not include . . . ‘[i]ntracompany or interplant transfer of a device between establishments within the same parent, subsidiary, and/or affiliate company.’” 21 C.F.R. § 807.3. The development and use of LDTs involves purely internal transfers of LDTs because payors or clinicians are not paying for the LDT itself. Thus, even if LDTs could be viewed as being “held for sale,” they certainly almost always involve only internal transfers, or no transfers at all, and thus would not, if challenged by a savvy litigant, satisfy the plain meaning of FDA’s regulation.
To marginalize the importance of movement outside the walls of the laboratory is to equate “held for sale” and “commercial distribution,” which would be inconsistent with both its plain meaning and the well-established canon of statutory interpretation that the use of different words or terms within a statute demonstrates that Congress intended to convey a different meaning for those words. See *Russello v. United States*, 464 U.S. 16, 23 (1983); *Persinger v. Islamic Republic of Iran*, 729 F.2d 835, 843 (D.C. Cir. 1984) (“When Congress uses explicit language in one part of a statute to cover a particular situation and then uses different language in another part of the same statute, a strong inference arises that the two provisions do not mean the same thing.”); *Nat’l Insulation Transp. Comm. v. ICC*, 683 F.2d 533, 537 (D.C. Cir. 1982); *Russell v. Law Enforcement Assistance Admin.*, 637 F.2d 354, 356 (5th Cir. 1981) (stating the “well settled rule of statutory construction that where different language is used in the same connection in different parts of a statute it is presumed that the Legislature intended a different meaning and effect”) (internal quotation marks omitted); *NLRB v. Food Fair Stores, Inc.*, 307 F.2d 3, 10 (3rd Cir. 1962) (stating the rule of statutory construction which holds that different words appearing in the same statute are presumed to have different meanings). Even words with remarkably similar definitions can still convey a unique or distinct meaning or flavor from words that are similar or even synonymous in nature because of their differing tone or usage within a sentence.
###### C. The “Person” Requirement—Sections 510(e), 510(k), 515(e), and 21 C.F.R. pt. 803
In addition to the statutory coverage issue, the “held for sale,” and the “commercial distribution” requirements of the FDCA, portions of the Act only apply to a “person.” Thus, the registration and premarket review requirements of section 510(c) and 510(k), premarket application requirement of section 515(c), and the adverse event reporting requirements of 21 C.F.R. pt. 803 apply only to “persons.” See 21 C.F.R. § 803.3(1) (stating that a “Manufacturer means any person”). Under the Act, though, a “state” is not “person.”
1. State is Not a “Person”
Many of the more sophisticated laboratories that are the ones most likely to first develop LDTs in response to an infectious disease are located in state public health departments and academic medical centers at state universities. A state, including its departments and state-owned universities, is presumed by definition not to be a “person.” See *Vt. Agency for Nat. Res. v. U.S. ex rel. Stevens*, 529 U.S. 765 (2000) (applying its “longstanding interpretive presumption that ‘person’ does not include the sovereign” to find that a state is not a “person” within the meaning of the False Claims Act). That presumption is not necessary here because the Act defines “person” to “include[] [an] individual, partnership, corporation, and association.”
FDCA § 201(e). The Act separately defines “State,” “except as used in the last sentence of section 372(a) of this title, [to mean] any State or Territory of the United States, the District of Columbia, and the Commonwealth of Puerto Rico.” Id. § 201(a). The two definitions are not linked or cross-referenced. Thus, a “person” is not a “State.”
2. Premarket Review, Registration, and Related Provisions Only Apply to “Persons” and Not States
Section 510(c) requires “[e]very person upon first engaging in manufacture ... of ... a device ... shall register with the Secretary. . . .” The premarket notification provision of section 510(k) applies to “[e]ach person who is required to register under this section . . . .” Inasmuch as a state would not be required to register, it is also not required to file a premarket notification under section 510(k). If a device manufacturer does not take advantage of this pathway, it is generally subject to review under other more rigorous premarket review pathways in the Act, such as the premarket approval in section 515 or the de novo review in section 513(f)(2). For most manufacturers, this is true by operation of two provisions in the statute. First, under section 513(f)(1) of the FDCA, a non-grandfathered device is automatically classified in class III unless the device “is substantially equivalent to another device” or has been classified pursuant to a petition or request, such as a de novo request.
If such a device cannot be found to be substantially equivalent under the 510(k) pathway and if it has not been classified through another process, such as the de novo process, it is automatically classified in class III. Second, under section 515(a)(2), a device that is in class III by virtue of section 513(f) is “required to have ... an approval under this section of an application for premarket approval.” Devices that are subject to these provisions and that lack premarket approval are adulterated. See FDCA § 501(f)(1)(B).
In the case of a state actor, though, the normal interplay between sections 501, 510, 513, and 515 breaks down. First, a state is not required to file a premarket notification under section 510(k) or to register under section 510(c). Second, to avoid being automatically treated as a class III device, section 513(f) merely requires that the device is “substantially[ly] equivalent[]” to another lawfully marketed device. The section does not require that the Secretary make this finding or receive a report under section 510(k). Even assuming that section 513(f) applied and the device were by default classified into class III, that would still not impose any burdens on a state because it is likely that the premarket approval provision of section 515 does not apply to states and may not apply to LDTs, at all, and the adulteration provision also does not apply to states.
A device is adulterated if it were classified under section 513(f) into class III; a class III device, under section 515(a) “is required to have an approval under this section of an application for premarket approval . . . .” This presupposes that the state actor is required to file such an application. Section 515(c), though, limits those who may file applications to “persons:” “[a]ny person may file with the Secretary an application for premarket approval for a class III device.” FDCA § 515(c)(1) (emphasis added). It would be anomalous to require an approved application from an entity not required to file an application. One could argue that the phrase “any person may file” does not foreclose a state from filing a PMA. Courts, though, have viewed similar or identical phrases in other statutes as restricting the class that can file. Thus, under the False Claims Act, “[a] person may bring a civil action for a violation of section 3729 for the person and for the United States Government.” 31 U.S.C. § 3730(b). No one has suggested, following the Court’s decision in ex rel. Stevens, that a state could act as a relator and file a qui tam suit under section 3730(b). We believe the most natural way to read these provisions is recognize that when the FDCA and MDA were enacted and amended no one contemplated that they would apply to states. This is especially so given that the penalty provisions of the FDCA only apply to “persons.” See FDCA § 303. The fact that state public health and academic medical center laboratories appear to fall between the regulatory cracks in the case of LDTs, strongly suggest that the Act was never intended to reach these services.
As a result, FDA’s registration, premarket review, and adverse event reporting requirements would not, if challenged by a sophisticated litigant, likely apply, as a matter of law, to any state-owned laboratory, whether in a state department of public health or university.
In sum, although it appears that FDA was acting within its discretion by treating LDTs as medical devices and that section 301(k) could be applied, its premarket review authority would not apply to LDTs, because the provisions require the device itself (i.e., the reagent) to be placed into commercial distribution. Further, the registration, premarket review and adverse event reporting requirements only apply to “persons.” State laboratories are unlikely to be considered persons within the meaning of the FDCA.
##### II. FDA’s Policy that LDTs Are Devices Was Adopted Without Notice and Comment Rulemaking or a Regulatory Flexibility Analysis and Is Therefore Void
The APA establishes the procedures federal administrative agencies must use for “rule making,” defined as the process of “formulating, amending, or repealing a rule.” 5 U.S.C. § 551(5). “Rule,” in turn, is defined broadly to include “statement[s] of general or particular applicability and future effect” that are designed to “implement, interpret, or prescribe law or policy.” Id. § 551(4); see Perez v. Mortgage Bankers Ass’n, 575 U.S. 92, 95–96 (2015). Rules fall into two broad categories—legislative rules and interpretive rules. Legislative rules can only be issued through notice and comment rulemaking, formal rulemaking or negotiated rulemaking; interpretive rules can be issued unilaterally. See 5 U.S.C. § 553(b). Therefore, whether an agency’s issuance is a legislative rule or interpretive rule can have major consequences. Differentiating between the two, though, is complicated.
We believe that FDA’s determination that an LDT is a device is a legislative rule for at least three independent reasons: (1) it fills a gap in the Act; (2) the Agency has treated its determination as legally binding forming the basis of enforcement and the exercise of enforcement discretion; and (3) the Agency’s determination is inconsistent with an extant legislative rule of the Department.
###### A. FDA’s Guidances and Determinations Are “Gap Filling” and Therefore Legislative Rules
First, a legislative rule “performs a legislative function when it makes ‘reasonable but arbitrary (not in the “arbitrary and capricious” sense) rules that are consistent with the statute or regulation under which the rules are promulgated but not derived from it, because they represent an arbitrary choice among methods of implementation.’” Catholic Health Initiatives v. Sebelius, 617 F.3d 490, 495 (D.C. Cir. 2010) (citing Hoctor v. USDA, 82 F.3d 165, 170 (7th Cir. 1996)). Gap-filling is a quintessential characteristic of a legislative rule.
FDA’s determination starting in 1992, confirmed in 1997, reconfirmed in the 2014 draft guidances, and reconfirmed in its January 13, 2017 White Paper that LDTs are devices were all gap-filling policy determinations with significant economic and regulatory implications. The proposed LDT framework in the 2014 draft guidances would have required FDA to review virtually all LDTs. Under the White Paper, FDA review would be limited to “new and significantly modified high and moderate risk LDTs.” White Paper at 4–5. As a result, FDA envisions that the process could be completed in four years, rather than the rather prolonged nine-year period originally envisioned in the draft guidances. In the White Paper, the Agency also stated that “[t]o protect patients from tests that could lead to harm, the Agency would retain its ability to enforce premarket review, quality systems, and other applicable requirements for any LDT, including those listed above, if the agency identified one or more of the following, taking into account all available evidence.” Id. at 4. It also represents a clear choice, opting to define an LDT as a device; it thereby filled a gap in the statute, a quintessential characteristic of a legislative rule.
Nor is this a case where one can argue that the organic legislation unmistakably leads to the conclusion that LDTs are devices and an enforcement action can be based solely on the statute. Laboratory developed tests are not mentioned in the FDCA nor are they defined in it. Rather, they are only defined in FDA guidances and similar issuances. See, e.g., Framework for Regulatory Oversight of Laboratory Developed Tests (LDTs) at 5 (Oct. 3, 2014) (defining LDT in guidance Document”). It would be difficult to argue that FDA regulation of LDTs is so inherent in the FDCA that no regulation is necessary. This is especially so where the Secretary has issued rules implementing Medicare and CLIA that strongly suggest that LDTs are not devices and not within FDA’s jurisdiction.
The argument that LDTs could be regulated without a regulation is also belied by the public comments submitted in response to the 2014 draft guidances which challenged FDA’s contention that an LDT is a device. One commenter argued that
- [i]t is far-fetched to suppose that laboratory-developed testing services become medical devices in their own right merely because they sometimes utilize other medical devices. FDA’s own regulations recognize the distinction between a service that uses devices and a device itself. For example, the FDA regulation excluding laboratories from device registration requirements specifically recognizes that laboratories’ “primary responsibility to the ultimate consumer is to ... provide a service through the use of a previously manufactured device.” 21 C.F.R. §807.65(i) (emphasis added). Laboratories may well draw on both reagents and laboratory equipment of many kinds in executing their clinical testing services, but that plainly does not render the services these laboratories perform themselves “medical devices.”
Comment submitted by Paul D. Clement & Laurence H. Tribe on Behalf of the American Clinical Laboratory Association at 9.
FDA’s ability to regulate LDTs is not inherent in the language of the Act, which is silent
on the point. When, as here, the statute is silent, an agency’s attempt to describe the contours of its authority is “gap-filling.” Gap-filling, though, can only occur through notice and comment rulemaking. *See Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc.*, 467 U.S. 837, 843–44 (1984).
###### B. FDA’s Determinations Were Intended to Be Binding and Have the Force and Effect of Law
Second, an agency action that purports to impose legally binding obligations or prohibitions on regulated parties—and that would be the basis for an enforcement action for violations of those obligations or requirements—is a legislative rule. An agency action that sets forth legally binding requirements for a private party to obtain a permit or license is a legislative rule. *National Min. Ass’n v. McCarthy*, 758 F.3d 243, 251–52 (D.C. Cir. 2014); *see also Appalachian Power Co. v. E.P.A.*, 208 F.3d 1015, 1021 (D.C. Cir. 2000). Correspondingly, legislative rules, as opposed to interpretive rules, “‘grant rights, impose obligations, or produce other significant effects on private interests;’ ‘narrowly constrict the discretion of agency officials by largely determining the issue addressed;’ and ‘[has] substantive legal effect.’” *U.S. Telecom Ass’n v. FCC*, 400 F.3d 29, 35 (D.C. Cir. 2005) (quoting *Batterton v. Marshall*, 648 F.2d 694, 701–02 (D.C. Cir. 1980)).
The finding that an LDT is a device is a sentinel determination enabling the Agency, at any time, to take enforcement action, to require registration, listing, compliance with quality systems, and premarket review and clearance or approval, at the Agency’s discretion. Because this finding has significant economic effects on private interests, it raises the specter that the Agency, exercising discretion that is arguably not reviewable, could require laboratories to comply with any or all of these requisites that govern ordinary devices, the determination fits the profile of a legislative rule. The Agency’s determination that an LDT is a device “would be the basis for an enforcement action for violations of those obligations.” *National Min. Ass’n, supra.* Consistent with that description, the Agency recently took action in the form of a Warning Letter against a laboratory based on its determination that an LDT is a device. *See* Warning Letter to Inova Genomics Laboratory (April 4, 2019). That Warning Letter is, to a reviewing court, convincing evidence that the decision to treat an LDT as a device was intended to have the force and effect of law and has been treated as such by the Agency. Since the determination was issued without the benefit of notice and comment rulemaking, it is likely to be considered void if challenged.
FDA has acknowledged that its issuances have the force and effect of law, even though its guidance documents trumpet the opposite in boilerplate. The Agency noted that it had exercised enforcement discretion with respect to LDTs, but that the 2014 draft guidances, when finalized, would have ended that. *See* Guidance Document at 6. Two years later, when abandoning the 2014 draft guidances, the Agency indicated its intent to continue extending enforcement discretion to LDTs, except in the event of a pandemic. *See* https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/information-laboratories-implementing-ivd-tests-under-eua (March 1, 2020) (last reviewed June 15, 2020) (“FDA generally has not enforced premarket review and other legal requirements [with respect to LDTs].”). Obviously, an agency can only exercise enforcement discretion if it believes that it has the authority to enforce its determination, in this case that an LDT is a device.
###### C. FDA’s Determination Is Inconsistent with Extant Departmental Regulations and Is Therefore Void Absent Notice and Comment Rulemaking
Third, if an agency adopts a position that is “inconsistent with an existing regulation, or effects ‘a substantive change in the regulation,’ notice and comment are required.” *U.S. Telecom Ass’n v. F.C.C.*, 400 F.3d 29, 35 (D.C. Cir. 2005) (quoting *Shalala v. Guernsey Mem’l Hosp.*, 514 U.S. 87, 100 (1995)). Here, before FDA’s initial determination in 1992 that LDTs are devices, the Secretary issued a comprehensive regulation implementing CLIA that expressly recognized three classes of laboratory tests—(i) those purchased by a laboratory that were FDA cleared or approved, (ii) those that are modifications of FDA cleared or approved tests, or (iii) “test system[s] not subject to FDA clearance or approval (including methods developed in-house [i.e., LDTs] and standardized methods such as text book procedures . . .).” 42 C.F.R. § 493.1253(b) (2019) (adopted 68 Fed. Reg. 3640, 3707 (Jan. 24, 2003), previously codified at 42 C.F.R. 493.1213(b), 57 Fed. Reg. 7163 (Feb. 28, 1992)). Those laboratories that use FDA cleared or approved tests are required to employ fewer quality controls than those laboratories that use modified tests or LDTs.
At bottom, the 1992 CLIA regulation recognizes LDTs as a separate class of tests not subject to FDA clearance or review, and by implication, FDA jurisdiction. That regulation is consistent with the legislative history underlying the 1988 amendments to the original Clinical Laboratory Improvement Act of 1967, which was limited to specimens traveling in interstate commerce. In supporting the 1988 amendments, Chairman Waxman noted the complete absence of federal regulation in certain instances: “many laboratories, particularly physicians' offices and smaller laboratories not accepting specimens in interstate commerce, are not subject to such Federal regulations.” FDA’s determinations that LDTs are devices, none of which was published for notice and comment rulemaking, are inconsistent with this CLIA rule and the legislative history surrounding the 1988 amendments.
This inconsistency leads to one outcome for two alternative reasons. An interpretive rule or other policy issued without the benefit of notice and comment is void *ab initio* if it is inconsistent with an existing legislative rule. The legislative rule takes precedence over the interpretive one. *See F.C.C. v. Fox Television Stations, Inc.*, 556 U.S. 502, 515 (2009) (“An agency may not, for example, depart from a prior policy *sub silentio* or simply disregard rules that are still on the books.”); *Berkovitz v. United States*, 486 U.S. 531 (1988) (HHS is not free to ignore its own legislative rules); *Gunderson v. Hood*, 268 F.3d 1149, 1154 (9th Cir. 2001) (If a rule is inconsistent with or amends an existing legislative rule, then it cannot be interpretive.”). Alternatively, the Agency determinations are void because they seek to modify or repeal an existing legislative rule which can only be accomplished through notice and comment rulemaking. *See Perez*, 575 U.S. at 105 (“APA rulemaking would still be required if [an agency] adopted a new position inconsistent with . . . existing regulations.”); *Motor Vehicle Manufacturers Ass’n v. State Farm Mutual Automobile Ins. Co.*, 463 U.S. 29 (1983).
Thus, even if none of the statutory impediments were ever existed, the Agency’s determination that an LDT is a “device” would still falter for want of notice and comment rulemaking.
##### III. CLIA and Other Provisions in the PHS Act Can Provide Appropriate Safeguards
Regardless of the advice outlined above, we note, in light of concerns raised by some regarding dual regulation by FDA and CMS in this space, that the Secretary retains authority to ensure administrative efficiency by channeling regulation of LDTs through one agency and to determine which agency should exercise that authority. Policymakers may wish to consider whether CMS, which regulates through the Spending Clause and already regulates the actual use of tests in the laboratory, is better suited legally and logistically to regulate LDTs than is FDA, which is tethered by the Commerce Clause and by statutory commerce clause requirements.
One might take the position that Congress has addressed the federal regulation of laboratory testing in CLIA, and the Secretary has determined or can determine that CMS is the agency within HHS to regulate clinical laboratories. This is not to say that by enacting CLIA Congress expressed an intent that no further regulation was necessary. Rather, CLIA’s comprehensive scheme arguably makes regulation by another HHS agency less essential. That is especially the case where the second agency’s authority is relatively limited or vulnerable to legal challenge. In such situations, the other agency often provides technical assistance and that could be a model in this instance as well.
## EXHIBIT G
**same as contents of 2023-12-04_Letter to FDA - ACLAs Comments on FDAs Proposed Regulation of LDTs as Medical Devices**
## EXHIBIT H
### Laboratory Developed Tests Final Rule
Docket No. FDA-2023-N-2177
Final Regulatory Impact Analysis
Final Regulatory Flexibility Analysis
Unfunded Mandates Reform Act Analysis
Economics Staff
Office of Economics and Analysis
Office of Policy, Legislation, and International Affairs
Office of the Commissioner
#### Executive Summary
This final rule amends FDA’s regulations in part 809 (21 CFR part 809) to make explicit that “in vitro diagnostic products” (IVDs) are devices as defined in section 201(h)(1) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) (21 U.S.C. 321(h)(1)) including when the manufacturer of the IVD is a laboratory. In conjunction with this amendment, FDA is phasing out its general enforcement discretion approach for laboratory developed tests (LDTs) so that IVDs manufactured by a laboratory will generally fall under the same enforcement approach as other IVDs, as discussed further in section V of the preamble to the rule.
We quantify benefits to patients from averted health losses due to problematic IVDs offered as LDTs.¹,² We focus mainly on certain broad disease categories associated with the majority of misdiagnosis-related harms in the U.S. Additional benefits include averted non-health losses from reduced spending on problematic IVDs offered as LDTs and unquantified reduction in costs from lawsuits. We quantify costs to affected laboratories for complying with statutory and regulatory requirements, as described in the phaseout policy. Additional costs include costs to FDA, which we include in our estimates. We estimate that the annualized benefits over 20 years range from $0.99 billion to $11.1 billion at a seven percent discount rate, with a primary estimate of $3.51 billion, and from $1.24 billion to $13.62 billion at a three percent discount rate, with a primary estimate of $4.34 billion. The annualized costs range from $566 million to $3.56 billion at a seven percent discount rate, with a primary estimate of $1.29 billion, and from $603 million to $3.79 billion at a three percent discount rate, with a primary estimate of $1.37 billion.
¹ See discussion of “problematic IVDs” in section I.B below.
² See discussion of “IVDs offered as LDTs” in section V.A.1 of the preamble to the final rule and section II.D below.
#### Table of Contents
I. Introduction and Summary ................................................................................................. 6
A. Introduction ..................................................................................................................... 6
B. Overview of Benefits, Costs, and Transfers .................................................................... 7
C. Comments on the Preliminary Economic Analysis of Impacts and Our Responses ...... 10
1. Comments (Number of Laboratories) ......................................................................... 10
2. Comments (Number of IVDs Offered as LDTs) ....................................................... 11
3. Comments (Percent of IVDs That Are Offered as LDTs) ......................................... 13
4. Comments (Attribution of Diagnostic Error to Analytic Phase of Laboratory Tests) 14
5. Comments (Percent of IVDs Offered as LDTs that are Problematic) ...................... 15
6. Comment (IVDs Offered as LDTs Perform Better Than FDA-Authorized Tests) .... 15
7. Comments (Effectiveness of FDA Review in Assuring Reliability of Diagnostic Tests) 16
8. Comment (Diagnostic Tests Only a Part of Diagnosis) ............................................ 17
9. Comments (StatinCheck Problem) ............................................................................ 18
10. Comments (Non-Invasive Prenatal Screening Tests Require Follow-Up) .............. 18
11. Comments (Innovation) ............................................................................................ 19
12. Comments (Impact on Prices) .................................................................................. 21
13. Comments (Increased Labor Cost/Strain) ................................................................. 24
14. Comments (Underestimation of Costs) ..................................................................... 25
15. Comments (Outsourcing Costs and Costs of Switching to FDA-Authorized Tests) . 26
16. Comment (FDA Would Not Have Sufficient Resources To Review IVDs Offered as LDTs) .............................................................................................................. 27
17. Comment (Small Entities) ......................................................................................... 30
18. Comment (Firm Exit and Market Concentration) ...................................................... 33
D. Summary of Changes from the Proposed Rule .............................................................. 34
1. Changes to the Phaseout Policy ................................................................................... 34
2. Baseline Conditions ..................................................................................................... 35
3. Benefits ........................................................................................................................ 36
4. Costs ............................................................................................................................ 37
5. Regulatory Alternatives ............................................................................................... 38
II. Final Economic Analysis of Impacts ................................................................................ 38
A. Background .................................................................................................................. 38
B. Need for the Rule ......................................................................................................... 40
C. Purpose of the Rule ...................................................................................................... 46
D. Baseline Conditions ..................................................................................................... 46
1. Number of Affected Entities ..................................................................................... 50
2. Baseline Market Revenue ......................................................................................... 55
3. Baseline FDA Premarket Reviews of Submissions/Applications .............................. 56
4. Baseline Risk of Problematic IVDs .......................................................................... 57
E. Benefits ........................................................................................................................ 59
1. Reduction in Harms from Diagnostic Errors ............................................................. 59
2. Non-Health Benefits .................................................................................................. 85
3. Summary of Benefits ................................................................................................. 88
F. Costs ............................................................................................................................ 91
1. Costs Under Stage 1 .................................................................................................. 92
2. Costs Under Stage 2 ................................................................................................. 100
3. Costs Under Stage 3 ................................................................................................. 106
4. Costs Under Stages 4 and 5 ...................................................................................... 112
5. Summary of Costs ..................................................................................................... 123
6. Other Unquantified Costs .......................................................................................... 125
G. Budgetary Impacts ....................................................................................................... 128
H. Transfers ...................................................................................................................... 132
I. Stream of Benefits, Costs, and Transfers ..................................................................... 135
J. Analysis of Regulatory Alternatives to the Final Phaseout Policy ............................... 137
K. Distributional Effects ................................................................................................... 142
L. International Effects .................................................................................................... 145
III. Final Small Entity Analysis ............................................................................................ 148
A. Description and Number of Affected Small Entities ................................................... 148
B. Description of the Potential Impacts of the Phaseout Policy on Small Entities ........... 149
C. Alternatives to Minimize the Burden on Small Entities .............................................. 153
IV. References ....................................................................................................................... 155
Appendix A. Estimation of the Number of Affected Labs and Tests ..................................... 163
Appendix B. Final Small Entity Analysis Estimates ............................................................... 173
#### I. Introduction and Summary
##### A. Introduction
We have examined the impacts of the final rule under Executive Order 12866, Executive Order 13563, Executive Order 14094, the Regulatory Flexibility Act (5 U.S.C. 601-612), and the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4).
Executive Orders 12866, 13563, and 14094 direct us to assess all benefits, costs, and transfers of available regulatory alternatives and to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety, and other advantages; distributive impacts; and equity). Rules are “significant” under Executive Order 12866 Section 3(f)(1) (as amended by Executive Order 14094) if they “have an annual effect on the economy of $200 million or more (adjusted every 3 years by the Administrator of [the Office of Information and Regulatory Affairs (OIRA)] for changes in gross domestic product); or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, territorial, or tribal governments or communities.” OIRA has determined that this final rule is a significant regulatory action under Executive Order 12866 Section 3(f)(1).
Because this rule is likely to result in an annual effect on the economy of $100 million or more or meets other criteria specified in the Congressional Review Act/Small Business Regulatory Enforcement Fairness Act, OIRA has determined that this rule falls within the scope of 5 U.S.C. 804(2).
The Regulatory Flexibility Act requires agencies to analyze regulatory options that would minimize any significant impact of a rule on small entities. Because most facilities that will be affected by this rule are defined as small businesses and the final rule is likely to impose a substantial burden on the affected small entities, we find that the rule will have a significant economic impact on a substantial number of small entities.
We prepared an analysis consistent with the Unfunded Mandates Reform Act of 1995 (section 202(a)), which requires the preparation of a written statement that includes estimates of anticipated impacts before issuing “any rule that includes any Federal mandate that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100,000,000 or more (adjusted annually for inflation) in any one year.” The current threshold after adjustment for inflation is $177 million, using the most current (2022) Implicit Price Deflator for the Gross Domestic Product. This final rule will result in an expenditure in at least one year that meets or exceeds this amount.
##### B. Overview of Benefits, Costs, and Transfers
This final rule amends FDA’s regulations to make explicit that in vitro diagnostic products (IVDs) are devices under the Federal Food, Drug, and Cosmetic Act (the FD&C Act) including when the manufacturer of the IVD is a laboratory. As discussed in section V of the preamble to the final rule, FDA is phasing out its general enforcement discretion approach for LDTs so that IVDs manufactured by a laboratory will generally fall under the same enforcement approach as other IVDs.
We anticipate that the benefits of phasing out FDA’s general enforcement discretion approach for LDTs includes a reduction in healthcare costs associated with unsafe or ineffective IVDs offered as LDTs (generally referred to in this document as “problematic IVDs”), including IVDs offered as LDTs that are promoted with false or misleading claims, and from therapeutic decisions based on unreliable results of those tests. Quantified benefits are the annualized sum of both health and non-health benefits. Unquantified benefits include, among others, possible reduction in costs from lawsuits. We discuss the benefits of phasing out of FDA’s general enforcement discretion approach for IVDs offered as LDTs in section II.E.
This phaseout policy will result in compliance costs for laboratories that are ensuring their IVDs offered as LDTs are compliant with statutory and regulatory requirements, as described in section V of the preamble. We discuss the costs of the phaseout policy in section II.F. These costs overlap somewhat with effects associated with this phaseout policy in the form of user fees, including annual registration fees, fees for premarket applications/submissions, and annual fees for periodic reporting concerning PMA-approved devices, which are paid from laboratories to FDA. These fees are paid by laboratories but are revenue for FDA; the approach to estimating fee effects is distinct from the approaches for either benefits or costs, so they will be presented as transfers. We discuss transfers in section II.H.
Table 1 summarizes the annualized benefits, costs, and transfers of the phaseout policy. At a seven percent discount rate, 20-year annualized benefits range from about $0.99 billion to $11.1 billion, with a primary estimate of $3.51 billion per year. At a three percent discount rate, 20-year annualized benefits range from $1.24 billion to $13.62 billion, with a primary estimate of $4.34 billion per year. At a seven percent discount rate, 20-year annualized costs range from about $566 million to $3.56 billion, with a primary estimate of $1.29 billion per year. At a three percent discount rate, annualized costs range from about $603 million to $3.79 billion, with a primary estimate of $1.37 billion per year. At a seven percent discount rate, 20-year annualized transfers range from $20 million to $81 million, with a primary estimate of $41 million per year. At a three percent discount rate, 20-year annualized transfers range from $29 million to $115 million, with a primary estimate of $58 million per year. These estimates do not include anticipated offsets from user fees. At a seven percent discount rate, 20-year annualized costs to FDA range from $61 million to $243 million, with a primary estimate of $121 million per year. At a three percent discount rate, 20-year annualized costs to FDA range from $65 million to $259 million, with a primary estimate of $129 million per year. Factoring in offsets from user fees at current levels, estimated costs to FDA are reduced to $40 million to $162 million at a seven percent discount rate, with a primary estimate of $81 million, and to $36 million to $144 million at a three percent discount rate, with a primary estimate of $72 million, covering approximately 30 to 40 percent of the estimated costs to FDA.
Table 1. Summary of Benefits, Costs and Transfers (millions of 2022 U.S. dollars)
| Category | Primary Estimate | Low Estimate | High Estimate | Year Dollars | Discount Rate | Period Covered | Notes |
|---------------|------------------|--------------|---------------|--------------|---------------|----------------|-------|
| **Benefits** | | | | | | | |
| Annualized Monetized ($m/year) | $3,509 | $988 | $11,096 | 2022 | 7% | 20 years | Major sources of benefits will be the avoidance of harms to patients from use of problematic IVDs offered as LDTs and the avoidance of spending on such IVDs. |
| | $4,341 | $1,244 | $13,619 | 2022 | 3% | 20 years | |
| Annualized Quantified | | | | | 7% | | |
| | | | | | 3% | | |
| Qualitative | | | | | | | |
| **Costs** | | | | | | | |
| Annualized Monetized ($m/year) | $1,287 | $566 | $3,559 | 2022 | 7% | 20 years | A portion of foreign costs will be passed on to domestic consumers. We estimate that up to $147 million in annualized costs (7%, 20 years) to foreign facilities could be passed on to domestic consumers. |
| | $1,372 | $603 | $3,789 | 2022 | 3% | 20 years | |
| Annualized Quantified | | | | | 7% | | |
| | | | | | 3% | | |
| Qualitative | | | | | | | |
| **Transfers** | | | | | | | |
| Federal Annualized Monetized ($m/year) | $41 | $20 | $81 | 2022 | 7% | 20 years | The main portion of transfers will be user fees for premarket submissions. |
| | $58 | $29 | $115 | 2022 | 3% | 20 years | |
| Other Annualized Monetized ($m/year) | | | | | 7% | | |
| | | | | | 3% | | |
| **Effects** | | | | | | | |
| State, Local, or Tribal Government: No significant effects | | | | | | | |
| Small Business: The phaseout policy will have a significant economic impact on a substantial number of small laboratories that manufacture IVDs offered as LDTs. | | | | | | | |
| Wages: N/A | | | | | | | |
| Growth: N/A | | | | | | | |
##### C. Comments on the Preliminary Economic Analysis of Impacts and Our Responses
On October 3, 2023, FDA published the proposed rule Medical Devices: Laboratory Developed Tests (88 FR 68006). Accompanying the proposed rule was a comprehensive preliminary regulatory impact analysis (hereinafter referred to as the preliminary analysis or PRIA) on which we requested public comments (Ref. [1]). We received many comments and have organized these comments and our responses by topic in the paragraphs below. The number assigned to each comment is purely for organizational purposes and does not signify the comment’s value, importance, or the order in which it was received.
###### 1. Comments (Number of Laboratories)
Comments suggested using data from the CMS Laboratory Registry which provides information on the number of laboratories in the United States and their accreditation status to estimate the number of laboratories affected by the rule.
**Response:** As mentioned in the PRIA, we acknowledge that we do not know the exact number of laboratories that will be affected by this rule. After reviewing comments, FDA revised the number of affected laboratories from 12,000 to 11,808 using data from the CMS Laboratory Registry. We still use information about laboratories in New York State (NYS) to estimate the percent of CLIA-certified laboratories that both comply with high complexity requirements and make IVDs offered as LDTs, assuming that NYS is representative of the U.S. laboratory community. We explain our revised estimate in greater detail in section II.D.1 and appendix A of this analysis.
###### 2. Comments (Number of IVDs Offered as LDTs)
Some comments claimed FDA overestimated the number of IVDs offered as LDTs on the market while others claimed FDA underestimated this number. One comment stated that there are 160,000 IVDs offered as LDTs in the United States from 12,000 laboratories (or 13 IVDs offered as LDTs per laboratory). Other comments provided estimates of the number of IVDs offered as LDTs ranging from 92 to 310 IVDs offered as LDTs per laboratory.
**Response:** As mentioned in the preliminary analysis (section II.D.1), we acknowledge that some large reference laboratories may make a large number of new IVDs offered as LDTs per year, whereas smaller laboratories may focus on fewer IVDs overall and may not introduce many or any new IVDs each year. Using the additional estimates on the number of IVDs offered as LDTs received from comments, the weighted average estimate of the affected tests is calculated to be approximately 69 IVDs offered as LDTs per affected entity, which is close to
However, we adjusted our estimate to reflect the enforcement discretion policies in the final phaseout policy as well as the Agency’s intention to initiate the reclassification process for most IVDs that are currently class III (high risk) into class II (moderate risk).[^4] FDA will also continue taking a risk-based approach in the initial classification of individual IVDs to determine the appropriate level of regulatory controls and whether a new test may be classified into class II through De Novo classification (and special controls established), rather than being class III and subject to the PMA pathway. Based on its experience, the Agency believes that special controls could be developed, along with general controls, that could provide a reasonable assurance of safety and effectiveness for most future companion diagnostic and infectious disease IVDs. As such they would be regulated as class II devices. As a result of this adjustment, and prior to additional adjustments to address enforcement policies, the estimated numbers of PMAs and PMA supplements submissions are lower while the estimated numbers of 510(k)s and De Novo submissions are higher after potential reclassification (see Table A.5). As the final phaseout policy includes an enforcement discretion policy with regards to QS requirements (except for requirements under 21 CFR part 820, subpart M (Records)) and premarket review requirements for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of this rule and that are not modified, or that are modified in certain limited ways as described in the preamble, we expect that fewer IVDs offered as LDTs will be affected by stages 3 through 5 of the phaseout policy than we estimated in our preliminary analysis. In addition, FDA has revised the phaseout policy to include several other enforcement discretion policies for certain other types of IVDs (see section V.B of the preamble) and we have revised our estimates accordingly. Our updated estimates are addressed in sections II.F.3 and II.F.4 of this document.
###### 3. Comments (Percent of IVDs That Are Offered as LDTs)
As discussed in section VI.C of the preamble, some comments claimed FDA overestimated the number of IVDs offered as LDTs on the market. Relatedly, comments suggested that the percent of test order volume for IVDs offered as LDTs is lower than 50%. One comment claimed that FDA’s estimate of the number of IVDs offered as LDTs was more than “10 times what researchers found in a peer-reviewed study published in the American Journal of Clinical Pathology of actual clinical test orders at University of Utah Health: 3.9%” (see Ref. [3]). Another comment stated that only 6% of tests performed in their laboratory are offered as LDTs.
Other comments suggested that FDA underestimated the number of IVDs offered as LDTs on the market. Among these, a comment noted that their laboratory, itself part of an academic medical center, offers 123 LDTs out of 124 tests, a percentage higher than 99%. Another comment stated that more than 99% of their tests are LDTs, and further clarified that these tests comprised an even higher percent of their test volume.
**Response:** Based on public comments, the percent of IVDs offered as LDTs and the percent of test order volume comprised by such appear to vary widely across settings. Using test orders from a U.S. academic hospital system, Rychert et al. (2023) estimate that IVDs offered as LDTs are 3.9% of test order volume and 45% of distinct tests (Ref. [2]). Specifically for estimating the percent of patients who are tested with IVDs offered as LDTs, we thus consider a range from 3.9% to 45%, with a primary estimate of 10%. This reflects the assumption that, while we take 45% as a reasonable estimate of the percent of IVDs that are offered as LDTs, we consider the percent of patients tested with those IVDs offered as LDTs to be closer to the referenced 3.9%, and, using professional judgement, selected 10% as our primary estimate, rather than using 3.9% directly, to reflect uncertainty given that the 3.9% was based on information for one single laboratory. Compared to the estimate of 50% used in the preliminary analysis, the revised estimate of 10%, if holding all else equal, reduces estimated benefits by a factor of five. With respect to the analysis in section II.E.2, this reflects that order volume likely better represents distinct patients.
###### 4. Comments (Attribution of Diagnostic Error to Analytic Phase of Laboratory Tests)
Comments suggested that the percent of diagnostic errors attributable to faulty diagnostic test results is likely lower than 50%, the estimate we used in the preliminary analysis. A comment suggested instead, based on published literature, a range of 1-4%, with a central estimate of 2.5% (Refs. [3], [4], [5], [6], [7], [8], [9], [10]).
**Response:** Our final analysis uses an updated methodology which no longer directly estimates this parameter. However, our range of estimates of the number of diagnostic errors attributable to faulty tests and resulting in harm is consistent with much rarer attribution of diagnostic errors to tests. This analysis estimates in total about 53,000 annual preventable harms attributable to diagnostic tests (the sums of the primary estimates of avoidable harms across Table 5, Table 11, and Table 14). Singh et al. (2014) estimate that approximately 12 million U.S. adult patients experience diagnostic errors in outpatient care every year (Ref. [11]). Our primary estimate thus represents about half a percent of this total. As our estimate of preventable harms
###### 5. Comments (Percent of IVDs Offered as LDTs that are Problematic)
Comments stated that the percent of IVDs offered as LDTs that are problematic is likely much lower than 47%, the estimate we used in the preliminary analysis. Comments also suggested that it is inappropriate to extrapolate this parameter from as narrow a sample as cited in the preliminary analysis.
**Response:** We agree that a broader basis for estimating this parameter is appropriate and have revised the relevant analysis accordingly, as described in detail in section II.E.1.a “Cancer: Mortality Risk.” Using statistics from the NYS Department of Health Clinical Laboratory Evaluation Program (CLEP) (Ref. [12]) and FDA’s 2020 assessment of EUA requests from laboratories for molecular diagnostic COVID tests, we consider a range of scenarios in which 22%, 38%, and 54% of IVDs offered as LDTs without FDA oversight would be a problematic IVD. This was extrapolated to estimate that 22%, 38%, and 54% of patients tested with IVDs offered as LDTs would be tested with problematic IVDs. Compared to the estimate of 47% used in the preliminary analysis, the revised primary estimate of 38%, if holding all else equal, reduces estimated benefits by approximately one fifth.
###### 6. Comment (IVDs Offered as LDTs Perform Better Than FDA-Authorized Tests)
As further detailed in section VI.C.4 of the preamble, some comments pointed out omission of multiple publications claiming comparable or better performance of IVDs offered as LDTs compared to “FDA IVDs.” Some comments suggested that patients would lose access to IVDs offered as LDTs that perform well, even some IVDs offered as LDTs that may perform better than FDA-authorized IVDs. Comments also suggested adjusting downwards our estimates of benefits from avoiding preventable misdiagnosis-related harms by subtracting harms from baseline problems of FDA-authorized tests.
**Response:** We do not agree that IVDs offered as LDTs generally perform comparably to or better than FDA-authorized tests. Thus, we do not agree that this analysis should reflect such a situation. Concerning the scientific merits of the claims in these comments, please refer to FDA’s responses in section VI.C.4 of the preamble, “Evidence of the Need for Greater FDA Oversight.” In particular, we discuss publications purported to compare the performance of IVDs offered as LDTs and FDA-authorized tests in our response to Comment 34.
With respect to estimating the difference in reliability between problematic IVDs offered as LDTs, specifically, and FDA-authorized competitor tests, we lack systematic data on the exact issues with all problematic IVDs offered as LDTs and their particular uses in the process of diagnosis. As described in section II.E.1.a “Cancer: Mortality Risk,” we consider a range of rates at which avoidable diagnostic error might result from usage of problematic IVDs offered as LDTs that would not occur using an FDA-authorized test.
###### 7. Comments (Effectiveness of FDA Review in Assuring Reliability of Diagnostic Tests)
Citing examples of FDA-authorized tests with alleged issues affecting reliability, comments suggested that our analysis of the proposed phaseout policy overestimated the effectiveness of FDA review in assuring the reliability of diagnostic tests and reducing the use of problematic IVDs offered as LDTs.
**Response:** Unlike in our preliminary analysis, as explained in section II.E.1.a, we now use statistics from the NYS CLEP to inform our estimates of avoidable problematic IVDs offered as LDTs. We believe this is a relevant extrapolation to expected detection of reliability issues through FDA oversight.
###### 8. Comment (Diagnostic Tests Only a Part of Diagnosis)
One comment expressed concern that FDA does not consider that the risks of IVDs offered as LDTs, including erroneous results, "is mitigated by the fact that they are part of a multi-faceted medical assessment and are rarely used in isolation for clinical decision-making.”
**Response:** Due to uncertainty about the rate at which erroneous test results lead to erroneous treatment decisions, this analysis considers that inaccurate results might be identified during follow-up or other parts of the process of diagnosis before leading to harm from diagnostic error. As described in section II.E.1.a “Cancer: Mortality Risk,” we consider a range of rates at which avoidable errors might result from usage of problematic IVDs offered as LDTs that would not occur using an FDA-authorized test. However, although for the purpose of this analysis we consider a wide range for these rates, FDA expects that erroneous test results often result in erroneous treatment decisions. As discussed in the response to Comment 6 in the preamble, FDA does not consider all clinicians to be aware of the limitations of tests. FDA routinely consults with healthcare providers and has encountered many who do not understand the limitations of tests and do not consider that a test result provided by a test may be incorrect. For additional discussion of this comment please see our response to Comment 6 in the preamble.
###### 9. Comments (StatinCheck Problem)
Comments requested an explanation of why we included, in the preliminary analysis, the StatinCheck test for KIF6 genotype as an example of a problematic test.
**Response:** This test was marketed as a way to predict the risk of heart disease and determine a patient’s response to statin drugs, based on the belief that patients with the Trp719Arg polymorphism of the KIF6 protein had an elevated risk of cardiovascular disease (CVD) events and would have a greater reduction in CVD events when on statin therapy than patients without this polymorphism. However, the results from studies of the association between the polymorphism, CVD risk, and statin response were conflicting, and multiple scientific publications reported no association between the polymorphism and elevated CVD risk or statin response (Refs. [13] [14]). Accordingly, the totality of scientific evidence does not support that there is a clinically valid relationship between the polymorphism, elevated CVD risk, and statin response. In 2011, FDA informed the manufacturer that its submission for premarket approval of this test was not approvable stating that the evidence submitted was insufficient to support the test’s safety and effectiveness in determining risk of heart disease or in predicting statin response. As described in FDA’s 2015 report, additional problems included that the test was incorrectly validated and marketed for unproven uses. Inaccurate assessment of patient risk or likelihood of responding to statin therapy could lead to overtreatment, with an associated risk of adverse events, as well as undertreatment, with the risk of failing to prevent CVD events and death.
###### 10. Comments (Non-Invasive Prenatal Screening Tests Require Follow-Up)
As detailed in section VI.C of the preamble, FDA received comments regarding FDA’s use of a New York Times article on NIPS as evidence of a problem (Ref. [15]). Specifically, comments stated that the article conflated screening with diagnostic testing. They asserted that the article mischaracterized false positive results as test failures and that the “problem” with this category of tests is with “the lack of understanding of its purpose and limitations by the providers and patients who were interviewed by the reporters.”
**Response:** FDA agrees that NIPS tests, which may tell people the risk of their fetus having certain genetic abnormalities, are different from diagnostic tests used to more definitively confirm or rule out a suspected genetic abnormality. FDA agrees with comments that NIPS tests should not be used to confirm or rule out a suspected abnormality. While higher false positive rates are often more acceptable for screening tests than tests used for making a diagnosis, appropriate false positive rates for any particular test needs to be considered in the context of a full benefit-risk evaluation for that particular test. After publication of the New York Times article, FDA issued a safety communication to explain the limitations of NIPS tests and provide information to educate both patients and health care providers to help reduce the inappropriate use of NIPS tests.7 Increased oversight of NIPS tests, including labeling requirements, can help ensure such tests are appropriately labeled with transparent information regarding performance, clear instructions, and appropriate limitations. Including the example of NIPS in this final analysis reflects our expectation that phasing out the enforcement discretion approach will ensure tests are appropriately safe and effective for their intended use. We also expect truthful, accurate, and clear statements about test use and performance to prevent patient and provider misunderstanding.
###### 11. Comments (Innovation)
FDA received comments stating that the phaseout policy will have a negative impact on innovation in the testing space, as laboratories working to come into compliance would be either unable or unwilling to engage in innovative test development. Some comments stated that the regulatory constraints associated with the phaseout policy would cause laboratory manufacturers to develop fewer tests, hindering the timely development and deployment of cutting-edge therapies and diagnostic tools and ultimately harming patients. A comment from the Association of Pathology Chairs (APC) stated that it had conducted a survey of its members and found that 92% (36/39) of APC survey respondents reported that there will be less innovation to create and offer new tests to improve patient care due to the FDA’s proposed phaseout policy. Comments claimed that the high cost of premarket review may lead to less investment in innovation, fewer new tests developed, and longer timelines for new innovation to reach the market, and that some tests may not have market viability, given the premarket review costs.
Several comments noted that laboratories must be able to modify existing tests quickly to diagnose new conditions and monitor the impact of new therapies. Some comments stated that stifling modifications of currently marketed IVDs offered as LDTs would force pathologists and other healthcare providers to use older, less optimal tests, and noted that many patients do not have the time to wait for diagnostic development and rely on laboratories to be nimble and adapt to changing diagnostic criteria. One comment asserted that predetermined change control plans (PCCPs) would not help alleviate delays in modifications because only manufacturers can submit PCCPs, and thus laboratories seeking to modify an IVD for local conditions would need to undertake premarket review to do so. One other comment expressed concern that the phaseout policy would lead to slowed growth in the number of LDTs manufactured by laboratories because the phaseout policy would “prohibit” labs from sharing their discoveries about such
**Response:**
As explained in the preamble to the final rule, the phaseout policy is intended to better protect public health by helping to assure the safety and effectiveness of IVDs offered as LDTs—while also accounting for other important public health considerations such as patient access and reliance.
Premarket review is not required for all IVDs offered as LDTs. FDA premarket review is required only for certain tests (generally those in class II or class III). FDA estimates that approximately 50 percent of IVDs offered as LDTs will not require premarket review. A manufacturer's modifications to tests that have already been cleared, approved, or granted marketing authorization by FDA only require FDA review in certain circumstances (see 21 CFR 814.39; 21 CFR 807.81(a)(3)). Even when premarket review is required for an IVD offered as an LDT, FDA does not agree that such review necessarily impairs innovation. In fact, sponsors have sought and obtained FDA authorization for innovative IVDs offered as LDTs. FDA also has several programs that may facilitate the development and premarket authorization of innovative tests.
Moreover, better assuring the safety and effectiveness of IVDs offered as LDTs will foster innovation. By applying the same general oversight approach to laboratories and non-laboratories that manufacture IVDs, FDA’s phaseout policy will remove a disincentive for non-laboratory manufacturers to develop novel tests. We anticipate that phasing out the general enforcement discretion approach for LDTs will spur innovation for IVDs for which there is a reasonable assurance of safety and effectiveness.
###### 12. Comments (Impact on Prices)
Several comments stated that ending the general enforcement discretion approach for LDTs would lead to higher prices for clinical tests due to the costs of complying with applicable FDA requirements. Some comments further stated that the cost of complying with applicable requirements would result in the closure of many laboratories or the outsourcing of certain laboratory tests, which in turn will increase the costs of tests due to decreased test availability, decreased market competition, increased handling costs (e.g., costs associated with shipping samples to a centralized laboratory), or supply chain contractions. One comment expressed skepticism regarding FDA’s statement that any losses may be offset by the market entry of IVDs from other manufacturers. FDA also received a comment which argued that increased prices for clinical tests will disincentivize people from seeking preventive care until they suffer an emergency, which will increase costs for the overall healthcare system. Collectively, these comments suggested that laboratories will pass increased costs to their customers, which some comments noted could result in higher insurance premiums. However, one comment stated that insurance companies will be more likely to cover tests (because they will have FDA authorization), which may allow for greater access to more affordable testing. One comment noted that it is inaccurate to assume that IVDs offered as LDTs are always cheaper.
**Response:**
FDA recognizes that some laboratories may pass the costs of compliance with applicable requirements, including the specific examples listed in the comments, to their customers by raising prices for IVDs offered as LDTs. We also recognize that if many laboratories reduce operations or exit the market, production may be concentrated in a few large laboratories, which may cause prices for certain IVDs offered as LDTs to increase. However, we note that in the final phaseout policy, which will also affect small laboratories and Academic Medical Centers (AMCs), there may be less laboratories that scale back operations or exit the market relative to the estimates in our preliminary analysis.
FDA intends to exercise enforcement discretion and generally not enforce premarket review and QS requirements (except for requirements under 21 CFR 820, subpart M (Records)) for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of this rule and that are not modified, or that are modified in certain limited ways as described in the preamble. FDA also intends to exercise enforcement discretion and generally not enforce premarket review requirements for LDTs approved by NYS CLEP. FDA also intends to exercise enforcement discretion and generally not enforce premarket review requirements and QS requirements (except for requirements under 21 CFR part 820, subpart M (Records)) for LDTs manufactured and performed by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system. These enforcement discretion policies may significantly reduce the costs of compliance under the final phaseout policy, thus reducing the number of laboratories that scale back operations or exit the market. In addition, we anticipate that FDA oversight could help to support coverage and reimbursement determinations for IVDs offered as LDTs, which we anticipate will make certain IVDs offered as LDTs for which there is a reasonable assurance of safety and effectiveness more affordable for patients. As a result, FDA does not agree that patients will necessarily be disincentivized from seeking preventive care resulting in increased costs to the healthcare system as a result of the phaseout policy.
In addition, phasing out the general enforcement discretion approach for LDTs will help to reduce other healthcare costs. Greater oversight by FDA will help to address the hidden costs associated with unsafe or ineffective IVDs (including IVDs promoted with false or misleading claims), such as costs incurred from inappropriate treatments, additional or repeat testing, unnecessary consultations with providers, or additional treatment that became necessary due to the progression or worsening of a disease or condition following misdiagnosis. While certain costs may be passed on to individuals and insurers, we expect some of these costs will be offset by the associated benefits.
###### 13. Comments (Increased Labor Cost/Strain)
FDA received comments expressing concern that phasing out the general enforcement discretion approach for LDTs would require laboratories to have increased resources to afford the necessary staffing and other costs related to test development and regulatory submissions and emphasized the thin financial margins with which small laboratories operate. Some comments stated that the impact on small laboratories will result in a loss of expertise and infrastructure. In addition, comments noted that such centralization of IVDs offered as LDTs at large laboratories may negatively impact medical education and training in pathology, resulting in labor shortages. Some comments also suggested that workforce shortages will make it difficult for FDA to recruit and retain adequate numbers of qualified reviewers trained in laboratory diagnostics needed to review premarket submissions, which could potentially lead to delays in FDA’s premarket review process and patient access to tests.
**Response:** FDA appreciates the concerns regarding financial and administrative challenges for smaller laboratories. FDA anticipates that the enforcement discretion policies discussed in section V.B of the preamble will sufficiently address these concerns and help to avoid undue disruption to the testing market. For example, FDA intends to exercise enforcement discretion and generally not enforce premarket review and QS requirements (except for requirements under 21 CFR part 820, subpart M (Records)) for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of this rule and that are not modified, or that are modified as described in section V.B.3 of the preamble, which means laboratories would generally not need to dedicate staff or resources to handle premarket submissions for their existing IVDs offered as LDTs.
It is possible that some laboratories could need additional staff to handle premarket submissions for new IVDs and we account for this in our analysis. However, we expect that FDA’s enforcement discretion policy for currently marketed IVDs offered as LDTs will greatly reduce the volume of submissions from the estimate in our preliminary analysis, thereby avoiding any sudden or drastic increase in labor costs.
###### 14. Comments (Underestimation of Costs)
Several comments stated that costs are substantially underestimated. Some comments elaborated on specific types of costs, especially costs of premarket review. In support of their arguments some comments provided cost estimates for premarket review per entity while others provided cost ranges per test including analytical and clinical validation costs. Another comment focused on how the cost of modifying an SOP could be more burdensome than estimated as it would have to occur for every IVD offered as an LDT. Some comments also conveyed concern that the cost of a possible increase in LDT outsourcing due to FDA’s phaseout of enforcement discretion were not considered. Several comments stated that the costs of hiring new labor to comply with the phaseout of enforcement discretion was underestimated.
**Response:** FDA has revised the phaseout policy to include several enforcement discretion policies for certain types of IVDs as described in section V.B of the preamble. For example, FDA intends to exercise enforcement discretion for premarket review and QS requirements (except for requirements under 21 CFR 820, subpart M (Records)) for IVDs offered as LDTs that were first marketed prior to the date of issuance of the final rule and that are not modified, or that are modified as described in the preamble. As such, we do not expect that premarket submissions will be submitted for most currently marketed IVDs offered as LDTs in the immediate future, thus reducing the costs of the phaseout policy including the costs of premarket submission and review. We have revised our estimates consistent with revisions to the phaseout policy as explained in section II.F of this analysis.
###### 15. Comments (Outsourcing Costs and Costs of Switching to FDA-Authorized Tests)
Some comments stated that if FDA phases out the general enforcement discretion approach for LDTs, the commenters may decide to switch from an IVD offered as an LDT to an FDA-authorized test or to outsource their tests to other laboratories. Some comments provided information about the cost differential between an IVD offered as an LDT and an FDA-authorized test or from outsourcing certain tests. Some comments provided estimates on the number or percentage of tests that they would consider outsourcing or switching to an FDA-authorized test.
**Response:** FDA has revised the phaseout policy to include several enforcement discretion policies for certain types of IVDs as described in section V.B of the preamble. For example, FDA intends to exercise enforcement discretion for premarket review and QS requirements (except for requirements under 21 CFR 820, subpart M (Records)) for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of the final rule and that are not modified, or that are modified as described in the preamble.
We generally do not expect laboratories with currently marketed IVDs offered as LDTs to switch from an IVD offered as an LDT to an FDA-authorized test or to outsource their tests to other laboratories. We agree, however, that some laboratories may pursue outsourcing their testing needs or switching to use of an FDA-authorized test rather than introducing a new test, that does not fall within an enforcement discretion policy in the phaseout policy. However, as we explain in section II.F.6. of this FRIA, the cost of switching to an FDA-authorized test when available, would cost less than the cost of submitting a premarket submission. A laboratory would likely switch to FDA-authorized tests or outsource their testing needs only if submitting a premarket submission was more costly than either of these alternatives. Either way, the decision would be a private decision made according to their business plan. To the extent that any number of laboratories switch to any number of FDA-authorized tests, their costs would be less than the costs of submitting a premarket submission.
###### 16. Comment (FDA Would Not Have Sufficient Resources To Review IVDs Offered as LDTs)
Some comments expressed concerns that FDA would not have sufficient resources to conduct timely premarket review of IVDs offered as LDTs to meet the public health needs. Some of these comments questioned whether FDA would have adequate capacity to provide timely review of applications/submissions for IVDs offered as LDTs because many EUA requests were not reviewed due to resource limitations during the COVID-19 pandemic. At least one comment cited FDA’s review of a particular EUA request for an LDT during the COVID-19 pandemic, in which FDA’s review of the request did not conclude until after the subject LDT had been removed from the market, as proof that FDA does not have adequate resources to conduct premarket review of IVDs offered as LDTs. Another comment referenced a supposed FDA delay in recognizing a particular consensus standard, based on FDA’s “prolonged review.”
Other comments referenced FDA’s MDUFA IV performance report from FY2020 to 2022 (during the COVID-19 pandemic) and predicted that the increased volume of submissions from laboratory manufacturers that would result from the phaseout policy would affect FDA’s overall ability to review premarket submission for all IVDs, meet its MDUFA performance goals, and conduct other essential work, including policy and post-market activities. Finally, some comments recommended that FDA modify the phaseout policy to prolong the period of time prior to phasing out the general enforcement discretion approach with respect to premarket review requirements, and/or continue to apply the general enforcement discretion approach with respect to premarket review requirements for certain LDTs, to reduce the FDA resource needs.
**Response:**
FDA disagrees that the Agency will lack sufficient resources to conduct premarket review of IVDs offered as LDTs in a timely manner. First, FDA does not intend to phase out the general enforcement discretion approach with respect to premarket review requirements for high-risk IVDs until 3½ years after publication of the phaseout policy, and for moderate- and low-risk IVDs (that require premarket submissions), until 4 years after publication of the phaseout policy. This timeline aligns with the next reauthorization of MDUFA. This alignment will provide an opportunity for FDA and industry to negotiate regarding user fees and performance goals with the knowledge that laboratory manufacturers will be expected to comply with applicable premarket review requirements.
Second, FDA generally intends to exercise enforcement discretion with respect to certain requirements for certain tests as described in the final phaseout policy. These enforcement discretion policies are discussed further in section V.B of the preamble and collectively will significantly reduce the number of premarket submissions for IVDs offered as LDTs, as compared to our preliminary estimates.
Third, FDA’s device authorities require premarket review only for certain IVDs. FDA estimates that approximately 50 percent of IVDs currently under active oversight are low risk and do not require premarket review, and FDA assumes this estimate also applies to IVDs offered as LDTs (see section II.F.2.c of this analysis). However, there are uncertainties surrounding the estimate of total numbers of IVDs offered as LDTs on the market because FDA generally has not enforced the registration and listing requirements for LDTs under section 510 of the FD&C Act (21 U.S.C. 360), 21 CFR part 607, and 21 CFR part 807 (excluding subpart E). By 2 years after publication of this final rule, at stage 2 of the phaseout policy, FDA will obtain registration and listing information from laboratory manufacturers offering IVDs as LDTs. This information will help FDA assess and plan for the resources needed for premarket review of those IVDs before stages 4 and 5 of the phaseout policy.
Fourth, FDA is currently working to enhance its 510(k) Third Party Review Program to handle the review of low- and moderate-risk devices by recognized Third Party review organizations. This will free up Agency staff time to review more complex, innovative, high-risk devices. FDA estimates that half of the IVDs offered as LDTs for which a 510(k) will be submitted will be reviewed under the Third Party review program. FDA also recognizes that if CLIA accreditation organizations seek accreditation under FDA’s Third Party review program, there may be certain efficiencies or other advantages, because the two programs are complementary, as described in response to Comment 7 of the preamble. FDA also intends to exercise enforcement discretion and generally not enforce premarket review requirements for LDTs approved by NYS CLEP and to generally not enforce requirements for LDTs.
Finally, FDA disagrees that decision timelines on EUA requests, in general, are a good indicator to predict FDA’s timelines for review of premarket applications/submissions for IVDs offered as LDTs, and further disagrees that FDA’s review of any one particular EUA request submitted for an LDT during the COVID-19 pandemic is indicative of how FDA will review premarket applications/submissions for IVDs offered as LDTs generally.
As discussed in response to comment 275 in the preamble, FDA’s authority to issue EUAs for LDTs is under a different statutory provision (section 564 of the FD&C Act (21 U.S.C. 360bbb-3)) than traditional premarket reviews. Moreover, FDA is not required to review individual EUA requests submitted to FDA or review them on a specific timeline, or to authorize the emergency use of a medical product even if it meets the relevant criteria for an EUA, giving FDA flexibility to determine how to prioritize its efforts in emergencies to protect and promote public health.
Second, during the COVID-19 pandemic, FDA received a large influx of submissions that had not been anticipated. In the context of the phaseout policy, FDA has estimated the number and type of premarket submissions we can expect in Stages 4 and 5, and annually thereafter, and can prepare for those submissions. See our responses to comments 37 and 275 in the preamble for additional discussion on this topic.
###### 17. Comment (Small Entities)
As discussed in section VI.G of the preamble, FDA received comments expressing concern that phasing out the general enforcement discretion approach for LDTs will put financial and administrative pressure on small laboratories. These comments state that the phaseout of general enforcement discretion could result in laboratory closures and potential monopolies in the testing space. Several comments stated that large laboratories will be able to monopolize LDT processing as they have the resources to afford the necessary staffing and other costs related to test development and regulatory submission. One comment discussed small laboratories within a medical system closing, stating that the removal of pathologists due to this kind of laboratory exit would decrease the quality of patient care.
**Response:** FDA appreciates the concerns regarding financial and administrative challenges for smaller laboratories. Specifically, FDA recognizes that smaller laboratories may face an increase in total cost such that they will exit the market and potentially cause increased testing market concentration. The extent in which smaller laboratories may be disproportionately impacted by the phaseout of the general enforcement discretion approach for LDTs, is dependent on the number of IVD's offered as LDTs per lab.
FDA anticipates that the enforcement discretion policies discussed in the preamble of the final rule will moderate these concerns and help to avoid complete disruption to the test market. As noted in Appendix B – Table 8, the average costs per LDT are smallest for stages 1 through 3 of the phaseout policy representing 10% of costs and up to 59% of affected tests, whereas average costs per LDT for stages 4 and 5 represent 90% of costs affecting 3% of tests. The percentage of tests that may experience costs under stages 4 and 5 will increase as new laboratories and tests enter the market during and after stages 4 and 5, as they will fall within the enforcement discretion policy for currently marketed tests.
However, they may still fall within the scope of other enforcement discretion policies described in the preamble to the final rule, including those for unmet needs and LDTs approved by NYS CLEP. However, in the event that a new lab does not fall within the scope of other enforcement discretion policies, costs under stages 4 and 5 could present as a potential barrier to entry in the LDT market for new laboratories.
In Table B.7, total costs and transfers for all stages of the phaseout policy are estimated to be on average anywhere between 2.5, 5.8 and 16 percent over receipts for all entities. We do not have the information about labs to determine how the average estimates are distributed among the firms (including new firms) according to their size categories.
Also, costs would be higher for a lab that has several IVDs offered as LDTs but sells fewer unit tests whereas costs would be smaller for labs with only one IVD offered as LDTs selling a large number of unit tests. In the same manner, profit margins could be higher for labs with a smaller number of IVDs offered as LDTs but with high volume unit tests sold, compared to labs with a larger number of IVDs offered as LDTs but with low volume units tests sold.
Depending on profit margins with respect to revenue, the costs of this rule may be prohibitive for some small labs, making it more likely that some small entities in this size category will exit the market, reduce operations, sell the business, be subject to acquisitions by larger firms or not enter the market. If profit margins were too small for many small firms considering the costs, it is possible that this rule will be too burdensome for some small entities.
While we do not have the data on profit margins to properly estimate the number of labs that would be adversely impacted by this rule, we estimate that small laboratories make fewer IVDs offered as LDTs than large firms. We estimate that small labs make up 92 percent of all labs, and that they also hold a 24 percent share of IVDs offered as LDTs. With the low number of IVDs offered as LDTs per small lab, it is more likely that the percent of costs over receipts per lab would be closer to our low average estimate 2.7 percent.
With the above referenced revisions to the phaseout policy, we do not expect significant disruptions to access to IVDs offered as LDTs, significant increases in test prices, or delays in diagnosis and treatment. However, the high cost of pre-market approval also makes innovation less likely to come from smaller labs.
###### 18. Comment (Firm Exit and Market Concentration)
Some comments have claimed that certain laboratories, such as academic, small, public health, and specialty laboratories, will disproportionately exit the market relative to their counterparts. These comments claim that since these labs already have low revenues, any additional cost could be enough to cause market exit.
Other comments stated that by reducing the availability of IVDs offered as LDTs through market exit, the phaseout policy would lead to delays in testing, including by potentially increasing reliance on reference laboratories which may increase the time individuals obtained test results. Some comments expressed concern that the laboratories surviving general enforcement discretion phaseout would receive an influx of test orders and may not be able to handle the test volume, which may have an overall negative impact on the turnaround time for test results. Two comments have addressed the exit of academic labs as particularly concerning given their role in diagnosing and monitoring rare diseases. Further, many comments stated that a potential increase in firms exiting the market could increase unemployment among laboratory technicians and increase market concentration in the healthcare industry.
A few comments also addressed children’s hospital laboratories as particularly likely to be negatively affected by the phaseout policy. These comments stated that because these hospitals rely largely on Medicaid payment, the laboratories in these hospitals may have small revenue levels and may reduce their IVD offerings, exit the market, or send samples to other laboratories for testing if the total cost increase for meeting applicable requirements that result from the phaseout policy is too high.
**Response:** FDA appreciates the comments on potential firm exit and market concentration as a result of the phaseout policy. Given that FDA intends to exercise enforcement discretion and generally not enforce premarket review and QS requirements (except for requirements under 21 CFR 820, subpart M (Records)) for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of the final rule and that are not modified, or that are modified as described in the preamble, and for LDTs developed by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system (as described in section V.B.3 of the preamble), we do not expect significant market concentration and firm exit to result from the phaseout policy. With the above referenced revisions to the phaseout policy, we also do not expect current disruption to access to IVDs offered as LDTs, significant increases in test prices, or delays in diagnosis and treatment.
##### D. Summary of Changes from the Proposed Rule
Compared to the preliminary economic analysis, this final analysis reflects revisions to the phaseout policy and to our analytical methodology. We include updates and revisions to our discussion of baseline conditions, estimated health and non-health benefits, costs, budgetary impacts, transfers, regulatory alternatives, and impacts to small entities as summarized below.
###### 1. **Changes to the Phaseout Policy**
The final phaseout policy differs significantly from the proposed policy in that it includes the following additional enforcement discretion policies:
- FDA intends to exercise enforcement discretion and generally not enforce premarket review and QS requirements, with the exception of requirements under 21 CFR part 820, subpart M (Records), for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of this rule and that are not modified, or that are modified in certain limited ways as described in section V.B.3 of the preamble.
- FDA intends to exercise enforcement discretion and generally not enforce premarket review requirements for LDTs approved by NYS CLEP;
- FDA intends to exercise enforcement discretion and generally not enforce premarket review requirements and QS requirements, with the exception of requirements under 21 CFR part 820, subpart M (Records), for LDTs manufactured and performed by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system;
- FDA intends to exercise enforcement discretion and generally not enforce requirements for LDTs manufactured and performed within the Veterans Health Administration (VHA) or the Department of Defense (DoD); and
- FDA intends to exercise enforcement discretion and generally not enforce premarket review and QS requirements, with the exception of requirements under 21 CFR part 820, subpart M (Records), for non-molecular LDTs for rare red blood cell antigens where such tests are manufactured and run in transfusion services and immunohematology laboratories and where there is no alternative available to meet the patient’s need for a compatible blood transfusion.
Where relevant, we adjust estimates in this final analysis in accordance with these changes to the phaseout policy. More details of IVDs within the scope of the phaseout policy are described in section V.A of the preamble.
###### 2. Baseline Conditions
After reviewing comments, FDA revised the number of laboratories affected by the phaseout policy using data from the CMS Laboratory Registry as explained in appendix A.
Using the CMS data, the revised primary estimate of affected laboratories is 1,181, which is close to the estimate of 1,200 in the preliminary analysis.
###### 3. Benefits
We have made several changes to our analysis of health benefits. While there are individual changes that increase as well as decrease estimated benefits, overall total estimated benefits have decreased due to incorporating new information and assumptions. However, while including data and information from public comments as well as additional research has lowered estimated annualized benefits from expected reductions in cancer mortality to about one fiftieth of the preliminary estimate, we now also use this information to quantify benefits that we previously discussed qualitatively or only addressed incompletely. In particular, we now include general, yearly estimates of mortality avoidable in cardiovascular disease and morbidity avoidable in infectious diseases.
In response to comments, and as described in section II.E.1.a of this analysis, we have revised our methods for estimating avoidable harms related to cancers. We have also applied revised methods in newly estimating avoidable harms related to cardiovascular and infectious diseases. Revisions concern both reference information and analytical assumptions.
We now source certain parameters addressed in public comments, such as the rate of usage of IVDs in cancer, cardiovascular diseases, and infectious diseases, from published literature and other data. Additionally, we now estimate the rate of usage of problematic IVDs offered as LDTs based on application review statistics from the NYS Department of Health Clinical Laboratory Evaluation Program (CLEP) (Ref. [12]) and FDA’s 2020 assessment of EUA requests from laboratories for molecular diagnostic COVID tests.^9
We have also refined analytical assumptions. For example, although we did not assume in the preliminary analysis that 100% of uses of problematic IVDs offered as LDTs result in a harm from diagnostic error, we have refined our assumptions to avoid any implication that this is the case.
Due to our high degree of uncertainty about several of the parameters used to estimate health benefits, we now use Monte Carlo simulations to determine a plausible range for benefits pertaining to each disease category by allowing parameters to vary independently of each other. Not using such an approach would implicitly convey a strong and unrealistic assumption that all uncertain parameters share a joint probability distribution and are perfectly dependent (i.e., aligning all best- and worst-case scenarios across parameters).
With respect to non-health benefits, we have removed discussion and estimates made in section II.E.3 of the Preliminary Regulatory Impact Analysis (PRIA) (Ref. [1]) where we had previously requested supporting information in public comment and did not receive any. Additionally, we have edited discussion for clarity, in part to address certain public comments.
Finally, as described in sections II.E.1 and II.E.3, we adjust estimates of benefits to account for existing review by NYS CLEP and the enforcement discretion policy for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of the final rule.
###### 4. Costs
We have made several changes to our cost analysis. We use updated data for wages, FDA costs, and MDUFA fees. We made the following revisions as a result of changes to the final phaseout policy: exclude currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of the final rule from premarket review and QS (except for records) compliance costs; exclude LDTs manufactured and performed by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system from premarket review and QS compliance costs (except for records); and exclude LDTs expected to be reviewed by NYS CLEP from premarket review compliance costs. We also consider that some of the IVDs currently classified in class III, requiring PMAs/PMA supplements, may be reclassified to Class II or Class I (described in Appendix A and section II.F.4).
We have revised our estimates of FDA review costs to adjust the FTE weight of PMA review costs, to include review costs of MDRs, IDEs, and Q-submissions, and to consider premarket submissions that will be reviewed by third party or NYS CLEP (see section II.G). We have also refined some estimates in the analysis based on data received in public comments.
###### 5. Regulatory Alternatives
The section on regulatory alternatives in the final analysis retains only the first two regulatory options from the preliminary analysis. For the final analysis, we include as an additional alternative the phaseout policy as initially proposed. See section II.J.
#### II. Final Economic Analysis of Impacts
##### A. Background
In 1976, the Medical Device Amendments (MDA) amending the FD&C Act created a comprehensive system for the regulation of devices intended for human use, including IVDs. Since 1976, FDA has considered IVDs to be devices within the meaning of the device definition in the FD&C Act (see section 201(h)(1) of the FD&C Act (21 U.S.C. 321(h)(1)); 21 CFR
However, in implementing the MDA since 1976, FDA has exercised enforcement discretion such that it generally has not enforced applicable legal requirements with respect to most LDTs because they mostly:
- were manufactured in small volumes by local laboratories that served their local communities;
- were typically intended for use in diagnosing rare diseases or other uses to meet the needs of a local patient population or were generally similar to well-characterized, standard IVDs;
- tended to employ manual techniques (and did not use automation) and were performed by laboratory personnel with specialized expertise;
- were to be used and interpreted by physicians or pathologists in a single institution responsible for the patient (and who were actively involved in patient care); and
- tended to be manufactured using components legally marketed for clinical use, such as general purpose reagents or immunohistochemical stains marketed in compliance with FDA requirements.
This enforcement discretion approach for LDTs developed as a matter of general practice.
However, since 1976, the development and usage of LDTs have evolved considerably. LDTs are now more complex, sometimes including proprietary algorithms. Today’s LDTs are also used more widely, by a more diverse population, with an increasing reliance on high-tech instrumentation and software, and more frequently for the purpose of guiding critical healthcare decisions. They are often performed in large volumes in reference laboratories for patients from different institutions around the world and are sometimes assembled using components intended for research use only. Some LDTs are manufactured by corporations that market the IVDs nationwide as they accept specimens from patients across the country and run their tests in very large volumes in a single laboratory. In this regard, most LDTs today are similar to other IVDs that have not been under FDA’s general enforcement discretion approach.
Clinical laboratory tests are foundational to healthcare. The Centers for Disease Control and Prevention (CDC) estimates that 70 percent of medical decisions are based on laboratory test results (Ref. [16]). IVDs offered as LDTs are a growing sector of that market (Ref. [17]). Given the role these tests play in modern healthcare, their safety and effectiveness significantly impact public health. Although many of the IVDs offered as LDTs today are similar to other IVDs and may often serve the same role in clinical practice, FDA has generally not enforced applicable device requirements for LDTs. As a result, there is generally less assurance of the safety and effectiveness of IVDs offered as LDTs compared to other IVDs.
##### B. Need for the Rule
As the growing number of IVDs offered as LDTs entering and currently on the market (some of which may be problematic IVDs) typically are not reviewed by FDA, patients might be at risk when their providers rely on certain IVDs offered as LDTs to guide their care. Results from problematic IVDs can lead to delayed diagnosis or treatment of the true disease or condition, unwarranted interventions (some of which may carry risk of serious side effects), needless distress, progression of disease (in some cases costing the opportunity for life-saving treatment), and the spread of infectious diseases.
While laboratories that offer IVDs are regulated by the Centers for Medicare & Medicaid Services (CMS) under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), CLIA addresses laboratory operations and personnel qualifications and not the development of individual tests in a laboratory (see 42 U.S.C. 263a and 42 CFR part 493) (Ref. [18]). In particular, under CLIA, CMS does not:
- regulate laboratory test development;
- evaluate the performance of an IVD before the test is offered to patients and healthcare providers;
- assess clinical validity (i.e., the accuracy with which a test identifies, measures, or predicts the presence or absence of a clinical condition or predisposition in a patient);
- regulate certain manufacturing activities, such as design controls and acceptance activities;
- provide human subject protections for patients who participate in IVD clinical research trials; or
- require adverse event reporting.
By contrast, the device provisions of the FD&C Act and FDA’s regulations focus on the safety and effectiveness of the IVDs themselves. Given this distinction, CMS has described the FDA and CMS “regulatory schemes” as “different in focus, scope and purpose, but […] intended to be complementary (Ref. [19]).”
FDA’s experience with emergency use authorization (EUA) requests from laboratories for COVID-19 tests during the COVID-19 pandemic increased FDA’s concerns about the safety and effectiveness of IVDs offered as LDTs.[^12] While FDA had received requests for EUAs for tests from laboratories in prior emergencies, the scope of the COVID-19 pandemic resulted in an unusually high number of EUA requests from laboratories, revealing the approach that many laboratories might take to test validation. In an analysis of the first 125 EUA requests received from laboratories during the COVID-19 pandemic for molecular diagnostic tests, FDA found that 82 tests had design or validation problems, or both. The tests involved relatively well-understood techniques and the laboratories represented these tests as appropriately validated.[^13] To the extent that this sample represents larger trends in the performance of IVDs offered as LDTs, it indicates the need for greater oversight.
Problems with IVDs offered as LDTs have also come to light in the scientific literature, news articles, and anecdotal reports submitted to the Agency, among other sources. Multiple publications in the scientific literature have described a high degree of variability among IVDs offered as LDTs (Ref. [20]). For example, in one study, analytical accuracy was significantly lower than that of the parallel test approved by FDA for almost half of the tests studied (Ref. [21]).
News and other outlets have also reported on problems with IVDs offered as LDTs, including the New York Times (Ref. [15]), and lawsuits have been filed relating to pharmacogenomic and non-invasive prenatal screening IVDs offered as LDTs.[^14]
FDA has received complaints, allegations, and reports regarding IVDs offered as LDTs for oncology, non-invasive prenatal screening, and infectious diseases, among others. Some laboratories have submitted data to FDA in premarket submissions for their IVDs offered as LDTs, and we have observed that many failed to perform the appropriate studies to show that their IVDs work. Some have submitted data from appropriate studies, but the data show that their IVDs do not work. In both cases, laboratories have continued to offer such IVDs for clinical use.
While it is theoretically possible that, over time, patients and providers might learn the differences between competing tests and eventually stop purchasing ineffective tests regardless of regulation, that has not universally happened to date, even though the disparity between IVDs offered as LDTs and IVDs meeting applicable FDA requirements has been ongoing for decades. Further, we know from experience that providers and patients often do not even know what test was performed by a laboratory and, without widespread awareness of the different types of tests and regulatory disparities, we expect that learning of this kind would be rare, if it ever occurred, and would be complicated by the rapidly changing market, with new tests introduced regularly. Moreover, during the time that it would take for any such learning to occur, providers and patients may be using inaccurate or unreliable tests, with all the associated risks to patients. As for patients, ability to internalize the relevant risks may be precluded by not knowing the difference between IVDs offered as LDTs and FDA-authorized IVDs or having meaningful informed choice in the purchase decision.
Furthermore, FDA is aware that some entities have adopted business practices that claim a connection to laboratories in order to offer IVDs as LDTs, even when they are not LDTs, because they are not actually designed, manufactured, and used within a single laboratory (See for example Refs. [22] and [23]). For example, FDA notes:
- Manufacturers offering unauthorized home specimen collection kits manufactured outside of the laboratory for use with LDTs;
- Software developers offering software for high-risk clinical use with LDTs through laboratory partnerships;
- Laboratories offering test kits previously alleged to be “research use only” test kits;
- Manufacturers of home specimen collection kits with consumer facing platforms providing the ordering and resulting interface while outsourcing testing to unspecified laboratories; and
- Contract manufacturers claiming to be consulting firms that design and validate tests for customer laboratories to perform.
This puts non-laboratory, conventional test manufacturers who develop IVDs, whose IVDs have not been under FDA’s general enforcement discretion approach for LDTs, at a competitive disadvantage compared to laboratory manufacturers of IVDs offered as LDTs. IVD manufacturers who are not laboratories might currently be discouraged from investing time and resources into developing novel tests due to the concern that once the manufacturer receives marketing authorization for its test, laboratories will develop similar tests and market their tests without complying with FDA requirements (Refs. [24] and [25]). We anticipate that applying the same general oversight approach to laboratories and non-laboratories that manufacture IVDs, and phasing out the general enforcement discretion approach for LDTs, will better assure the safety and effectiveness of IVDs offered as LDTs, and remove a disincentive for non-laboratory manufacturers to develop novel tests, thereby spurring innovation and access to IVDs for which there is a reasonable assurance of safety and effectiveness. Without the phaseout policy, and without better assurance of the safety and effectiveness of IVDs offered as LDTs, limited investment and healthcare funding may be expended on improving problematic IVDs.
The enforcement discretion approach for LDTs has created distortions in the diagnostics market.15 These distortions not only complicate understanding the IVDs used in clinical practice, impeding FDA’s ability to ensure the safety and effectiveness of IVDs, but might also disincentivize high standards of quality control and accuracy and thus entail social costs.16
In order to curtail offering of problematic tests, FDA is phasing out the general enforcement discretion for LDTs so that IVDs manufactured by a laboratory will generally fall under the same enforcement approach as other IVDs.
In addition, to ensure clarity and understanding by industry and the public, FDA is amending its regulations to make explicit that IVDs are devices under the FD&C Act including when the manufacturer of the IVD is a laboratory.
##### C. Purpose of the Rule
The purpose of the rule, which amends 21 CFR part 809, is to make explicit that IVDs are devices under section 201(h)(1) of the FD&C Act (21 U.S.C. 321(h)(1)) including when the manufacturer of the IVD is a laboratory. This amendment will reflect the fact that the device definition in the FD&C Act does not differentiate between entities manufacturing the device, and will provide further clarity to stakeholders affected by the accompanying changes to FDA’s general enforcement discretion approach for LDTs.
In addition, as discussed in section V of the preamble to the rule, FDA is also phasing out its general enforcement discretion approach for LDTs so that IVDs manufactured by a laboratory will generally fall under the same enforcement approach as other IVDs (i.e., FDA’s expectations for compliance will generally be the same). This phaseout policy includes limited enforcement discretion policies for specific categories of IVDs manufactured by a laboratory, including currently marketed IVDs offered as LDTs and LDTs for unmet needs. This phaseout policy is intended to better protect the public health by helping to assure the safety and effectiveness of IVDs offered as LDTs, while also accounting for other important public health considerations such as patient access and reliance. In addition, by applying the same general oversight approach to laboratories and non-laboratories that manufacture IVDs, FDA will give stakeholders more stability, clarity, and confidence, and facilitate investment in the development of innovative IVDs.
For additional discussion, see section III.B of the preamble.
##### D. Baseline Conditions
We consider the current environment, including the general enforcement discretion approach, as a reasonable approximation of the baseline (the projected future without phasing out FDA’s general enforcement discretion approach for LDTs) against which to measure the costs and benefits of the phaseout policy and the regulatory alternatives discussed in section II.J.
FDA has generally described LDTs as IVDs that are designed, manufactured, and used in a single laboratory that is certified under CLIA and that meets the regulatory requirements under CLIA to perform high complexity testing (Ref. [26]).17 However, as discussed in the preamble and section II.F “Costs,” the phaseout policy will affect not only LDTs, but IVDs manufactured and offered as LDTs, even if those IVDs do not fall within FDA’s traditional understanding of an LDT because they are not designed, manufactured, and used within a single laboratory.18, 19 Throughout this document, we refer to these IVDs as “IVDs offered as LDTs.”
As described in section V of the preamble, FDA is including various enforcement discretion policies with regard to all applicable requirements for certain categories of tests manufactured by laboratories. One such category of tests is referred to in this document as “1976-Type LDTs.” Such tests have the following characteristics common among LDTs offered in 1976 (discussed in section III of the preamble):
- use of manual techniques (without automation) performed by laboratory personnel with specialized expertise;
- use of components legally marketed for clinical use; and
- design, manufacture, and use within a single CLIA-certified laboratory that meets the requirements under CLIA for high complexity testing.
FDA will also continue the general enforcement discretion approach for Human Leukocyte Antigen (HLA) tests that are designed, manufactured and used in a single CLIA-certified, high-complexity histocompatibility laboratory that meets the requirements to perform high-complexity histocompatibility testing when used:
- in connection with organ, stem cell, and tissue transplantation to perform HLA allele typing,
- for HLA antibody screening and monitoring, or
- for conducting real and “virtual” HLA crossmatch tests.
FDA will also continue the general enforcement discretion approach for tests intended solely for forensic (law enforcement) purposes. This approach has been in place for over 20 years and applies to such tests regardless of whether they are offered as an LDT.
FDA also intends to continue the general enforcement discretion approach for LDTs manufactured and performed within DoD or VHA. To meet the needs of their patient populations (i.e., military personnel, veterans, and their families) and fulfill their mandates, DoD and VHA often manufacture unique LDTs, such as tests for diseases or chemicals to which their patients may be exposed while serving abroad but which do not exist at home.
We lack information to quantify the number of tests that fall in the above categories and thus the exclusions are not assessed in this regulatory impact analysis.
FDA also intends to exercise enforcement discretion and generally not enforce premarket review and QS requirements, with the exception of requirements under 21 CFR 820, subpart M (Records), for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of this rule that are not modified, or that are modified in certain limited ways. FDA generally expects compliance with premarket review and QS requirements when a laboratory changes the indications for use of the IVD, alters the operating principle of the IVD (e.g., changes in critical reaction components), includes significantly different technology (e.g., addition of artificial intelligence / machine learning to the test algorithm, a change from targeted sequencing to whole genome sequencing, a change from immunoassay to mass spectrometry, or a change from manual to automated procedures), or adversely changes the performance or safety specifications of the IVD.
In addition, FDA intends to exercise enforcement discretion and generally not enforce premarket review and QS requirements, with the exception of requirements under 21 CFR 820, subpart M (Records), for LDTs manufactured and performed by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system. For the purpose of this phaseout policy, FDA considers an LDT to be for an unmet need where there is no available FDA-authorized test that meets the patient’s needs. This may be because – (1) there is no FDA-authorized IVD for the disease/condition; (2) there is an FDA-authorized IVD for the disease/condition but it is not indicated for use on the patient, or a unique attribute needs to be added to the IVD to meet the patient’s needs; or (3) there is an FDA-authorized IVD but it is not available to the patient. This is discussed further in section V.B.3 of the preamble.
FDA also intends to exercise enforcement discretion and generally not enforce premarket review requirements for LDTs approved by NYS CLEP.
We expect that a number of laboratories offering IVDs as LDTs, and those IVDs, do not currently meet applicable requirements—including premarket review, quality system, registration and listing, and adverse event reporting requirements—given FDA’s general enforcement discretion approach for LDTs.
We do not have complete information about IVD performance or patient harm. As discussed in detail in section III.B of the preamble, FDA has increasingly seen problems with IVDs offered as LDTs that have caused or might be causing harm. However, the tests involved likely do not represent all problematic tests that might be affected by the phaseout of the general enforcement discretion approach for LDTs, as laboratories do not typically submit premarket submissions for IVDs offered as LDTs to FDA or report adverse events associated with those tests given the general enforcement discretion approach.
Without registration and listing information, it is difficult to estimate the exact baseline number of manufacturers of IVDs offered as LDTs that will be affected by the phaseout policy. It is also difficult to estimate the number of IVDs offered as LDTs currently on the market, when or why many of them are used, or exactly how they each perform compared to other IVDs.
Without adverse event reporting or other information that FDA will obtain upon the phaseout of the general enforcement discretion approach, it is difficult to estimate the exact baseline number of patients that can benefit from the phaseout of the general enforcement discretion approach given current information. In order to account for potential uncertainty and variability, we present all expected costs and benefits in ranges of low, central, and high estimates. We address baseline risks (and costs due to risks) in the benefits section of this analysis.
###### 1. Number of Affected Entities
Since laboratories that offer IVDs as LDTs have not generally registered and listed, we do not know the exact number of laboratories or IVDs offered as LDTs that will be affected by the phaseout of the general enforcement discretion approach for LDTs.
Comments suggested we use CMS data to estimate the number of affected labs. Using the CMS data, we estimate that there are 11,808 high complexity CLIA laboratories that have IVDs offered as LDTs that will be affected by the phaseout of the general enforcement discretion approach. We therefore revise our original estimate of 12,000 to 11,808. The steps in developing this estimate are explained in appendix A. Laboratories that meet the requirements to perform high complexity testing are the only laboratories that can perform LDTs under CLIA regulations, because LDTs are considered high complexity tests (Ref. [27]). Additionally, while CLIA regulations contemplate that such laboratories may deploy IVDs offered as LDTs, we do not expect that every such laboratory does so. We are not aware of suitable sources for the exact number of such laboratories that are currently offering IVDs as LDTs.
We rely on information about laboratories and IVDs in NYS to estimate the percent of high complexity labs that make IVDs offered as LDTs (Ref. [28]). NYS requires laboratories offering tests to NYS residents, whether or not the laboratory is located in NYS, to obtain a permit through the NYS CLEP, as well as “explicit test-specific approval” for certain IVDs that are not “designated as FDA-cleared, approved or exempt.” (Ref. [29]) To FDA’s knowledge, NYS is the only state that requires approval for LDTs that are not FDA-cleared, approved, or exempt. Further, NYS is a relatively large space with a variety of demographics, including urban to rural areas, and a variety of laboratories such as academic medical centers, reference laboratories, public health laboratories, and local hospital laboratories, similar to the variety found throughout the U.S. Therefore, FDA determined that the information about laboratories and IVDs in NYS could be extrapolated to estimate the number of laboratories throughout the U.S. that might be offering IVDs as LDTs.
NYSDOH provided information indicating that there are approximately 500 laboratories located in NYS with a NYS CLEP permit that are certified under CLIA and that meet or exceed the regulatory requirements under CLIA to perform high complexity testing, and that approximately 50 of such laboratories offers at least one IVD as an LDT approved by NYS CLEP (Ref. [28]). From these data, we calculate that approximately 10% of laboratories located in NYS that are certified under CLIA and that meet the regulatory requirements under CLIA to perform high complexity testing are manufacturing IVDs offered as LDTs.
For our primary estimate, we assume that NYS is representative of the U.S. laboratory community, as discussed above. Based on the information from NYS and the assumption that NYS is representative of the entire U.S., we estimate that approximately 10% of 11,808 (or 1,181) laboratories in the U.S. that are certified under CLIA and that meet the regulatory requirements under CLIA to perform high complexity testing currently manufacture IVDs offered as LDTs. To account for potential variability across the country, we estimate the proportion of high complexity laboratories making IVDs offered as LDTs to vary from 5% of 11,808 (or 590) laboratories to a high estimate of 20% of 11,808 (or 2,362) affected laboratories by reducing the primary estimate by 50% and doubling the primary estimate, respectively.
Based on these two sources and methods, for purposes of this analysis, we use 590, 1,181 and 2,362 as low, central (primary), and high estimates of the number of laboratories affected by the phaseout of the general enforcement discretion approach for LDTs. We also expect that there will be new laboratories entering the market every year. To calculate the number of new laboratories per year, we use an average of firms’ entry and exit rates from 2010 to 2018 in the United States (approximately 8 percent) (Ref. [30]). Multiplying this by the number of affected entities, we estimate the number of new laboratories per year to range from 47 to 189, with a primary estimate of 94.^20^
Because there is no single source containing information on the number of IVDs offered as LDTs currently on the market, FDA also used information about laboratories and IVDs reviewed in NYS to extrapolate estimates for affected IVDs across the country. According to NYSDOH’s website, there are currently approximately 2,200 IVDs with approval from NYSDOH offered by laboratories located in NYS (Ref. [29]). NYSDOH provided the number of distinct laboratories within NYS that are certified under CLIA, that meet the regulatory requirements under CLIA to perform high complexity testing, and that are manufacturing and offering at least one IVD offered as an LDT (Ref. [28]), as well as the breakdown of risk categories for submissions to NYS, as determined by NYS CLEP risk criteria. From these data, FDA calculated that each laboratory in NYS that manufactures IVDs offers an average of 67 IVDs as LDTs. Extrapolating to the rest of the country, FDA estimates that 39,557, 79,114, or 158,227 IVDs may be currently offered as LDTs and therefore affected by the phaseout of the general enforcement discretion approach, based on the low, central, and high estimates of affected entities discussed above (see Table 2). These estimates assume that NYS is representative of the U.S. laboratory community.
We took a similar approach to estimating the number of new IVDs offered as LDTs that are expected to be introduced per laboratory per year. NYSDOH provided information indicating that laboratories within NYS that manufacture IVDs offered as LDTs introduce an average of 6 new IVDs offered as LDTs per year. For purposes of this analysis, we assume that laboratories in NYS are representative of the U.S. laboratory community, and estimate that 3,542, 7,085, or 14,170 new IVDs offered as LDTs may be affected per year. We also expect that there would be new IVDs offered as LDTs from new laboratories entering the market every year. In addition, we expect 50 percent of currently marketed IVDs offered as LDTs (34 IVDs offered as LDTs per laboratory = 67 * 0.5) will be modified in such a way as to require premarket review over the next twenty years. We thus estimate 2 IVDs offered as LDTs per year per laboratory will be modified in such a way as to require premarket review (2 = 34 / 20 years). The total number of new IVDs offered as LDTs per year is estimated to range from 5,007 to 20,026, with a primary estimate of 10,013. We understand anecdotally that some large reference laboratories may make as many as 100 new IVDs per year, whereas smaller or more specialized laboratories may focus on one or a few IVDs overall and may not introduce many or any new IVDs every year. Throughout this analysis, we define the terms “affected labs” and/or “affected entities” as laboratories offering IVDs as LDTs and therefore affected by the phaseout of the general enforcement discretion approach for LDTs. In a similar manner, we also define the terms “affected IVDs” as IVDs offered as LDTs associated with costs as incurred during their relevant policy stages 1 through 5 (discussed in detail in section II.F).
Table 2 shows the estimated number of laboratories and IVDs offered as LDTs affected by the phaseout of the general enforcement discretion approach for LDTs.
**Table 2. Estimated Number of Laboratories and IVDs Offered as LDTs Affected by this Rule**
| | Primary Estimate | Low Estimate | High Estimate |
|---|------------------|--------------|---------------|
| Affected Labs | 1,181 | 590 | 2,362 |
| New Affected Labs Entering the Market Per Year | 94 | 47 | 189 |
| Affected Tests Currently on the Market | 79,114 | 39,557 | 158,227 |
| New Affected Tests Per Year | 10,013 | 5,007 | 20,026 |
||
*Notes: Product across table may not be exact due to rounding. The number of new affected IVDs per year include currently marketed IVDs that would be modified and new affected IVDs from both affected labs and new labs entering the market per year. These numbers reflect the baseline numbers for affected laboratories and affected tests and are further adjusted in later sections of this analysis to estimate costs under Stages 4 and 5, where only a subset of these laboratories and tests may incur costs, as described in sections II.F.4 and II.G.*
###### 2. Baseline Market Revenue
Data from the 2017 U.S. Census for the entire industry under NAICS code 621511 reported 3,365 firms with $36 billion in annual revenues. From Table 2 above, we estimate 1,181 affected laboratories or firms which represent 35% of the 3,365 firms in the Census data. If we assume the same average annual receipts for all firms, then the corresponding annual receipts for affected laboratories would represent 35% of total annual receipts or $15 billion (in 2022 dollars).
In Table 3, we estimate annual industry revenue in 2023 between $19 and $21 billion based on a projection from 2017 Census data of the $15 billion using compounded annual growth rates (CAGRs) of 4.2% and 6% (Refs. [17] [31]).
**Table 3. Estimated Market Revenue for IVDs Offered as LDTs ($1,000, 2022 U.S. dollars)**
| Year | Primary (Average between low and high projection) | Low Projection ($1,000) (4.2% CAGR) | High Projection ($1,000) (6% CAGR) |
|------|--------------------------------------------------|------------------------------------|----------------------------------|
| 2023 | $20,093,935 | $19,062,398 | $21,125,471 |
| 2030 | $28,594,674 | $25,424,450 | $31,764,898 |
||
###### 3. Baseline FDA Premarket Reviews of Submissions/Applications
To better understand the magnitude of anticipated premarket submissions/applications for IVDs offered as LDTs that FDA would receive on an annual basis, Table 4 below shows the 5 year average number of submissions/applications for all devices (2017-2021) along with the estimated annual number of submissions/applications expected for IVDs offered as LDTs after this rule become effective (Ref. [32]). The estimated annual reviews for premarket submissions/applications are adjusted to account for the enforcement discretion policies discussed above, potential reclassifications of class III IVDs to class II, and the 510(k) Third Party Review Program.
**Table 4. FDA Review Workload by Submission Type**
| Submission/Application Type | 5-Year Average (FY 2017 to 2021) | Expected Annual Reviews for New IVDs Offered as LDTs |
|----------------------------------------------|----------------------------------|------------------------------------------------------|
| | | Primary | Low | High |
| Original PMAs, PDPs, Panel-Track PMA Supplements | 73 | 103* | 52* | 206* |
| 510(k) Premarket Notifications | 3,877 | 1,090 | 545 | 2,179 |
| De Novo Classification Requests | 66 | 267 | 134 | 534 |
||
Note: FDA annual reviews of Q-submissions, MDRs and IDE applications are not included in Table 4 but are estimated in section II.G Budgetary Impacts and described in Table 38.
\* The estimated reviews include original PMAs and panel-track PMA supplements. See Table 29 and Table 31 for estimated numbers of original PMAs and panel-track PMA supplements, respectively. Totals may not add due to rounding.
###### 4. Baseline Risk of Problematic IVDs
We measure benefits of phasing out the general enforcement discretion approach for LDTs against a baseline scenario in which FDA continues the general enforcement discretion approach with respect to all applicable requirements for all IVDs offered as LDTs. Due to the current general enforcement discretion approach for LDTs, we lack systematic data on the exact incidence of harms specifically resulting from usage of problematic IVDs offered as LDTs that can be avoided by phasing out the general enforcement discretion approach for LDTs.
To estimate the baseline incidence of harms that can be avoided by phasing out the general enforcement discretion approach for LDTs, we focus mainly on three broad disease categories identified by Newman-Toker et al. (2021) as accounting for about 75% of serious misdiagnosis-related harms in the U.S.: cancers, cardiovascular disease, and infections (Ref. [33]). As described in the following section, we multiply the numbers of U.S. patients in each disease category—estimated from sources described below—by rates from literature of the proportions of patients in each category that are tested using IVDs. Based on Rychert et al. (2023) (Ref. [2]), as described in section II.E.1, we estimate that 3.9% to 45% of patients tested with IVDs are tested with IVDs offered as LDTs. This yields our baseline estimates of the numbers of patients tested using IVDs offered as LDTs. To estimate usage specifically of problematic IVDs that can be curtailed by phasing out the general enforcement discretion approach for LDTs, we refer to statistics from NYS CLEP on application review outcomes and FDA’s 2020 assessment of EUA requests from laboratories for molecular diagnostic COVID tests. Since we do not expect that LDTs approved by NYS CLEP would undergo FDA premarket review, when estimating numbers of U.S. patients in each disease category, we exclude from this analysis the number that we attribute, proportionally by population, to New York state. We note however for LDTs approved by NYS CLEP, FDA intends to exercise enforcement discretion with respect to premarket review requirements but not other applicable requirements under the FD&C Act and FDA regulations.
Lacking systematic data on the exact issues with applications for LDTs initially rejected by NYS CLEP and those LDTs’ roles in the process of diagnosis, we consider a range of rates at which avoidable errors might result from usage of problematic IVDs offered as LDTs.
Finally, in section II.E.3 “Summary of Benefits,” we adjust estimated total benefits to account for the enforcement discretion policy for IVDs offered as LDTs that are already currently on the market. As a result of exercising enforcement discretion with respect to premarket review and QS requirements, with the exception of requirements under 21 CFR 820 subpart M (Records), for currently-marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of the final rule, IVDs offered as LDTs will generally undergo premarket review only in certain circumstances. However, FDA expects these IVDs to be in compliance with other applicable requirements under the FD&C Act and FDA regulations, including post market requirements, as discussed in the phaseout policy. In order to account for this, we adjust estimated total benefits in each year—beginning with enforcement of QS and premarket review requirements—based on the proportions of IVDs falling within an enforcement discretion policy versus IVDs not falling within an enforcement discretion policy. We note, however, as described in section V.B.3 of the preamble, FDA intends to take targeted steps to address currently marketed IVDs offered as LDTs that are problematic. In particular, we intend to use available tools to identify and act against currently marketed IVDs offered as LDTs that specifically raise concerns, such as IVDs that are potentially inaccurate or poorly validated.
##### E. Benefits
Expected benefits of phasing out the general enforcement discretion approach for LDTs consist mainly of avoided harms to patients, including unnecessary costs, monetary and otherwise, that would result from usage of problematic IVDs offered as LDTs. Harms can vary in severity according to the particular problematic aspects of an IVD and their consequences for patient care.
We expect the phaseout to produce both health and pecuniary benefits via averting diagnostic error and its consequences, such as incorrect or unnecessary treatment, treatment delays, and disease progression or transmission. Pecuniary benefits also include reduced spending on problematic IVDs offered as LDTs, including non-invasive prenatal screening (NIPS) tests, as well as reduced spending on litigation over alleged harms caused by problematic IVDs.
###### 1. Reduction in Harms from Diagnostic Errors
We expect public health benefits from phasing out the general enforcement discretion approach for LDTs due to improved safety and effectiveness of IVDs offered as LDTs. To...
estimate the baseline incidence of harms that can be avoided by the phaseout, we focus mainly on three broad disease categories identified by Newman-Toker et al. (2021) as accounting for about 75% of serious misdiagnosis-related harms in the U.S.: cancers, cardiovascular disease, and infections (Ref. [33]).
a. Cancer: Mortality Risk
We quantify health benefits in the form of reduced baseline mortality risk based on expected reduction of cancer related misdiagnosis with problematic IVDs offered as LDTs. Based on the data available to us, this analysis focuses specifically on benefits in the form of reduced mortality risk (i.e., benefits associated with reducing false negative diagnoses). However, we anticipate that the phaseout policy will lead to other benefits as well, such as reduced risk of undergoing unnecessary, potentially harmful treatments based on false positive diagnoses.
We also present these estimates with the caveat that the incidence of misdiagnosis-related mortality depends on the manner of attribution of harm to diagnostic delays, and therefore our estimates might imply a number of cases bearing mortality risk consequences that differs from certain available estimates of the number of deaths attributable to misdiagnosis (Ref. [34]).[^27]
With a correct diagnosis, death can be delayed to a later date than one following an incorrect diagnosis. However, depending on when a misdiagnosis occurs, death might still be delayed to a degree depending on how soon a patient seeks follow-up and receives a correct diagnosis at a later time. Life expectancy in this case would still be shortened compared to if the initial diagnosis had been correct, but this would not necessarily be counted as a death due to misdiagnosis.[^28] It is also possible that the differences in risk of death from a delayed diagnosis could be attributable to treatment differences such as fewer effective therapies for later-stage lung cancers contributing to the adverse impact of diagnostic delays (Ref. [33]).
Although we do not estimate the benefits from avoiding false positives, accurate testing for patients can help maximize the benefits of certain therapies that patients need to treat or manage their condition. False test results may result in some treatments being denied to eligible patients, which may worsen their health outcomes.
Expected Reduction in Cancer Misdiagnosis
To estimate the reduction in cancer mortality risk from the phaseout policy, we start from an estimate of annual deaths attributable to diagnostic error and apply four probabilities: the probability of a patient having been tested with an IVD; the probability that the IVD had been offered as an LDT; the probability that the IVD offered as an LDT was problematic; and, finally, the probability that the problematic IVD offered as an LDT resulted in preventable diagnostic error. With respect to this last probability, we note that an IVD that yields a false result in an individual case is not necessarily a problematic IVD (indeed, no test is perfect 100% of the time).
Newman-Toker et al. 2019 (Ref. [35]) state that about 5-10% of the 2.7 million deaths annually in the United States are attributable to diagnostic error—or between 0.135 million and 0.27 million fatalities across all misdiagnosed conditions. Based on the annual US incidence of serious misdiagnosis-related harms across vascular events, infections, and cancers per Newman-Toker et al. 2023 (Ref. [34]), we estimate that about 11% (= 1.5M / 13.7M) of misdiagnosis-related fatalities are associated with cancer.[^29] This results in a range of 0.015 million, 0.022 million and 0.03 million misdiagnosis-related deaths from cancer.
Excluding the state of New York proportionally by population,[^30] we assume that about 20,900 U.S. misdiagnosis-related cancer deaths occur outside of NY and could thus potentially involve tests not approved by NYS CLEP. It is likely that some patients outside of the state of New York are also tested with LDTs approved by NYS CLEP and hence would not necessarily benefit from the phaseout of enforcement discretion for premarket review requirements but will still benefit from the phaseout of enforcement discretion for other requirements, as would patients inside the state of New York. According to Rohr et al. (2016), 91% of U.S. oncology patients undergo IVD testing (Ref. [36]). Using test orders from a U.S. academic hospital system, Rychert et al. (2023) estimate that IVDs offered as LDTs are 3.9% of test order volume and 45% of distinct assays (Ref. [2]). In estimating the percent of patients tested with IVDs who are tested with IVDs offered as LDTs, we thus consider a range from 3.9% to 45%, with a primary estimate of 10%. Using the primary rate, we estimate that about 13,700 U.S. (non-NY) cancer patients would rely on IVDs offered as LDTs (= 150,554 x 0.91 x 0.10).
To estimate the number of these patients tested with IVDs offered as LDTs that would not be authorized by FDA following a premarket submission to the Agency (i.e., following the phaseout of the general enforcement discussion approach), we consult FDA’s 2020 assessment of EUA requests from laboratories for molecular diagnostic COVID tests and statistics from NYS CLEP on application outcomes and assume that similar rates of initial denial would apply under FDA oversight.
A public comment from NYSDOH informed us that, since September 30, 2021, among applications subject to technical review:
- 46% were approved based on the original application;
- another 33% were approved in a second round of review after the applicant provided additional information; and
- 20% could not be approved after the second round of review (though they might have been approved later) (Ref. [12]).
Regarding applications not initially approved, NYSDOH stated in its comment:
- “Tests that are not approved based on the original application have a range of issues. Analytical validity issues include design flaws, inadequate validation data, and process problems that call into question the reliability of the results. For example, the test may not be capable of detecting the target analytes. One application claimed to detect cytomegalovirus (CMV) in a transplant recipient population, but a primer/probe design flaw resulted in the detection of only two CMV subtypes. This error would have endangered patient safety and was only identified during NYS CLEP review. The laboratory redesigned the assay with input from NYS CLEP subject matter experts so that all four subtypes could be detected.” (Ref. [12])
We thus consider a range of scenarios reflecting different possible rates of problematic IVDs offered as LDTs. As a low estimate, we consider that 22% of EUA requests in FDA’s 2020 assessment of EUA requests from laboratories for molecular diagnostic COVID tests had significant design issues and indications for use issues. As a high estimate, we use the 54% of submissions that are not initially approved by New York State. We consider initial approval rates because information contained in New York State’s public comment suggests that “additional information” included in response to original review may include design changes, and thus tests not initially approved might, without review, have gone on to yield unreliable results. For our primary estimate, we average the above two, resulting in 38%.
In the central scenario with an expected initial rejection rate of 38%, about 720 misdiagnosis-related cancer deaths involve patients tested using IVDs offered as LDTs that will not be authorized by FDA following a premarket submission—at least without changes. We assume that some of the time when these IVDs are used, they yield inaccurate results that would not occur using an IVD that could be authorized by FDA. Of these instances of inaccurate results, some might be caught during follow-up or other parts of the process of diagnosis before leading to harm from diagnostic error.
Lacking systematic data on the exact issues with applications for IVDs offered as LDTs initially rejected by NYS CLEP and these LDTs’ roles in the process of diagnosis, we consider a range of rates at which avoidable error might result from usage of problematic IVDs offered as LDTs: from a low of 25% to a high of 75%, with a central estimate of 50%. However, some of these errors might not have consequences for patient care if a patient would in any case be unable or unwilling to obtain treatment. A patient diagnosed with cancer may go untreated for various reasons—including, in some cases, because no effective treatment exists. Ward et al. (2013) analyze data on nontreatment of cancer from the National Cancer Data Base and the Iowa Cancer Registry, which show that between roughly 8 and 12 percent of newly diagnosed cancer patients in Iowa did not receive a first course of treatment (Ref. [37]). Assuming that Iowa cancer patients are representative of the rest of the U.S., we thus estimate that diagnostic error has treatment implications for 88% to 92% of patients, with a central estimate of 90%. Thus, using our central estimates, we expect the phaseout policy to avoid about 325 harms from diagnostic error among cancer patients.
**Table 5. Avoidable Harms Related to Diagnostic Error Among Cancer Patients**
| | Primary | Low | High |
|---|---|---|---|
| a) Deaths from Misdiagnosis (Non-NYS) | 20,863 | 13,908 | 27,817 |
| b) Percent Tested with IVDs | 91% | 91% | 91% |
| c) Probability of IVD Being Offered as an LDT | 10.0% | 3.9% | 45.0% |
| d) Patients Tested with IVDs Offered as LDTs (= a * b * c) | 1,898 | 494 | 11,391 |
| e) Percent of IVDs offered as LDTs Not Authorized by FDA Following a Premarket Submission | 38% | 22% | 54% |
| f) Tests Using Problematic IVDs Offered as LDTs (= d * e) | 721 | 109 | 6,151 |
| g) Percent Leading to Diagnostic Error | 50% | 25% | 75% |
| h) Treatment-to-Diagnosis Ratio | 0.9 | 0.88 | 0.92 |
| i) Harms Avoidable by the Phaseout Policy (= f * g * h) | 325 | 24 | 4,244 |
||
Value of Reduced Mortality Risk
As a first step in valuing reduced mortality risk from the phaseout policy, we estimate the gain in life expectancy associated with a correct diagnosis for someone who has cancer.
First, we consult 2023 data on estimated new cancer cases along with the five-year relative survival rate covering 2012-2018 (Ref. [38]). The five-year relative survival rate (RSR) in column B of Table 6, represents the percentage of individuals surviving their cancer diagnosis 5 years after diagnosis compared to individuals who are cancer free.
estimate the absolute survival rate (of individuals with cancer who are diagnosed) further down below.
At the bottom of column D, we obtain the average five-year RSR across cancer sites, weighting by percent of total new cancer cases. For example, the weight on the RSR for breast cancer is the number of breast cancers divided by the sum of all new cancer cases (290,560 / 1,818,030 = 16%). The estimated five-year weighted average RSR for all new cancer cases is the sum of column D, 68.6%.
**Table 6. Calculating the Weighted Average Relative Survival Rate (RSR) for New Cancer Cases**
| Site | Estimated New Cases (2022) A | Relative Survival (%) (2012–2018) B | % New Cases C | RSR x Percent weight D (=B*C/100) |
|-----------------------------------|------------------------------|------------------------------------|---------------|----------------------------------|
| Breast | 290,560 | 90.5 | 16% | 14.46 |
| Prostate | 268,490 | 96.8 | 15% | 14.30 |
| Lung and Bronchus | 236,740 | 22.9 | 13% | 2.98 |
| Colon and Rectum | 151,030 | 65.1 | 8% | 5.41 |
| Melanoma of the Skin | 99,780 | 93.7 | 5% | 5.14 |
| Bladder | 81,180 | 77.1 | 4% | 3.44 |
| Non-Hodgkin Lymphoma | 80,470 | 73.8 | 4% | 3.27 |
| Kidney and Renal Pelvis | 79,000 | 76.5 | 4% | 3.32 |
| Uterus | 65,950 | 81.3 | 4% | 2.95 |
| Pancreas | 62,210 | 11.5 | 3% | 0.39 |
| Leukemia | 60,650 | 65.7 | 3% | 2.19 |
| Oral Cavity and Pharynx | 54,000 | 68 | 3% | 2.02 |
| Thyroid | 43,800 | 98.4 | 2% | 2.37 |
| Liver and Intrahepatic Bile Duct | 41,260 | 20.8 | 2% | 0.47 |
| Myeloma | 34,470 | 57.9 | 2% | 1.10 |
| Other | 168,440 | 60.35 | 9% | 4.78 |
| **Sum** | **1,818,030** | | **100%** | **68.60%** |
||
Note: Product across table may not be exact due to rounding.
Thus, on average, a person with cancer who is diagnosed has 68.6% of the chance of living another five years than a person who is cancer free. According to the National Cancer Institute, the median age of a cancer diagnosis is 66 years (Ref. [39]). Per CDC life tables, the 5-year survival rate for all age-66 individuals is approximately 91.13%.^33 To estimate the absolute 5-year survival of persons with cancer who receive a correct diagnosis from diagnostic testing, we multiply the RSR of 68.60% by 91.13%, thereby obtaining 62.52%. This estimate is likely lower than the true 5-year survival of persons with cancer who receive a correct diagnosis from diagnostic testing for the following reasons: 1) 91.13% does not in fact represent the 5-year survival rate of cancer-free individuals aged 66, but instead the 5-year survival rate of all age-66 individuals, including those with cancer, and 2) the SEER data attempts to represent all cases, which would thus include some that are missed upon initial diagnostic testing and only detected later. Based on the above, and the fact that the 5-year survival rate of 62.52% is more than half, or 50%, the median remaining life expectancy of someone with cancer who is correctly diagnosed by diagnostic testing is at least 5 years.
Next, based on survival of untreated individuals, we estimate the median remaining life expectancy of someone with cancer who is not diagnosed as such. The median survival time for untreated individuals is 2.3 years in cases of breast cancer (Ref. [40]) and 11.94 months, or 0.995 years, in cases of lung cancer (Ref. [41]). We average these two survival times, weighting by the numbers of new cases of breast and lung cancer, respectively, from Table 6 above, and thus obtain a survival time for untreated cancer patients of about 1.71 years. While we acknowledge that uncertainty is introduced by assuming that lung and breast cancers are representative of cancer in general, we received no comment indicating that this assumption is unsuitable.
We therefore estimate the gain in life expectancy from appropriate treatment upon diagnostic testing to be about 3.29 years (= 5 – 1.71). Thus, for an age-66 person with cancer who has just been tested, treating the cancer is worth about 3.29 more years of life starting about 1.71 years from the time of testing. Table 7 shows these life years discounted to the time of the diagnostic test at rates of three and seven percent.
**Table 7. Life Years Due to Treatment of Cancer**
| Time from treatment (years) | Treatment | Discounted to time of treatment (3%) | Discounted to time of treatment (7%) |
|-----------------------------|-----------|-------------------------------------|-------------------------------------|
| 1.714 | 1 | 0.951 | 0.890 |
| 2.714 | 1 | 0.923 | 0.832 |
| 3.714 | 1 | 0.896 | 0.778 |
| 4.714 | 0.286 | 0.249 | 0.208 |
| **Total** | **3.286** | **3.018** | **2.708** |
||
We note that untreated and undiagnosed cancers may not have the same average prognosis. A patient diagnosed with cancer may go untreated for various reasons—including, in some cases, because no effective treatment exists.
Finally, we value these mortality risk reductions (at the time of the diagnostic test) using estimates of the value per statistical life year (VSLY), which is the rate at which a consumer or patient substitutes money for reductions in mortality risk, measured by the willingness to pay for an increase in life expectancy by one year. We use VSLYs derived from the value of a statistical life (VSL) under assumptions of three and seven percent discounting, paired with estimates of the statistical life years gained per case.^34,35 VSLYs are those projected for 2024 but using 2022 base year dollars for consistency with the rest of this analysis. Table 8 below represents our estimates of the value (at the time of the diagnostic test), of the additional expected life years from an accurate diagnosis.
**Table 8. Estimated Value Per Case of Accurate Diagnosis (2022$)**
| | (a) VSLY (3% discounting) | (b) Value Per Case (VSLY 3%) (= a * 3.018) | (c) VSLY (7% discounting) | (d) Value Per Case (VSLY 7%) (c = c * 2.708) |
|-------|---------------------------|--------------------------------------------|---------------------------|--------------------------------------------|
| Primary | $546,735 | $1,650,181 | $915,435 | $2,479,329 |
| Low | $255,143 | $770,084 | $427,203 | $1,157,020 |
| High | $832,253 | $2,511,942 | $1,393,495 | $3,774,090 |
||
Note: Product across table may not be exact due to rounding.
To estimate total benefit in Table 9 below, we multiply the estimated reduction in harms by the benefit per avoided harm and by the portion of relevant risk not already internalized in decision-making by medical providers and patients. Because providers who frequently order tests might note quality trends across different labs, we assume that only 95% of the risk of problematic IVDs offered as LDTs is not already internalized at baseline, with a range from 90-100%. Total internalization is unlikely, because without deliberate study of records aided by statistical tools, internalization of the risks of different tests would depend on provider recall and coincident identification of an association from the noise of a provider’s experiences.
**Table 9. Widest Range of Recurring (Annual) Benefit from Reduced Mortality from Cancer-Related Diagnostic Error**
| | Primary | Low | High |
|-------------------------------------|-----------|----------|----------|
| a) Harms Avoidable by the Phaseout Policy | 325 | 24 | 4,244 |
| b) Value Per Harm (VSLY using 3% discounting) | $1,650,181 | $770,084 | $2,511,942 |
| c) Value Per Harm (VSLY using 7% discounting) | $2,479,329 | $1,157,020 | $3,774,090 |
| d) Percent Not Internalized at Baseline | 95% | 90% | 100% |
| e) Total Benefit (VSLY using 3% discounting) | $508,931,983 | $16,558,006 | $10,661,349,657 |
| f) Total Benefit (VSLY using 7% discounting) | $764,649,367 | $24,877,722 | $16,018,239,255 |
||
However, due to our high degree of uncertainty about several of the parameters used to estimate the reduction in mortality risk from misdiagnosis related to cancer, we use a Monte Carlo simulation to determine a plausible range for total benefits by allowing each parameter (the rows in Table 5, the values per case in Table 8, and the internalization percentage in Table 9) to vary independently of the others. Whereas Table 9 implicitly assumes that all uncertain parameters share a joint probability distribution and are perfectly dependent (i.e., aligning all best- and worst-case scenarios across parameters), Table 10 below assumes certain parameters to be independent random variables as follows:
- the yearly number of premature deaths from misdiagnosis related to cancer follows a PERT distribution with a minimum, mean, and maximum taken from row (a) of Table 5;
- the probability that an IVD is offered as an LDT follows a PERT distribution with a minimum, mode, and maximum taken from row (c) of Table 5;
- the percent of such tests that would not be authorized by FDA follows a uniform distribution defined by the low and high estimates of row (e) of Table 5;
- the percent of such tests leading to a preventable misdiagnosis follows a uniform distribution defined by the low and high estimates of row (g) of Table 5;
- the treatment-to-diagnosis ratio follows a uniform distribution defined by the low and high of row (h) of Table 5;
- the values per harm using VSLYs that assume three and seven percent discounting follow triangular distributions with minimums, means, and maximums taken from rows (b) and (c), respectively, of Table 9; and
- the percent of risk of problematic IVDs not already internalized at baseline follows a uniform distribution defined by the low and high estimates from row (d) of Table 9.
Per HHS guidance (Ref. [42]), the low, primary, and high benefit estimates in Table 10 represent the 5th, 50th, and 95th percentiles from running the above simulation 100,000 times.
**Table 10. Simulated Plausible Range of Recurring (Annual) Benefit from Reduced Mortality from Cancer-Related Diagnostic Error**
| | Primary | Low | High |
|-------------------------------------|-------------|-------------|------------|
| e) Total Benefit (VSLY using 3% discounting) | $616,052,630 | $191,389,437 | $1,800,143,089 |
| f) Total Benefit (VSLY using 7% discounting) | $926,834,309 | $286,994,300 | $2,704,265,559 |
||
Given the uncertainty in this analysis and the implausibility of all best- and worst-case scenarios perfectly aligning across the uncertain parameters, we use the results from Table 10 to inform our total benefits estimates in II.E.4 “Summary of Benefits” and in Table 1, the main summary of benefits, costs, and transfers. As we explain in II.E.4 “Summary of Benefits” below, estimates in Table 1 are further adjusted to account for the enforcement discretion policy and the timing of the phase-in.
b. Cardiovascular Disease
Cardiovascular disease is prevalent in the U.S. According to the American Heart Association, in 2020, 48.6% of U.S. adults aged 20 and older had some form of cardiovascular disease, including coronary heart disease, heart failure, stroke, and hypertension (Ref. [43]). Additionally, the CDC notes that “heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States” (Ref. [44]).
Table 11 below shows our estimated range for the number of harms from diagnostic error among patients with cardiovascular disease that we expect phasing out the general enforcement discretion approach for LDTs to avoid.
Using an estimate by Raisi-Estabragh et al. (2022) of about 20.6 million cardiovascular emergency department encounters in adults in the U.S. between 2016-2018 (Ref. [45]), we estimate about 6.9 million (= 20.6 million / 3) annual cardiovascular emergency department visits. It is likely that not all of these healthcare encounters involve initial diagnoses. However, IVDs are still used in visits concerning known conditions for monitoring of disease, prognosis, predicting treatment response, assessing the risk of developing a disease or disorder, and guiding patient management (Ref. [36]).
Excluding the state of New York proportionally by population, we assume that about 6.5 million such cases are outside of NY and could thus potentially be managed using tests not approved by NYS CLEP. It is likely that some patients outside of the state of New York are also tested with LDTs approved by NYS CLEP and hence will not necessarily benefit from FDA’s phaseout of enforcement discretion for premarket review requirements, but will still benefit from the phaseout of enforcement discretion for other requirements. According to Rohr et al. (2016), 62% of U.S. cardiology patients undergo IVD testing (Ref. [36]). Using test orders from a U.S. academic hospital system, Rychert et al. (2023) estimate that IVDs offered as LDTs are 3.9% of test order volume and 45% of distinct assays (Ref. [2]). In estimating the percent of patients tested with IVDs who are tested with IVDs offered as LDTs, we thus consider a range from 3.9% to 45%, with a primary estimate of 10%. Using the primary estimate, we estimate that about 0.4 million U.S. (non-NY) patients with cardiovascular disease would rely on IVDs offered as LDTs (= 6,461,000 x 0.62 x 0.10).
As described in the previous section on harms related to diagnostic error among cancer patients, we consider a range of estimates of the number of these patients tested using IVDs offered as LDTs that will not be initially authorized by FDA following a premarket submission. As explained above, based on statistics from NYS CLEP on approved and denied applications, we consider initial rejection rates of 22%, 38%, and 54%.
In the central scenario with an expected rejection rate of 38% percent, about 152,000 patients with cardiovascular disease are managed using IVDs offered as LDTs that will not be authorized by FDA following a premarket submission—at least without changes. We assume that some of the time when these tests are used, they yield inaccurate results that would not occur using a test that could be authorized by FDA. Of these instances of inaccurate results, some might be caught during follow-up or other parts of the process of diagnosis before leading to harm from diagnostic error.
Lacking systematic data on the quality of applications for IVDs offered as LDTs rejected by NYS CLEP and these tests’ roles in the process of diagnosis, we consider a range of rates at which avoidable errors might result from usage of problematic IVDs offered as LDTs: from a low of 25% to a high of 75%, with a central estimate of 50%. However, some of these errors might not have consequences for patient care if a patient would in any case be unable or unwilling to obtain treatment. Cardiovascular disease includes several different conditions, each of which might go untreated for various reasons. The American Heart Association reports treatment rates of high cholesterol (44.9%) and hypertension (52%), as well as the rate of diabetes patients with established atherosclerotic cardiovascular disease who are treated with a statin (58.6%) (Ref. [43]). Based on these, we estimate that diagnostic error has treatment implications for 44.9% to 58.6% of patients, with a central estimate of 52%. Thus, using our central estimates, we expect the phaseout policy to avoid about 39,600 harms among patients with cardiovascular disease.
**Table 11. Avoidable Harms Related to Diagnostic Error Among Cardiovascular Disease Patients**
| | Primary | Low | High |
|---|---|---|---|
| a) Annual US Cardiovascular Emergency Department Encounters (Non-NYS) | 6,461,262 | 6,461,262 | 6,461,262 |
| b) Percent Tested with IVDs | 62% | 62% | 62% |
| c) Probability of IVD Being Offered as an LDT | 10.0% | 3.9% | 45.0% |
| d) Patients Tested with IVDs Offered as LDTs (= a * b * c) | 400,598 | 156,233 | 1,802,692 |
| e) Percent of IVDs Offered as LDTs Not Authorized by FDA Following a Premarket Submission | 38% | 22% | 54% |
| f) Tests Using Problematic IVDs Offered as LDTs | 152,227 | 34,371 | 973,454 |
| g) Percent Leading to Diagnostic Error | 50% | 25% | 75% |
| h) Treatment-to-Diagnosis Ratio | 0.52 | 0.449 | 0.586 |
| i) Harms Avoidable by the Phaseout Policy (= f * g * h) | 39,579 | 3,858 | 427,833 |
||
Harms from diagnostic error are diverse and can vary widely in severity, from avoidable inconvenience and expense to unnecessary treatments, disability, and premature mortality. As one example, between 2008 and early 2011, one laboratory sold over 160,000 StatinCheck tests designed to determine an individual’s KIF6 genotype. This test was marketed as a way to determine a patient’s response to statin drugs, based on the idea that patients with the Trp719Arg polymorphism of the KIF6 protein would have a greater reduction in cardiovascular disease (CVD) events when on statin therapy than patients without this polymorphism. However, research showed no association between the polymorphism and statin response (Refs. [13] [14]).
Additionally, in April 2011, FDA denied premarket approval of this test, citing lack of sufficient evidence of the safety and effectiveness of the test based in particular on clinical validity concerns.
Approximately 35% of patients in studies on CVD have the Trp719Arg polymorphism (Refs. [13] [14]). If 35% of the StatinCheck test recipients were identified as having the Trp719Arg polymorphism, then 56,000 patients may have been informed that they would respond better to statin therapy than other patients. If these patients received lower-potency statin treatment than is standard, a loss of health likely occurred, though medical expenditures were likely reduced. According to Conly et al. (2011), the use of high-potency statins results in an increase of 0.13 QALYs relative to the use of low-potency statins (Ref. [46]). Since this consists almost entirely of mortality effects, we value the health gains from high-potency statins in terms of life years. Conly et al. report life expectancy averages of 21.0 years for patients taking low-potency statins and 21.4 years for patients taking high-potency statins. Discounting at three and seven percent, this represents a gain of about 0.22 and 0.10 discounted life years, respectively, at the time of initiation of statin use. However, the use of high-potency statins in Canada costs CAD $1,200 more than low-potency statins (Ref. [46]). Converting to USD at the current rate of CAD $1.36 to USD $1.00, this is about $882. Based on a report prepared for the Department of Health and Human Services comparing international prescription drug prices, prices across all prescription drugs in Canada are about 44% of U.S. prices (Ref. [47]). We thus divide again by 0.44, resulting in a cost difference between high and low potency statins of about $2,005. Using a Value of a Statistical Life Year (VSLY) of $546,735 (the central VSLY that assumes three percent discounting), the value of lost health from using low-potency statins instead of high-potency statins is $121,086 (= $546,735 x 0.2215). The net lost benefit for each person using low-potency statins is $119,080 (= $121,086 - $2,005), and the estimated total welfare losses are thus about $6.7 billion (= $119,080 x 56,000). Using a VSLY of $915,435 (the central VSLY that assumes seven percent discounting), the value of lost health from using low-potency statins instead of high-potency statins is $94,626 (= $915,435 x 0.1034). VSLYs are those projected for 2024 but using 2022 base year dollar values for consistency with the rest of this analysis. The net lost benefit for each person using low-potency statins is $92,621 (= $94,626 - $2,005), and the estimated total welfare losses over the period 2008-2011 are thus about $5.2 billion (= $92,621 x 56,000).
Thus, as a proxy for the value of an average harm from diagnostic error to a patient with a cardiovascular disease, we use $119,080 as our primary estimate given three percent discounting and $92,621 as our primary estimate given seven percent discounting. Further below, we also include estimates based on the low and high VSLY estimates.
To estimate total benefit in Table 12 below, we multiply the estimated reduction in harms by the benefit per avoided harm and by the portion of relevant risk not already internalized in decision-making by medical providers and patients. Because providers who frequently order tests might note quality trends across different labs, we assume that only 95% of the risk of problematic IVDs offered as LDTs is not already internalized at baseline, with a range from 90-100%. Total internalization is unlikely, because without deliberate study of records aided by statistical tools, internalization of the risks of different tests would depend on provider recall and coincident identification of an association from the noise of a provider’s experiences.
**Table 12. Widest Range of Recurring (Annual) Benefit from Avoiding Harms from Diagnostic Error Related to Cardiovascular Disease**
| | Primary | Low | High |
|-----------------------------|------------|---------|-------------|
| a) Harms Avoidable by the Phaseout Policy | 39,579 | 3,858 | 427,833 |
| b) Value Per Harm (VQALY using 3% discounting) | $119,080 | $54,501 | $182,314 |
| c) Value Per Harm (VQALY using 7% discounting) | $92,621 | $42,154 | $142,037 |
| d) Percent Not Internalized at Baseline | 95% | 90% | 100% |
| e) Total Benefit (VQALY using 3% discounting) | $4,477,436,064 | $189,248,233 | $77,999,873,099 |
| f) Total Benefit (VQALY using 7% discounting) | $3,482,562,142 | $146,372,612 | $60,768,070,609 |
||
Due to our high degree of uncertainty about several of the parameters used to estimate the reduction in morbidity risk from diagnostic error related to cardiovascular disease, we use a Monte Carlo simulation to determine a plausible range for total benefits by allowing each parameter (the rows in Table 11 and the values per case and internalization percentage in Table 12) to vary independently of the others. Whereas Table 12 implicitly assumes that all uncertain parameters share a joint probability distribution and are perfectly dependent (i.e., aligning all best- and worst-case scenarios across parameters), Table 13 below assumes certain parameters to be independent random variables as follows:
- the percent of patients tested with IVDs who are tested with IVDs offered as LDTs follows a PERT distribution with a minimum, mode, and maximum taken from row (c) of Table 11;
- the percent of such tests that would not be authorized by FDA follows a uniform distribution defined by the low and high estimates of row (e) of Table 11;
- the percent of such tests leading to a preventable misdiagnosis follows a uniform distribution defined by the low and high estimates of row (g) of Table 11;
- the treatment-to-diagnosis ratio follows a PERT distribution with a minimum, mode, and maximum taken from row (h) of Table 11;
- the values per harm using VSLYs that assume three and seven percent discounting follow triangular distributions with minimums, means, and maximums taken from the low, primary, and high estimates in rows (b) and (c), respectively, of Table 12; and
- the percent of risk of problematic IVDs not already internalized at baseline follows a uniform distribution defined by the low and high estimates from row (d) of Table 12.
Per HHS guidance (Ref. [42]), the low, primary, and high benefit estimates in Table 13 represent the 5th, 50th, and 95th percentiles from running the above simulation 100,000 times.
**Table 13. Simulated Plausible Range of Recurring (Annual) Benefit from Avoiding Harms from Diagnostic Error Related to Cardiovascular Disease**
| | Primary | Low | High |
|---------------------------------------|---------------|---------------|----------------|
| e) Total Benefit (VQALY using 3% discounting) | $5,430,362,350 | $1,716,966,298 | $15,579,610,547 |
| f) Total Benefit (VQALY using 7% discounting) | $4,233,288,851 | $1,327,584,767 | $12,131,010,945 |
||
Given the uncertainty in this analysis and the implausibility of all best- and worst-case scenarios perfectly aligning across the uncertain parameters, we use the results from Table 13 to inform our total benefits estimates in II.E.4 “Summary of Benefits” and in Table 1, the main summary of benefits, costs, and transfers. As we explain in II.E.4 “Summary of Benefits” below, estimates in Table 1 are further adjusted to account for the enforcement discretion policy and the timing of the phase-in.
c. Morbidity Due to Infections
Table 14 below shows our estimated range for the number of harms from diagnostic errors related to infections that we expect the phaseout policy to avoid. There are many kinds of infectious diseases. Because we cannot comprehensively analyze expected consequences of the phaseout policy with respect to all possible infectious diseases, we base our estimate of the number of relevant cases on the CDC’s statistics on selected national notifiable infectious diseases (Ref. [48]). For the year 2019, CDC reports 2,738,992 cases of those selected infectious diseases, over 93% of which are sexually transmitted infections.
We believe this to be about half or more of all serious infectious diseases in the U.S., but we use this figure for lack of a comprehensive accounting of all other possible infectious diseases. Excluding the state of New York proportionally by population, we assume that about 2,577,300 such cases occur outside of NY and could thus potentially involve tests not approved by NYS CLEP. It is likely that some patients outside of the state of New York are also tested with LDTs approved by NYS CLEP and hence would not necessarily benefit from the phaseout of enforcement discretion for premarket review requirements, but will still benefit from the phaseout of enforcement discretion for other requirements.
According to Rohr et al. (2016), 64% of U.S. oncology and cardiology clinical decisions involve IVD testing (Ref. [36]), and due to lack of more directly relevant data, the oncology and cardiology estimate is extrapolated to the infectious disease context. Using test orders from a U.S. academic hospital system, Rychert et al. (2023) estimate that IVDs offered as LDTs are 3.9% of test order volume and 45% of distinct assays (Ref. [2]). In estimating the percent of patients tested with IVDs who are tested with IVDs offered as LDTs, we thus consider a range from 3.9% to 45%, with a primary estimate of 10%. Using the primary rate, we estimate that about 164,900 U.S. (non-NY) patients with infectious disease would rely on IVDs offered as LDTs (= 2,577,283 x 0.64 x 0.10).
As described in the earlier section on harms from diagnostic error related to cancers, we consider a range of estimates of the number of these patients tested using IVDs offered as LDTs that will not be initially authorized by FDA following a premarket submission. As explained above in the section on cancers, based on statistics from NYS CLEP on approved and denied applications, we consider rejection rates of 22%, 38%, and 54%.
In the central scenario with an expected rejection rate of 38% percent, about 62,700 patients with infections are tested using IVDs offered as LDTs that will not be authorized by FDA following a premarket submission—at least without changes. We assume that some of the time when these tests are used, they yield inaccurate results that would not occur using a test that could be authorized by FDA. Of these instances of inaccurate results, some might be caught during follow-up or other parts of the process of diagnosis before leading to harm.
Lacking systematic data on the exact issues with applications for IVDs offered as LDTs initially rejected by NYS CLEP and these tests’ roles in the process of diagnosis, we consider a range of rates at which avoidable error might result from usage of problematic IVDs offered as LDTs: from a low of 25% to a high of 75%, with a central estimate of 50%. However, some of these errors might not have consequences for patient care if a patient would in any case be unable or unwilling to obtain treatment. There are many kinds of infections, each of which might go untreated for various reasons.
Based on treatment rates from Li et al. (2023) for chlamydia and gonorrhea among symptomatic and asymptomatic men and women in the US (Ref. [49]), and assuming equal numbers of men and women patients, overall treatment rates are about 36.42% for gonorrhea and 42.18% for chlamydia. Averaging between these two rates while weighting by their respective shares of notifiable disease cases (about three cases of chlamydia to one case of gonorrhea), we estimate that diagnostic error has treatment implications for 40.7% of infectious disease patients, with a range from 30-50%. Thus, using our central estimates, we expect the phaseout policy to avoid about 12,800 harms among patients with infections.
**Table 14. Avoidable Harms from Diagnostic Error Related to Infections**
| | Primary | Low | High |
|--------------------------------------|-----------|---------|----------|
| a) Yearly U.S. Infections (Non-NYS) | 2,577,283 | 2,577,283 | 2,577,283 |
| b) Percent Tested with IVDs | 64% | 64% | 64% |
| c) Probability of IVD Being Offered as an LDT | 10.0% | 3.9% | 45.0% |
| d) Patients Tested with IVDs Offered as LDTs (= a * b * c) | 164,946 | 64,329 | 742,258 |
| e) Percent of IVDs Offered as LDTs Not Authorized by FDA Following a Premarket Submission | 38% | 22% | 54% |
| f) Tests Using Problematic IVDs Offered as LDTs (= d * e) | 62,680 | 14,152 | 400,819 |
| g) Percent Leading to Diagnostic Error | 50% | 25% | 75% |
| h) Treatment-to-Diagnosis Ratio | 0.41 | 0.30 | 0.50 |
| i) Harms Avoidable by the Phaseout Policy (= f * g * h) | 12,761 | 1,061 | 150,307 |
||
Harms from diagnostic error are diverse and can vary widely in severity, from avoidable inconvenience and expense to unnecessary treatments, disability, and premature mortality. As over 93% of CDC notifiable infectious disease cases are sexually transmitted diseases, we use average QALY loss from chlamydia and gonorrhea as a proxy for the value of an average harm from diagnostic error to a patient with an infectious disease. Based on discounted lifetime QALY loss estimates from Li et al. (2023) for chlamydia and gonorrhea among men and women in the US (Ref. [49]), and assuming equal numbers of men and women patients, average QALY losses are about 0.008 from gonorrhea and 0.024 from chlamydia. However, part of this health loss occurs during the acute infection, prior to diagnosis. Considering only the portions of health loss attributable to sequelae based on Figure 6 (Ref. [49]), these losses are about 0.007 from gonorrhea and 0.022 from chlamydia.39
Averaging between these two diseases while weighting by their respective shares of notifiable disease cases (about three cases of chlamydia to one case of gonorrhea), we estimate that the average case entails a discounted lifetime QALY loss of about 0.0185. Health loss estimates by Li et al. consider lifetime sequelae and complications from lack of treatment such as pelvic inflammatory disease, but both gonorrhea and chlamydia are curable within a few days with antibiotics.40 According to Malek et al. (2013), “delay in seeking care for STDs can [...] increase the likelihood of consequences such as infertility and chronic pelvic pain” (Ref. [50]).
Using a VQALY of $649,215 (the central VQALY that assumes three percent discounting), we thus assume that the value of lost health from an average infectious disease case without timely identification and treatment is about $12,000 (= $649,215 x 0.0185). Using a VQALY of $1,070,162 (the central VQALY that assumes seven percent discounting), the value of lost health is about $19,800. VQALYs are those projected for 2024 but using 2022 base year dollar values for consistency with the rest of this analysis.
Diagnostic error for infectious disease tests may lead to uncontrolled spread of communicable infectious diseases from contact with patients relying on false results from problematic IVDs. Our estimates do not account for harms from these downstream infections.
To estimate total benefit in Table 15 below, we multiply the estimated reduction in harms from diagnostic error by the benefit per avoided harm and by the portion of relevant risk not already internalized in decision-making by medical providers and patients. Because providers who frequently order tests might note quality trends across different labs, we assume that only 95% of the risk of problematic IVDs offered as LDTs is not already internalized at baseline, with a range from 90-100%. Total internalization is unlikely, because without deliberate study of records aided by statistical tools, internalization of the risks of different tests would depend on provider recall and coincident identification of an association from the noise of a provider’s experiences.
**Table 15. Widest Range of Recurring (Annual) Benefit from Avoiding Harms from Diagnostic Error Related to Infections**
| | Primary | Low | High |
|-----------------------------------|----------|---------|------------|
| a) Harms Avoidable by the Phaseout Policy | 12,761 | 1,061 | 150,307 |
| b) Value Per Harm (VQALY using 3% discounting) | $11,995 | $5,598 | $18,259 |
| c) Value Per Harm (VQALY using 7% discounting) | $19,772 | $9,227 | $30,098 |
| d) Percent Not Internalized at Baseline | 95% | 90% | 100% |
| e) Total Benefit (VQALY using 3% discounting) | $145,414,428 | $5,347,319 | $2,744,440,950 |
| f) Total Benefit (VQALY using 7% discounting) | $239,700,470 | $8,814,497 | $4,523,923,748 |
||
Due to our high degree of uncertainty about several of the parameters used to estimate the reduction in morbidity risk from diagnostic error related to infectious diseases, we use a Monte Carlo simulation to determine a plausible range for total benefits by allowing each parameter (the rows in Table 14 and the values per case and internalization percentage in Table 15) to vary independently of the others. Whereas Table 15 implicitly assumes that all uncertain parameters share a joint probability distribution and are perfectly dependent (i.e., aligning all best- and worst-case scenarios across parameters), Table 16 below assumes certain parameters to be independent random variables as follows:
- the percent of patients tested with IVDs who are tested with IVDs offered as LDTs follows a PERT distribution with a minimum, mode, and maximum taken from row (c) of Table 14;
- the percent of such tests that would not be authorized by FDA follows a uniform distribution defined by the low and high estimates of row (e) of Table 14;
- the percent of such tests leading to a preventable misdiagnosis follows a uniform distribution defined by the low and high estimates of row (g) of Table 14;
- the treatment-to-diagnosis ratio follows a PERT distribution with a minimum, mode, and maximum taken from row (h) of Table 14;
- the values per harm using VQALYs that assume three and seven percent discounting follow triangular distributions with minimums, means, and maximums taken from the low, primary, and high estimates in rows (b) and (c), respectively, of Table 15; and
- the percent of risk of problematic IVDs not already internalized at baseline follows a uniform distribution defined by the low and high estimates from row (d) of Table 15.
Per HHS guidance (Ref. [42]), the low, primary, and high benefit estimates in Table 16 represent the 5th, 50th, and 95th percentiles from running the above simulation 100,000 times.
**Table 16. Simulated Plausible Range of Recurring (Annual) Benefit from Avoiding Harms from Diagnostic Error Related to Infections**
| | Primary | Low | High |
|---|----------------|-------------|--------------|
| e) Total Benefit (VQALY using 3% discounting) | $189,393,046 | $54,670,583 | $577,904,403 |
| f) Total Benefit (VQALY using 7% discounting) | $311,957,235 | $90,634,571 | $953,299,062 |
||
Given the uncertainty in this analysis and the implausibility of all best- and worst-case scenarios perfectly aligning across the uncertain parameters, we use the results from Table 16 to inform our total benefits estimates in II.E.4 “Summary of Benefits” and in Table 1, the main summary of benefits, costs, and transfers. As we explain in II.E.4 “Summary of Benefits” below, estimates in Table 1 are further adjusted to account for the enforcement discretion policy and the timing of the phase-in.
###### 2. Non-Health Benefits
a. Spending on Inappropriate Use of Non-invasive Prenatal Screening (NIPS)
Non-invasive prenatal screening (NIPS) tests can provide information about the possibility of a fetus having certain genetic abnormalities that could result in a child being born with a serious health condition. Negative results can help pregnant individuals avoid the risks to fetal health of undergoing more invasive tests. However, as screening tests, positive results only indicate risk of a condition and require follow-up with diagnostic tests to confirm or rule out the suspected condition—in turn requiring discussion between patients and healthcare providers. NIPS test results should not be used by themselves to make critical healthcare decisions and should be discussed with a healthcare provider.
Given the increased use and marketing of these tests and recent media reports, FDA has warned the public of the risk of false results, inappropriate use, and inappropriate interpretation of NIPS test results, which might be addressed by phasing out the general enforcement discretion approach for LDTs. FDA is particularly concerned about reports of patients and health care providers that have made critical health care decisions based on results from these screening tests alone and without additional confirmatory testing, possibly related to misleading marketing.
Screening tests for extremely rare conditions caused by genetic microdeletions have generated significant revenue: “adding microdeletions can double what an insurer pays — from an average of $695 for the basic tests to $1,349 for the expanded panel, according to the health data company Concert Genetics” (Ref [15]). However, the five most common microdeletion tests screen for conditions that affect only one in 5,000-20,000 births. According to the NY Times, patients or their providers might lack the requisite understanding of NIPS to make informed purchase decisions: “doctors already order many tests during short prenatal care visits, meaning some probably thought little of tacking on a few more.” Additionally, the NY Times reveals evidence that patients or their providers might not understand that positive results from NIPS for rare conditions can be wrong up to 81 to 93 percent of the time (Ref. [15]). Misunderstanding by patients or their providers might result in avoidable distress and premature medical decisions or false reassurance. We consider that increased regulatory oversight might reduce spending on NIPS IVDs offered as LDTs to screen for a particular condition that have potentially unreliable, inaccurate, or misinterpreted results and require confirmatory diagnostic testing. Increased oversight of NIPS tests, including regarding labeling requirements, can help ensure such tests are appropriately labeled with transparent information regarding performance, clear instructions, and appropriate limitations.
A potentially unreliable, inaccurate, or misinterpreted test result imposes, at minimum, the monetary cost of the test to the patient or health care system payor and the burden of any resulting health consequences. We do not attempt to quantify any expected reduction in spending on these tests, but we note that the number of screening tests for microdeletions sold in 2020 was above 400,000, and patients or payors paid approximately an additional $654 for each expanded test.
b. Reduction in Expenses from Lawsuits.
Compliance with applicable legal requirements for IVDs offered as LDTs might also reduce the incidence of litigation related to problematic IVDs apart from that which stems directly from diagnostic error. We cannot quantify the welfare losses due to tort expenses that might be avoided by phasing out the general enforcement discretion approach for LDTs and do not include the avoidance of any such expenses in our estimate of benefits. However, we provide one case study concerning a COVID-19 test offered without emergency use authorization from FDA as an illustrative example.
On March 1st, 2022, Blue Cross and Blue Shield of Minnesota (Blue Cross or BCBSM) filed a lawsuit against COVID-19 testing laboratory GS Labs, LLC (GS Labs) to recover more than $10 million in overpayments made since the start of the pandemic (Ref. [51]). Blue Cross alleged violations of Minnesota consumer protection law, fraud, and ERISA violations. Among other issues, confusion between quality control processes specified by the test system manufacturer and the lab led GS Labs to issue a correspondence to patients about PCR tests that “inadvertently deviated from applicable laboratory standards for testing facilities” (Ref [52]). The case is currently ongoing (Refs. [51] and [53]).
In a 2022 report from the U.S. Chamber of Commerce Institute for Legal Reform (ILR), high costs in the tort system led to higher prices for other things in the economy. Compensation to claimants (when they win a case) only represents 53 percent of the total size of the tort system, while the remaining litigation and risk transfer costs make up about 47 percent of expenses in the system. In other words, for every $1.00 received by claimants, $0.88 was paid in legal and other costs ($1 / $1.88 =53%) (Ref. [54]). We assume that those total litigation and risk transfer costs are recaptured as savings when problems are prevented by compliance with applicable requirements instead of corrected via litigation. In a $10 million dollar case, for example, litigation and risk transfer costs would be 47 percent of $10 million dollars or $4.7 million.
###### 3. Summary of Benefits
Quantified health benefits include the avoidance of harms from diagnostic errors related to mortality (cancer and cardiovascular disease) and infections-related morbidity. Unquantified benefits include, among others, costs savings from avoiding payment for problematic IVDs, namely NIPS tests, and possible reduction in costs from lawsuits and reduction in costs to healthcare systems. We also note that we do not count individuals who may have contracted communicable infectious diseases from contact with patients relying on false results from problematic IVDs. We are not able to quantify the extent to which the phaseout policy might prevent the spread of communicable infectious diseases. Additionally, the phaseout policy might remove a disincentive for non-laboratory manufacturers, who do not have the benefit of enforcement discretion, to develop novel tests. These manufacturers may otherwise be discouraged from investing in novel tests due to the prospect of laboratory competitors offering IVDs as LDTs that claim to fulfill, equally effectively, the same needs without having to invest in meeting FDA requirements. This benefit would be distinct from avoiding patient harms by improving reliability in existing testing applications, since novel tests might offer new capabilities. We present total benefits and subtotal health and non-health benefits in Table 17.
**Table 17. Total Undiscounted Benefits (Millions 2022$)**
| Type | Level | Primary | Low | High |
|--------------|-------------|---------|------|--------|
| **Health Benefits (VSLY 3%)** | | | | |
| Cancer | Generalized | $616 | $191 | $1,800 |
| Cardiovascular | Generalized | $5,430 | $1,717 | $15,580 |
| Infections | Generalized | $176 | $55 | $502 |
| **Health Benefits (VSLY 7%)** | | | | |
| Cancer | Generalized | $927 | $287 | $2,704 |
| Cardiovascular | Generalized | $4,233 | $1,328 | $12,131 |
| Infections | Generalized | $291 | $91 | $830 |
| **Total Sum of Benefits (VSLY 3%)** | | $6,223 | $1,963 | $17,881 |
| **Total Sum of Benefits (VSLY 7%)** | | $5,451 | $1,705 | $15,666 |
||
We expect benefits to begin to accrue two years after publication of the final phaseout policy, though we do not expect all estimated benefits to take place all at once. Instead, we assume that one-time benefits will occur evenly over Stages 1 to 5 of the final phaseout policy (year 3 to year 5). We also expect recurring benefits to begin to accrue at an incremental rate of 0%, 50%, 75%, and 100% for the first four years (Table 18).
**Table 18. Undiscounted Potential Benefits Over Time (Primary Estimate in Millions 2022$, 20 years, 3% and 7%)**
| Stage | Rate | Year | If VSLY based on 3% discounting | If VSLY based on 7% discounting |
|-------|------------|------|---------------------------------|---------------------------------|
| | One-time | Recurring | Total | One-time | Recurring | Total |
| 1 | 0 | 0 | $0 | $0 | $0 | $0 | $0 |
| 2 | 1/3 | 1/2 | 3 | $3,111 | $3,111 | $0 | $2,725 | $2,725 |
| 3 & 4 | 1/3 | 3/4 | 4 | $0 | $3,151 | $3,151 | $0 | $2,760 | $2,760 |
| 4 & 5 | 1/3 | 1 | 5 | $0 | $4,420 | $4,420 | $0 | $3,871 | $3,871 |
| 0 | 1 | 6 | $0 | $4,613 | $4,613 | $0 | $4,041 | $4,041 |
| : | : | : | : | : | : | : | : |
| 0 | 1 | 20 | $0 | $5,899 | $5,899 | $0 | $5,167 | $5,167 |
| **Sum** | | | $0 | $91,718| $91,718| $0 | $80,339| $80,339|
||
However, as a result of exercising enforcement discretion with respect to premarket review and QS requirements, with the exception of requirements under 21 CFR 820, subpart M (Records), for currently-marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of the final rule, IVDs offered as LDTs will generally undergo review and comply with most QS requirements only in certain circumstances. However, FDA expects such IVDs offered as LDTs to be in compliance with other applicable requirements under the FD&C Act and FDA regulations, including post-market requirements, as discussed in the phaseout policy. We note that as described in section V.B.3 of the preamble, FDA intends to take targeted steps to address currently marketed IVDs offered as LDTs that are problematic. In particular, we intend to use available tools to identify and act against currently marketed IVDs offered as LDTs that specifically raise concerns, such as IVDs that are potentially inaccurate or poorly validated.
In order to account for this, we adjust estimated total benefits in each year—beginning with enforcement of QS and premarket review requirements—based on the proportions of IVDs falling within an enforcement discretion policy versus those that are not. IVDs falling within an enforcement discretion policy will not generally be expected to comply with premarket review and QS requirements (but will be expected to comply with all other applicable requirements as discussed in the phaseout policy). We thus assume that among patients using these IVDs, only half of the estimated potential benefits will be realized. The low and high benefits estimates reflect alternative assumptions that only 25% and 75% of benefits, respectively, will be realized among patients using IVDs falling within an enforcement discretion policy. In each year beginning with enforcement of QS and premarket review requirements in stage 3 and 4, we apply the following adjustment factor to estimated benefits:
*adjustment = prop. of IVDs NOT falling within ED policy + 0.5*
*prop. of IVDs falling within an ED policy*
In Table 19, the resulting adjusted annualized benefit estimates using three and seven percent discounting are approximately $4.3 billion and $3.5 billion, respectively.
**Table 19. Expected Benefits Over Time Accounting for Exercising Enforcement Discretion (Primary Estimate in Millions 2022$, 20 years)**
| Stage | Year | Proportions of IVDs by enforcement | c) Effect of ED | d) Adj. factor (= b + c*a) | Benefits (3% VSLY) | Benefits (7% VSLY) |
|-------|------|-----------------------------------|----------------|--------------------------|-------------------|-------------------|
| | | a) With ED | b) Without ED | policy (premarket review and most QS requirements) on benefits | e) Without ED | f) With ED (=d*e) |
| 1 | 1 | 0.918 | 0.082 | 0.5 | 0.541 | $- | $- |
| 2 | 2 | 0.818 | 0.182 | 0.5 | 0.591 | $- | $- |
| | 3 | 0.729 | 0.271 | 0.5 | 0.636 | $3,111 | $2,725 |
| 3 & 4 | 4 | 0.650 | 0.350 | 0.5 | 0.675 | $4,667 | $3,151 |
| 4 & 5 | 5 | 0.580 | 0.420 | 0.5 | 0.710 | $6,223 | $4,420 |
| 6 | 6 | 0.517 | 0.483 | 0.5 | 0.741 | $6,223 | $4,613 |
| 7 | 7 | 0.462 | 0.538 | 0.5 | 0.769 | $6,223 | $4,786 |
| 8 | 8 | 0.413 | 0.587 | 0.5 | 0.794 | $6,223 | $4,939 |
| 9 | 9 | 0.369 | 0.631 | 0.5 | 0.816 | $6,223 | $5,075 |
| 10 | 10 | 0.330 | 0.670 | 0.5 | 0.835 | $6,223 | $5,197 |
| 11 | 11 | 0.295 | 0.705 | 0.5 | 0.853 | $6,223 | $5,305 |
| 12 | 12 | 0.264 | 0.736 | 0.5 | 0.868 | $6,223 | $5,403 |
| 13 | 13 | 0.236 | 0.764 | 0.5 | 0.882 | $6,223 | $5,490 |
| 14 | 14 | 0.211 | 0.789 | 0.5 | 0.895 | $6,223 | $5,568 |
| 15 | 15 | 0.188 | 0.812 | 0.5 | 0.906 | $6,223 | $5,638 |
| 16 | 16 | 0.168 | 0.832 | 0.5 | 0.916 | $6,223 | $5,701 |
| 17 | 17 | 0.149 | 0.851 | 0.5 | 0.925 | $6,223 | $5,758 |
| 18 | 18 | 0.133 | 0.867 | 0.5 | 0.934 | $6,223 | $5,810 |
| 19 | 19 | 0.118 | 0.882 | 0.5 | 0.941 | $6,223 | $5,856 |
| 20 | 20 | 0.104 | 0.896 | 0.5 | 0.948 | $6,223 | $5,899 |
| Sum | | | | | $107,344 | $91,718 | $94,026 | $80,339 |
| Present Value (Discount Rate matches VSLY) | | | | | $64,584 | $37,177 |
| Annualized Value (Discount Rate matches VSLY) | | | | | $4,341 | $3,509 |
||
##### F. Costs
FDA is phasing out the general enforcement discretion approach for LDTs so that IVDs manufactured by a laboratory will generally fall under the same enforcement approach as other IVDs and be expected to meet applicable requirements. This phaseout is intended to help assure the safety and effectiveness of IVDs offered as LDTs, while also accounting for other important public health considerations such as patient access and reliance.
FDA intends that the phaseout of enforcement discretion will occur over a four-year period in five key stages as described in section V.C of the preamble. For a few categories of IVDs manufactured by laboratories, FDA is adopting enforcement discretion policies with respect to some or all applicable requirements as described in sections V.B and C of the preamble.
When calculating the costs associated with each stage of the phaseout policy described in the preamble, we use wage information from the Bureau of Labor Statistics Occupational Employment and Wage Statistics. Specifically, we use wage information for a specific industry: medical and diagnostic laboratories.
The remainder of this section discusses the estimated cost of the phaseout policy by stage of the phaseout policy. Section II.F.6 discusses additional cost considerations that we do not quantify.
###### 1. Costs Under Stage 1
Beginning 1 year after the publication date of this final rule, FDA will expect laboratories to comply with MDR requirements (requirements for adverse event reporting) under 21 U.S.C. 360i(a)-(c) and 21 CFR part 803, correction and removal reporting requirements under 21 U.S.C. 360i(g) and 21 CFR part 806, and QS requirements under § 820.198 (complaint files). During the first year following issuance of the final rule, laboratories will face costs associated with compliance with Stage 1, as well as costs associated with reading and understanding the rule in its entirety.
a. Reading and Understanding the Rule
We expect that laboratories affected by the phaseout policy will incur costs to read and understand the rule. We assume an average of one medical laboratory manager and one attorney at each entity will read the rule. Consistent with guidelines from the Department of Health and Human Services, we assume that the reading speed of reviewers ranges from 200 to 250 words per minute. The final rule has approximately 150,000 words. The overall burden in hours (per reader) to read the rule ranges from 10.00 hours (= (150,000 words / 250 words per minute) / 60 mins per hour) to 12.50 hours (= (150,000 words / 200 words per minute) / 60 mins per hour). The mean hourly wages for managers and lawyers in this industry are $57.60 and $80.30, respectively. Fully loaded wage rates are $115.20 an hour for managers and $160.60 an hour for lawyers (average: $137.90). We assume that one to three employees will read the rule. The estimated learning costs per entity would range from $1,379.00 (=10.00 hours x $137.90 per hour x 1 employee) to $5,171.25 (=12.50 hours x $137.90 per hour x 3 employees), with a primary cost of $3,064.44 (=11.11 hours x $137.90 per hour x 2 employees). Multiplying this estimate by the total numbers of affected laboratories per year yields a total one-time cost for reading the rule between $0.81 million and $12.21 million, with a primary estimate of $3.62 million. The estimated total recurring cost ranges from $0.07 million to $0.98 million, with a primary estimate of $0.29 million (see Table 20).
**Table 20. Costs of Reading and Understanding the Rule**
| | Primary | Low | High |
|--------------------------------|---------|---------|---------|
| Average reading speed (words/minute) | 225 | 250 | 200 |
| Length of preamble & codified (words) | 150,000 | 150,000 | 150,000 |
| Hours | 11.11 | 10.00 | 12.50 |
| Number of employees to read rule | 2 | 1 | 3 |
| Labor cost of hourly employee | $137.90 | $137.90 | $137.90 |
| Per-laboratory cost | $3,064.44 | $1,379.00 | $5,171.25 |
| Number of affected laboratories | 1,181 | 590 | 2,362 |
| Number of new laboratories per year | 94 | 47 | 189 |
| **Total One-time Costs (millions)** | **$3.62** | **$0.81** | **$12.21** |
| **Total Recurring Costs (millions)** | **$0.29** | **$0.07** | **$0.98** |
||
*Note: Product across table may not be exact due to rounding.*
b. Medical Device Reporting
Under Stage 1, FDA expects laboratories to comply with MDR requirements under 21 U.S.C. 360i(a)-(c) and 21 CFR part 803. In estimating the costs of compliance for laboratories, we use a similar approach to the *Medical Device Reporting: Electronic Submission Requirements* final regulatory impact analysis (Ref. [55]). We expect that laboratories will face one-time costs associated with establishing a reporting system for laboratories for which, at baseline, the requirement to have such systems generally has not been enforced. We also expect new laboratories to enter the market each year, so we assume that the new entities will incur recurring costs associated with establishing a reporting system.
We expect laboratories to establish standard operating procedures (SOPs) in response to the MDR requirements. We estimate it will take 1 – 3 management employees with an hourly wage of $61.36 ($122.72 fully-loaded) 8 – 12 hours each to establish a laboratory’s SOP and train the appropriate people on the new procedures. Multiplying these estimates, we estimate the one-time costs of modifying SOPs to be between $0.58 million and $10.43 million, with a primary estimate of $2.90 million. We estimate the recurring costs to range from $0.05 million to $0.83 million, with a primary estimate of $0.23 million. See Table 21.
We expect laboratories to install and validate e-Submitter software for the purposes of complying with MDR requirements. We expect this task to take a single computer and information system manager 48 to 56 hours, working at an hourly wage of $79.72 ($159.44 fully loaded). Multiplying by the number of affected entities, we estimate the one-time costs of installing and validating e-Submitter software to be between $4.52 million and $21.09 million, with a primary estimate of $9.79 million. We estimate the recurring costs to be between $0.36 million to $1.69 million, with a primary estimate of $0.78 million.
We expect 0.6% of covered laboratories to establish Health Level Seven (HL7) Individual Case Study Report (ICSR) capability (Ref. [55]). We expect this task to take a single computer and information system manager 48 to 52 hours, working at an hourly wage of $79.72 ($159.44 fully loaded). Multiplying by the small fraction of laboratories that we expect to establish such capabilities, we estimate the one-time costs to range between $0.03 million to $0.12 million, with a primary estimate of $0.06 million. We estimate the recurring costs to be between $0.002 million to $0.01 million, with a primary estimate of $0.005 million.
We expect laboratories to acquire an e-certificate from a third-party system to commence medical device reporting. We estimate that there is a small one-time search cost of acquiring the e-certificate of $20. Multiplied by the number of affected entities, we estimate the one-time costs of acquiring an e-certificate to range from $0.01 million to $0.05 million,
We estimate the recurring costs to range from $0.001 million to $0.004 million, with a primary estimate of $0.002 million.
We also expect a small recurring cost associated with the payment of an annual fee to maintain e-certification in the reporting system. We anticipate an annual $10 search cost that applies to each affected laboratory. Multiplying by the number of total laboratories, we estimate this recurring cost to range from $0.01 million to $0.02 million, with a primary estimate of $0.01 million.
Finally, we expect a recurring cost associated with filing and submitting MDRs. We estimate it will take computer and information system managers 430 hours, working with an hourly wage of $79.72 ($159.44 fully loaded). Multiplying by the number of affected entities, we estimate this recurring cost to range from $40.47 million to $161.88 million, with a primary estimate of $80.94 million.
Overall, we expect the total one-time costs for complying with MDR requirements in Stage 1 of the phaseout policy to range from $5.36 million to $32.57 million, with a primary estimate of $13.21 million. The estimated total recurring costs range from $40.91 million to $164.55 million, with a primary estimate of $82.03 million. See Table 21.
**Table 21. Costs of Medical Device Reporting**
| One-time/Annual | Primary | Low | High |
|--------------------------|---------|-----|------|
| **Establish SOPs** | | | |
| Hours | 10 | 8 | 12 |
| Wage | $122.72 | $122.72 | $122.72 |
| Employees | 2 | 1 | 3 |
| Entities affected | 1,181 | 590 | 2,362 |
| New entities per year | 94 | 47 | 189 |
| **One-time Subtotal (millions)** | $2.90 | $0.58 | $10.43 |
| **Recurring Subtotal (millions)** | $0.23 | $0.05 | $0.83 |
| **Install and Validate e-Submitter Software** | | | |
| Hours | 52 | 48 | 56 |
| Wage | $159.44 | $159.44 | $159.44 |
| Employees | 1 | 1 | 1 |
| Entities affected | 1,181 | 590 | 2,362 |
| New entities per year | 94 | 47 | 189 |
| **One-time Subtotal (millions)** | $9.79 | $4.52 | $21.09 |
| **Recurring Subtotal (millions)** | $0.78 | $0.36 | $1.69 |
| **Establish HL7ICSR capability** | | | |
| Hours | 50 | 48 | 52 |
| Wage | $159.44 | $159.44 | $159.44 |
| Employees | 1 | 1 | 1 |
| Entities affected | 7 | 4 | 14 |
| New entities per year | 1 | 0 | 1 |
| **One-time Subtotal (millions)** | $0.06 | $0.03 | $0.12 |
| **Recurring Subtotal (millions)** | $0.005 | $0.002 | $0.01 |
| **Acquiring e-Certificate** | | | |
| Search cost | $20.00 | $20.00 | $20.00 |
| Entities affected | 1,181 | 590 | 2,362 |
| New entities per year | 94 | 47 | 189 |
| **One-time Subtotal (millions)** | $0.02 | $0.01 | $0.05 |
| **Recurring Subtotal (millions)** | $0.002 | $0.001 | $0.004 |
| **Recurring Annual** | | | |
| Maintaining Certificates | | | |
| Search cost | $10.00 | $10.00 | $10.00 |
| Entities affected | 1,181 | 590 | 2,362 |
| **Recurring Subtotal (millions)** | $0.01 | $0.01 | $0.02 |
| Filing and submitting MDRs | | | |
| Hours | 430 | 430 | 430 |
| Wage | $159.44 | $159.44 | $159.44 |
| Entities affected | 1,181 | 590 | 2,362 |
| **Recurring Subtotal (millions)** | $80.94 | $40.47 | $161.88 |
| **Total One-time Costs (millions)** | $13.21 | $5.36 | $32.57 |
| **Total Recurring Costs (millions)** | $82.03 | $40.91 | $164.55 |
||
Notes: Total one-time and recurring costs include both costs to industry and FDA. See section II.G for FDA review costs of MDRs.
c. Correction and Removal Reporting
Under Stage 1, FDA expects laboratories to comply with correction and removal reporting requirements under 21 U.S.C. 360i(g) and 21 CFR part 806. In estimating the costs of compliance for laboratories, we use information from the 2023 FDA notice: *Agency Information Collection Activities; Submission for Office of Management and Budget Review; Comment Request; Medical Devices; Reports of Corrections and Removals* (Ref. [56]).
We expect that the majority of correction and removal reporting costs will be recurring costs associated with creating correction and removal reports. At baseline, the requirement to create such reports generally has not been enforced.
We expect 50% of laboratories to purchase a digital verification certificate to assist with correction and removal reporting (Ref. [56]). We expect this certificate to cost $50. Multiplying by the number of affected entities, we expect a one-time cost of purchasing a digital verification certificate to range from $0.01 million to $0.06 million, with a primary estimate of $0.03 million. Multiplying by the number of new entities per year, we expect a recurring cost of purchasing a digital verification certificate to range from $1,181 to $4,723, with a primary estimate of $2,362.
We expect laboratories to incur a recurring cost associated with correction and removal reporting requirements. We assume it will take a single general/operations manager working at an hourly wage of $57.60 ($115.20 fully-loaded) 10 hours to create a single correction and removal report. The 2023 FDA notice *Agency Information Collection Activities; Submission for Office of Management and Budget Review; Comment Request; Medical Devices; Reports of Corrections and Removals* acknowledged 1,033 correction and removal reports per year.
These numbers suggest that there are approximately 0.11 correction and removal reports per year per entity. We assume that ratio is the same for laboratories and apply the ratio to the total number of affected entities. Multiplying all elements together, we estimate the recurring cost of correction and removal reporting to range between $0.07 million to $0.30 million, with a primary estimate of $0.15 million.
Overall, we expect the total one-time costs for correction and removal reporting in Stage 1 of the phaseout policy to range between $0.01 million to $0.06 million, with a primary estimate of $0.03 million. The estimated total recurring costs range from $0.08 million to $0.30 million, with a primary estimate of $0.15 million. See Table 22.
**Table 22. Costs of Correction and Removal Reporting**
| | Primary | Low | High |
|--------------------------------|---------|-------|-------|
| **One-time/Annual** | | | |
| Digital Verification Certificate | | | |
| Flat fee | $50.00 | $50.00| $50.00|
| Entities affected | 590 | 295 | 1,181 |
| New entities per year | 47 | 24 | 94 |
| **One-time Subtotal (millions)** | $0.03 | $0.01 | $0.06 |
| **Recurring Subtotal** | $2,362 | $1,181| $4,723|
| **Recurring Annual** | | | |
| Reporting | | | |
| Hours per report | 10 | 10 | 10 |
| Number of reports per entity | 0.11 | 0.11 | 0.11 |
| Wage | $115.20 | $115.20| $115.20|
| Entities affected | 1,181 | 590 | 2,362 |
| **Recurring Subtotal (millions)** | $0.15 | $0.07 | $0.30 |
| **Total One-time Costs (millions)** | $0.03 | $0.01 | $0.06 |
| **Total Recurring Costs (millions)** | $0.15 | $0.08 | $0.30 |
||
d. Complaint Files
Under Stage 1, FDA will expect laboratories to comply with quality system (QS) requirements under 21 CFR part 820.198 (complaint files).[^56] In estimating the costs of complaint files, we use number of annual labor hours and proportion of types of labor (from vice president to clerical staff) needed to comply with complaint file requirements (Ref. [57]).[^57] We also use appropriate wage rates and number of affected entities to estimate costs of complaint files. The estimated total one-time costs for complaint files range from $0.60 million to $6.04 million, with a primary estimate of $2.11 million. The estimated total recurring costs range from $0.01 million to $0.05 million, with a primary estimate of $0.02 million.
**Table 23. Costs of Complaint Files**
| | Primary | Low | High |
|----------------------------------|---------|------|------|
| **One-time** | | | |
| 820.198 Complaint files | Hours | 14 | 8 | 20 |
| Entities affected | 1,181 | 590 | 2,362|
| **Recurring Annual** | | | |
| 820.198 Complaint files | Hours | 2 | 1 | 2 |
| New entities per year | 94 | 47 | 189 |
| **Total One-time Costs (millions)** | $2.11 | $0.60| $6.04|
| **Total Recurring Costs (millions)** | $0.02 | $0.01| $0.05|
||
###### 2. Costs Under Stage 2
Under Stage 2, FDA will expect that laboratories comply with requirements not covered during other stages of the phaseout policy beginning 2 years after the publication of the phaseout policy. These requirements include registration and listing requirements (21 U.S.C. 360 and 21 CFR part 807, excluding subpart E), labeling requirements (21 U.S.C. 352 and 21 CFR parts 801 and 809, subpart B), and investigational use requirements (21 U.S.C. 360j(g) and 21 CFR part 812).[^58]
a. Registration and Listing
Under Stage 2, FDA expects laboratories to comply with registration and listing requirements under 21 U.S.C. 360 and 21 CFR part 807 (excluding subpart E). In estimating the costs of compliance for laboratories, we use a similar approach to the 2016 *Requirements for Foreign and Domestic Establishment Registration and Listing for Human Drugs, Including Drugs That Are Regulated Under a Biologics License Application, and Animal Drugs* final regulatory impact analysis (Ref. [58]).[^59] We anticipate one-time costs associated with registration and listing requirements and recurring costs associated with re-registration.
We expect the registration and listing will take a general/operations manager 3 hours, working at a wage of $57.60 ($115.20 fully loaded), to complete registration for a single establishment and to list that establishment’s IVDs offered as LDTs.[^60] We also expect that annual re-registration and listing updates will take a general/operations manager 1 hour. Multiplying by the numbers of affected entities per year, we expect total one-time costs for registration and listing requirements to range between $0.20 million and $0.82 million, with a primary estimate of $0.41 million. The estimated total recurring costs range from $0.08 million to $0.34 million, with a primary estimate of $0.17 million. See Table 24.
**Table 24. Costs of Registration and Listing**
| | Primary | Low | High |
|-------------------------------|---------|-------|-------|
| **One-time/Annual** | | | |
| Initial registration and listing of IVDs offered as LDTs | | | |
| Hours | 3 | 3 | 3 |
| Wage | $115.20 | $115.20 | $115.20 |
| Entities affected | 1,181 | 590 | 2,362 |
| New entities per year | 94 | 47 | 189 |
| *One-time Subtotal (millions)*| $0.41 | $0.20 | $0.82 |
| *Recurring Subtotal (millions)* | $0.03 | $0.02 | $0.07 |
| **Recurring Annual** | | | |
| Re-registration | | | |
| Hours | 1 | 1 | 1 |
| Wage | $115.20 | $115.20 | $115.20 |
| Entities affected | 1,181 | 590 | 2,362 |
| *Recurring Subtotal (millions)* | $0.14 | $0.07 | $0.28 |
| **Total One-time Costs (millions)** | **$0.41** | **$0.20** | **$0.82** |
| **Total Recurring Costs (millions)** | **$0.17** | **$0.08** | **$0.34** |
||
b. **Labeling**
Under Stage 2, FDA expects laboratories to comply with labeling requirements under 21 U.S.C. 352, 21 CFR part 801, and 21 CFR part 809, subpart B. We anticipate one-time and recurring costs associated with revising existing labeling.
We expect it will take a general/operations manager, working at a wage of $57.60 ($115.20 fully-loaded),[^61] 8 to 54 hours (with a primary estimate of 31 hours) for regulatory affairs personnel and production personnel per laboratory to redesign existing labeling for IVDs offered as LDTs to comply with labeling requirements (Ref. [59]).[^62] Manufacturers would spend these hours to revise the labeling, including among other things, to perform internal review of the new content, to prepare and proofread new artwork, to replace labeling in the production system, and to submit the file to the agency. Multiplying by the number of expected entities, we expect the one-time cost of revising existing labeling to range between $0.54 million and $14.69 million, with a primary estimate of $4.22 million.[^63] Multiplying the estimates by the number of new entities per year, we expect the recurring cost to range between $0.04 million to $1.18 million, with a primary estimate of $0.34 million. See Table 25.
**Table 25. Costs of Labeling**
| | Primary | Low | High |
|-----------------------------|---------|-------|-------|
| Revise existing labeling | | | |
| Hours | 31 | 8 | 54 |
| Wage | $115.20 | $115.20 | $115.20 |
| Entities affected | 1,181 | 590 | 2,362 |
| New entities per year | 94 | 47 | 189 |
| *One-time Subtotal (millions)* | $4.22 | $0.54 | $14.69 |
| *Recurring Subtotal (millions)* | $0.34 | $0.04 | $1.18 |
| **Total One-time Costs (millions)** | **$4.22** | **$0.54** | **$14.69** |
| **Total Recurring Costs (millions)** | **$0.34** | **$0.04** | **$1.18** |
||
c. Investigational Use Requirements
Under Stage 2, FDA expects laboratories to comply with investigational use requirements under 21 U.S.C. 360j(g) and 21 CFR part 812. Investigational medical devices (i.e., that are the object of a clinical investigation or research involving one or more subjects to determine device safety and/or effectiveness) that have an approved investigational device exemption (IDE) application, that are considered to have an approved IDE under 21 CFR part 812.2(b), or that are exempt from most of the requirements in 21 CFR part 812 under 21 CFR 812.2(c), are exempted from various other requirements under the FD&C Act and FDA’s regulations, such as premarket approval. We anticipate one-time and annual costs associated with complying with investigational device exemption requirements under 21 U.S.C. 360j(g) and 21 CFR part 812.[^64]
We expect the cost of developing an IDE application for an IVD offered as an LDT to be $48,000 (Ref. [60]).[^65] We assume two percent of the existing IVDs offered as LDTs are investigational, based on extrapolation of internal information from NYSDOH regarding the percent of IVD submissions they receive that are for investigational IVDs offered as LDTs (Ref. [28]). NYSDOH receives IVD submission packages for IVDs offered as LDTs that are not “designated as FDA-cleared, approved, or exempt,” (Ref. [29]) and these submission packages include clinical trial tests as well as high, moderate, and low risk tests offered for clinical use, based on NYSDOH criteria. Over a two-year period, approximately two percent of IVD submission packages received by NYSDOH were for clinical trial IVDs per NYSDOH criteria.
Not all investigational IVDs require an IDE application.[^66] Based on the number of IVD IDE submissions and the number of IVD premarket submissions that FDA received over a four-year period, we estimate that we receive about 13.5 IVD IDE submissions for every 100 premarket submissions. Therefore, we estimate that about 13.5% of investigational IVDs offered as LDTs that would later be subject to premarket review would first submit an IDE application. We estimate that 50% of IVDs are exempt from premarket notification and 50% require a premarket submission. Applying these factors, we estimate that 6.75% (which represents 50% x 13.5%) of investigational IVDs would require an IDE application.
The number of IDE applications for IVDs currently offered as an LDT can be estimated by multiplying the percent of investigational IVDs currently offered as an LDT (2%) by the percent of investigational IVDs that would require an IDE application (6.75%) by the number of affected IVDs offered as LDTs.
We also expect there would be new investigational IVDs introduced every year, at a rate of anywhere between 1% and 100% of new IVDs. To account for our uncertainty, we assume that the mean value between 1% and 100% or 50% of the new IVDs would be investigational. As described above, we estimate that 6.75% of investigational IVDs would require an IDE.
Multiplying the cost estimates from literature by the relevant percentages and number of affected IVDs offered as LDTs, we expect the total one-time costs of preparing and submitting IDE applications for the existing IVDs offered as LDTs to range between $2.56 million and $10.25 million, with a primary estimate of $5.13 million. Table 26 shows the estimated annual costs, which range from $6.20 million to $24.79 million, with a primary estimate of $12.40 million.
**Table 26. Costs of Complying with Investigational Use Requirements**
| One-time | Primary | Low | High |
|-------------------------------------|---------|--------|--------|
| Total cost of preparing/ | | | |
| submitting IDE | | | |
| Inflation-adjusted estimate from | $48,000 | $48,000| $48,000|
| literature | | | |
| Percent of IVDs offered as LDTs | 2 | 2 | 2 |
| that are investigational | | | |
| Percent of investigational IVDs | 6.75 | 6.75 | 6.75 |
| offered as LDTs that require | | | |
| submission of IDE application | | | |
| IVDs currently offered as LDTs | 79,114 | 39,557 | 158,227|
| affected | | | |
| **One-time Subtotal (millions)** | **$5.13**| **$2.56**| **$10.25**|
| Annual | Primary | Low | High |
|-------------------------------------|---------|--------|--------|
| Total cost of preparing/ | | | |
| submitting IDE | | | |
| Inflation-adjusted estimate from | $48,000 | $48,000| $48,000|
| literature | | | |
| Percent of IVDs offered as LDTs | 50 | 50 | 50 |
| that are investigational | | | |
| Percent of investigational IVDs | 6.75 | 6.75 | 6.75 |
| offered as LDTs that require | | | |
| submission of IDE application | | | |
| New IVDs offered as LDTs per year | 7,652 | 3,826 | 15,303 |
| **Annual Subtotal (millions)** | **$12.40**| **$6.20**| **$24.79**|
**Total One-time Costs (millions)** | **$7.45**| **$3.73**| **$14.90**|
**Total Annual Costs (millions)** | **$18.02**| **$9.01**| **$36.03**|
||
Notes: Total one-time and recurring costs include both costs to industry and FDA. See section II.G for FDA review costs of IDEs.
###### 3. Costs Under Stage 3
Beginning 3 years after the publication of this final rule, FDA will expect compliance with the device current good manufacturing practices (CGMP) requirements of the QS requirements under 21 U.S.C. 360j(f) and 21 CFR part 820 (other than requirements under § 820.198 (complaint files), which are already addressed in stage 1).
However, for LDTs, FDA expects compliance with some, but not all, of the QS requirements. As described in section V.C.3 of the preamble, for these LDTs, FDA expects compliance with:
- design controls under 21 CFR 820.30;
- purchasing controls (including supplier controls) under 21 CFR 820.50;
- acceptance activities (receiving, in-process, and finished device acceptance) under 21 CFR 820.80 and 21 CFR 820.86;
- corrective and preventative actions (CAPA) under 21 CFR 820.100; and
- records requirements under 21 CFR part 820, subpart M (including requirements regarding complaint files under 21 CFR 820.198, for which FDA expects compliance during stage 1 of the phaseout policy).
As further described in section V.C.3 of the preamble, for IVDs that are within the scope of the phaseout policy but for which all manufacturing activities do not occur within a single laboratory, or which are transferred outside of that single laboratory, FDA also expects compliance with the other QS requirements under 21 U.S.C. 360j(f) and 21 CFR part 820. We lack evidence to quantify the numbers of such IVDs. To account for uncertainty, we consider different assumptions for low, primary, and high estimates. To estimate a lower bound estimate, we first assume that for all IVDs within the scope of the phaseout policy, all manufacturing activities occur within a single laboratory and, therefore, have zero costs associated with the QS requirements other than those listed above. For an upper bound estimate, we assume that all manufacturing activities do not occur within a single laboratory for any IVD within the scope of the phaseout policy and, therefore, have costs associated with all QS requirements. Since we expect there to be a mix of these two extremes within the scope of the phaseout policy, we use an average of the lower and upper bound estimates for our primary estimate.
In estimating the costs of compliance for laboratories, we use number of annual labor hours and proportion of types of labor (from vice president to clerical staff) needed to comply with each relevant provision of 21 CFR part 820. We also use wage rates to estimate costs of...
compliance with these provisions for affected entities (see Table 27). Table 28 shows the number of labor hours for compliance with each provision of Part 820 (Ref. [57]). We multiply the labor hours by appropriate wage rates and number of affected entities to estimate costs of compliance with the QS requirements under this stage.
Since FDA generally intends to exercise enforcement discretion with respect to QS requirements (other than requirements regarding records) for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of this rule and that are not modified, or that are modified as described in the preamble, we anticipate one-time costs of compliance with records requirements other than complaint files from existing IVDs offered as LDTs and recurring costs from new IVDs offered as LDTs under this stage. In addition, we estimate that the number of affected entities for Stage 3 is lower than Stages 1 and 2 as FDA intends to exercise enforcement discretion with respect to QS requirements (other than requirements regarding records) for LDTs manufactured and performed by a laboratory integrated within a health care system to meet an unmet need of patients receiving care within the same healthcare system. Further, it is our understanding, based on consultation with NYS CLEP, that compliance with NYS CLEP’s clinical laboratory standards (which exceed CLIA requirements in certain respects) and its premarket review requirements collectively could generally satisfy these subparts of the QS regulations except as to certain aspects of design control documentation. Therefore, FDA does not anticipate significant additional burden with respect to compliance with these QS requirements for laboratories offering LDTs approved by NYS CLEP. As discussed in appendix A, we estimate 12.1 percent of new premarket submissions for affected tests will be reviewed by NYS CLEP. For the purpose of estimating costs associated with compliance with Quality System requirements, we extrapolate this to the affected laboratories, estimating that 12.1 percent of affected laboratories (1,181) will have their LDTs reviewed by NYS CLEP. We also estimate that 40 to 70 percent of LDTs from the high complexity laboratories integrated within health care systems (459) are likely to be for unmet needs. We therefore estimate the affected laboratories incurring costs under Stage 3 to be 786 (=1,181 – 1,181*0.121 – 459*0.55).
We expect the total one-time costs for QS requirement (records other than complaint files under 21 CFR 820.198) in Stage 3 of the phaseout policy to range from $0.40 million to $4.02 million, with a primary estimate of $1.41 million. The total recurring costs are estimated to range from $1.94 million to $124.01 million, with a primary estimate of $24.66 million. See Table 28.
**Table 27. Medical and Diagnostic Laboratories Industry Wage Rates for Selected Labor Categories**
Labor Category | Wages (/hour) | NAICS | OCC Code
---|---|---|---
Vice president | $59.68 | 621500 | 11-1000
Upper management | $76.38 | 621500 | 11-2000
Middle management | $66.83 | 621500 | 11-3000
Technical | $30.36 | 621500 | 29-0000
Admin support | $32.67 | 621500 | 43-6011
Clerical | $18.37 | 621500 | 43-4000 |
||
**Table 28. Costs of Compliance with Quality System Requirements**
One-time/Annual | | Primary | Low | High
---|---|---|---|---
820.20(a) Quality Policy | Hours | 8 | 0 | 24
820.20(b) Organization | Hours | 6 | 0 | 20
820.20(d) Quality Planning | Hours | 14 | 0 | 40
820.20(e) Quality System Procedures | Hours | 14 | 0 | 40
820.22 Quality Audit | Hours | 8 | 0 | 24
820.25 Personnel, establish procedures for identifying training needs | Hours | 8 | 0 | 24
820.25 Personnel, train in CGMP revisions | Hours | 50 | 0 | 290
820.40 Document Controls | Hours | 14 | 0 | 40
820.60 Identification and Traceability | Hours | 8 | 0 | 24
820.72, 820.75 Inspection, measuring, and test equipment, process validation | Hours | 23 | 0 | 72
820.70(i) Automated Processes | Hours | 14 | 0 | 40
820.90 Nonconforming Product | Hours | 14 | 0 | 40
820.140 Handling | Hours | 8 | 0 | 24
820.200 Servicing | Hours | 14 | 0 | 40
820.30(a) General | Hours | 200 | 30 | 560
820.50(a) Assessment of Suppliers and Contractors | Hours | 75 | 25 | 125
820.100 Corrective and Preventive Action | Hours | 28 | 16 | 40
820.150 Storage | Hours | 15 | 8 | 24
820.198 Complaint Files | Hours | 14 | 8 | 20
Entities affected | | 786 | 393 | 1,571
New entities per year | | 63 | 31 | 126 |
**Recurring Annual** | | | | |
820.20(a) Quality Policy | Hours | 1 | 0 | 2
820.20(b) Organization | Hours | 1 | 0 | 2
820.20(c) Management Review | Hours | 8 | 0 | 24
820.20(d) Quality Planning | Hours | 4 | 0 | 10
820.20(e) Quality System Procedures | Hours | 4 | 0 | 10
820.22 Quality Audit | Hours | 1 | 0 | 2
820.25 Personnel, maintain procedures | Hours | 1 | 0 | 2
820.40 Document Controls | Hours | 2 | 0 | 4
820.60 Identification and Traceability | Hours | 1 | 0 | 2
820.72, 820.75 Inspection, measuring, and test equipment, process validation | Hours | 4 | 0 | 13
820.70(i) Automated Processes | Hours | 2 | 0 | 4
820.90 Nonconforming Product | Hours | 2 | 0 | 4
820.140 Handling | Hours | 1 | 0 | 2
820.200 Servicing | Hours | 2 | 0 | 4
820.30(a) General | Hours | 20 | 3 | 56
820.30(b) Design and Development Planning | Hours | 216 | 32 | 520
820.30(e) Design Review | Hours | 942 | 82 | 2,574
820.30(f) Design Verification | Hours | 1,681 | 249 | 4,047
820.30(h) Design Transfer | Hours | 43 | 6 | 104
820.30(i) Design Changes | Hours | 378 | 56 | 910
820.30(j) Design History File | Hours | 22 | 3 | 52
820.50(a) and (b) Purchasing control | Hours | 159 | 98 | 233
820.100 Corrective and Preventive Action | Hours | 3 | 2 | 4
820.150 Storage | Hours | 2 | 1 | 2
820.198 Complaint Files | Hours | 2 | 1 | 2
New entities per year | | 63 | 31 | 126
Total One-time Costs (millions) | | $1.41 | $0.40 | $4.02
Total Recurring Costs (millions) | | $24.66 | $1.94 | $124.01 |
||
We note that on February 2, 2024, FDA issued a final rule amending the device QS regulation, part 820, to align more closely with international consensus standards for devices (87 FR 10119). Specifically, FDA withdrew the majority of the current requirements in part 820 and instead incorporated by reference the 2016 edition of the International Organization for Standardization (ISO) 13485, Medical devices – Quality management systems for regulatory purposes, in part 820. As stated in that rule, the requirements in ISO 13485 are, when taken in totality, substantially similar to the requirements of the current part 820, providing a similar level of assurance in a firm’s quality management system, and FDA intends for the phaseout policy to apply with respect to the regulations promulgated through that rulemaking.
The amended QS requirements will take effect on February 2, 2026, before the beginning of Stage 3. Upon the start of Stage 3, or if the laboratory complies with QS requirements prior to the start of Stage 3, FDA expects compliance with the QS requirements that are in effect at that time.69 For further information on the QS requirements established pursuant to the amendments to the QS regulation, please refer to 89 FR 7496. Notably, the requirements relating to design controls, purchasing controls, acceptance activities, CAPA, and records requirements are set forth in the following ISO 13485 clauses as modified by the regulatory text for part 820:
- Clause 4. Quality Management System, Subclause 4.2.5;
- Clause 6. Resource Management;
- Clause 7. Product Realization, Subclause 7.1, Subclause 7.3, Subclause 7.4, and Subclause 7.4.3; and
- Clause 8. Measurement, Analysis, & Improvement, Subclause 8.2.2, Subclause 8.2.5, Subclause 8.2.6, and Subclause 8.3.
To the extent amended QS requirements are in effect, we do not expect the total costs for compliance with QS requirements in Stage 3 to substantially change (89 FR 7496, February 2, 2024).
###### 4. Costs Under Stages 4 and 5
Beginning 3½ years after the publication of this final rule, FDA will expect laboratories to comply with premarket review requirements for high-risk IVDs offered as LDTs (21 U.S.C. 360e and 21 CFR part 814). Laboratories will face costs of preparing and submitting premarket approval (PMA) applications and PMA supplements as well as greater annual reporting burdens associated with premarket approval. FDA will also face additional costs of reviewing the applications. We quantify these costs in the following sections.
Additionally, moderate risk IVDs offered as LDTs (IVDs that may be eligible for classification into class II) and low risk IVDs offered as LDTs (IVDs that may be eligible for classification into class I) that require a premarket submission will be expected to comply with 510(k) requirements or De Novo requirements beginning 4 years after the publication of the phaseout policy. Under this stage, we anticipate costs associated with preparing and submitting 510(k) premarket notifications or De Novo classification requests, and FDA review costs.
FDA generally intends to continue to exercise enforcement discretion with respect to premarket review for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of this rule and that are not modified, or that are modified as described in the preamble. FDA also generally intends to exercise enforcement discretion with respect to premarket review requirements for LDTs that receive approval through NYS CLEP. In addition, FDA generally intends to exercise enforcement discretion with respect to premarket review requirements for LDTs manufactured and performed by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system.
a. Number of Premarket Submissions
Due to the variations in the size of laboratories, business models, and types of IVDs, there is no comprehensive database or repository from which we can definitively calculate the number of IVDs offered as LDTs currently available or the rate at which new IVDs offered as LDTs are introduced. Likewise, there is insufficient data to definitively determine what percentage of IVDs offered as LDTs are likely to be in each class of devices. We rely on New York State Department of Health internal data to estimate the number of affected IVDs offered as LDTs (see section II.D.1 and Table 2).
As discussed in section II.D.1, we assume one laboratory offers 67 IVDs as LDTs and will offer 6 new IVDs as LDTs per year. Of the 67 IVDs as LDTs currently offered per laboratory, we assume that, on average, two will be modified in such a way as to require premarket review per year until they all are FDA authorized. As mentioned above, FDA
Because FDA generally intends to exercise enforcement discretion with respect to premarket review for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of this rule and that are not modified, or that are modified as described in the preamble, we only include costs from modified and new IVDs offered as LDTs under Stages 4 and 5.
**Table 29. Number of Premarket Submissions Under Stage 4 and Stage 5**
| | Primary | Low | High |
|-------------------------------|---------|------|------|
| PMA | 101 | 51 | 203 |
| PMA supplements | 31 | 15 | 61 |
| 510(k) Total | 2,179 | 1,090| 4,359|
| 510(k) with method comparison study | 1,286 | 643 | 2,572|
| 510(k) with moderately complex clinical study | 894 | 447 | 1,787|
| De Novo | 267 | 134 | 534 |
| **Total number of new premarket submissions per year for affected tests** | **2,578** | **1,289** | **5,157** |
||
*Notes: The numbers of tests include currently marketed tests that would be modified per year and new tests from both affected labs and new labs entering the market per year.*
b. PMA, 510(k), and De Novo requirements
In estimating the costs of compliance for laboratories, we use estimates for the 510(k) and the premarket approval processes derived by Eastern Research Group (ERG) (Ref. [61])[^70]. The estimates by ERG present the representative costs of regulatory-related activities based on semi-structured discussions with project consultants and other information and knowledge about the development process[^71].
Devices subject to premarket approval typically require premarket and post-market procedures that are not typically associated with 510(k) clearance, such as premarket manufacturing site and clinical site inspections and annual report submissions. In addition, the requirements relating to submissions for device modifications are generally different for devices that have received PMAs as compared with other devices. For example, supplements must be approved, such as for the use of a different facility or establishment to manufacture, process, or package the device. We have excluded costs that would already be part of compliance with the QS requirements under Stage 3, including costs of developing design controls, acquiring GMP-compliant manufacture capability, and developing a risk management system.
To estimate cost for submission and preparation of the PMA, IVDs are broken out by complexity of the clinical trial supporting IVD safety and effectiveness due to the different costs. We use the ERG estimates of the PMAs with complex clinical trials for lower bound estimates (Ref. [61]). For upper bound estimates, we use the ERG estimates of the PMAs with complex, extensive clinical trials. We updated the ERG estimates to account for inflation. We expect that most of the PMAs will involve complex clinical trials. We assume that of the PMAs, 95% are complex clinical trials and 5% are complex, extensive clinical trials. We take 95% of the low and 5% of the high estimates to calculate primary estimates. The total cost of submission and preparation per PMA is estimated to range from $4.10 million to $9.29 million, with a primary estimate of $4.36 million. Multiplying the estimates by the numbers of new IVDs per year and IVDs from new entities per year that are subject to premarket approval, excluding those that would be under enforcement discretion policies, we expect recurring cost of submission and preparation for PMAs to range from $207.60 million to $1,881.11 million, with a primary estimate of $441.47 million.
PMA holders are also subject to annual reporting requirements, which impose preparation costs on PMA holders and review costs on FDA. We use a prior estimate from the Microbiology Devices; Reclassification of Nucleic Acid-Based Systems for *Mycobacterium tuberculosis* complex final regulatory impact analysis (Ref. [62]) to estimate the recurring preparation cost[^72]. The current estimate after adjustment for inflation is $11,798 per PMA. Multiplying the estimates by the numbers of PMA submissions per year, we expect total recurring costs of PMA annual reporting requirements to range from $0.60 million to $2.39 million, with a primary estimate of $1.19 million.
Overall, we estimate the total recurring costs to industry of PMA requirements in Stage 4 to range between $208.20 million and $1,883.50 million, with a primary estimate of $442.67 million. See Table 30.
**Table 30. Costs to Industry of Premarket Approval Application**
| **Cost of Submission and Preparation** | Primary | Low | High |
|----------------------------------------|---------|-----|------|
| Develop necessary SOPs | $39,572 | $37,688 | $75,376 |
| Hold pre-submission meeting with FDA | $2,513 | $2,513 | $2,513 |
| Prepare indications for use | $25,125 | $25,125 | $25,125 |
| Perform clinical trials | $2,832,871| $2,638,150| $6,532,562|
| Preparing labeling | $25,125 | $25,125 | $25,125 |
| Pre-approval inspection | $115,576 | $115,576 | $115,576 |
| Prepare regulatory submission | $1,319,075| $1,256,262| $2,512,524|
| **Subtotal cost per submission** | $4,359,857| $4,100,439| $9,288,800|
| No. PMA submissions per year for affected tests | 101 | 51 | 203 |
| **Recurring Subtotal (millions)** | **$441.47** | **$207.60** | **$1,881.11** |
| **Recurring Annual** | | | |
| Annual Report preparation for existing PMAs | $11,798 | $11,798 | $11,798 |
| No. PMA submissions per year for affected tests | 101 | 51 | 203 |
| **Recurring Subtotal (millions)** | **$1.19** | **$0.60** | **$2.39** |
| **Total Recurring Costs (millions)** | **$442.67** | **$208.20** | **$1,883.50** |
||
Notes:
Unless otherwise specified, line-item estimates are inflation-adjusted estimates from Eastern Research Group, Inc. 2012: Economic Analysis of CDRH Submission Requirements. Totals may not add due to rounding. The numbers of PMA submissions per year include currently marketed tests that would be modified per year and new tests from both affected entities currently on the market and new entities entering the market per year. Total recurring costs do not include costs to FDA. See section II.G for FDA review costs of Q-submissions and PMAs.
*We calculate subtotals by multiplying subtotal cost per submission by the number of affected IVDs.
Some IVDs with PMAs might require a PMA supplement under 21 CFR 814.39 when certain modifications are made.[^73] There are several types of PMA supplements (see Table 31; each row is a type of PMA supplement). We first estimate the expected number of PMA supplements by supplement type by multiplying the number of expected PMAs by the number of expected PMA supplements per PMA[^74] and the share of supplements by supplement type.[^75] We also multiply by the Remaining PMA Rate (Table A.4, Column F) to adjust for potential reclassification of Class III IVDs into Class II IVDs. We assume that entities would submit PMA supplements in year 4. See Table 31 for the expected number of annual PMA supplements.
Next, to estimate the total costs to industry of PMA supplement preparation, we multiply the number of PMA supplements by an estimated full-time equivalent (FTE) cost[^76] associated with each supplement type and the cost of preparing a PMA from the previous section. This approach assumes the cost of preparing a PMA supplement for a laboratory is proportional to the FTE required for FDA to review the supplement type. Overall, we estimate the total recurring costs to industry of PMA supplements to range from $6.28 million to $56.89 million, with a primary estimate of $13.35 million. See Table 32.
**Table 31. Number of PMA Supplements by Submission Type**
| Submission Type | Cumulative share of supplements by type | Primary | Low | High |
|-------------------------------------------------------|----------------------------------------|---------|-----|------|
| 135 Review Track | 0.053 | 2 | 1 | 5 |
| Normal 180-day track | 0.205 | 5 | 3 | 11 |
| Normal 180-day track - No user fee | 0.128 | 4 | 2 | 7 |
| Panel-Track | 0.067 | 2 | 1 | 4 |
| Real-Time Process | 0.374 | 14 | 7 | 28 |
| Special CBE | 0.095 | 4 | 2 | 7 |
||
**Table 32. Costs to Industry of PMA Supplements**
| Submission Type | Adjusted FTE weights over PMA | Primary | Low | High |
|--------------------------------------------------------|-------------------------------|---------|-------|-------|
| 135 Review Track | 0.033 | $0.42 | $0.20 | $1.79 |
| Normal 180-day track | 0.033 | $0.98 | $0.46 | $4.18 |
| Normal 180-day track - No user fee | 0.033 | $0.67 | $0.32 | $2.88 |
| Panel Track | 1.000 | $9.85 | $4.63 | $41.98|
| Real Time Process | 0.010 | $0.79 | $0.37 | $3.35 |
| Special CBE | 0.033 | $0.64 | $0.30 | $2.71 |
| **Total Recurring Costs (millions)** | | **$13.35** | **$6.28** | **$56.89** |
||
Note: Total recurring costs do not include costs to FDA. See section II.G for FDA review costs of PMA supplements.
Similar to the PMA, we use the ERG estimates of the 510(k) process to estimate the one-time submission and preparation cost of 510(k)s, adjusting for inflation.[^77] We use the ERG estimates of 510(k) with small or simple clinical trials for 510(k) submissions with method comparison studies (see Table 33) (Ref. [61]). We use the ERG estimates of 510(k) with moderately complex clinical trials for 510(k) submissions with moderately complex clinical studies (see Table 34).[^78]
For any 510(k) submission (or De Novo request[^79]), we expect it will take one operations specialist manager, working at a wage of $66.83 ($133.66 fully loaded), 1 to 2 hours (with a primary estimate of 1.5 hours) to identify a predicate device (or determine that no predicate device exists, in the case of a De Novo). The other one-time submission and preparation costs are derived from the ERG estimates. The total cost of submission and preparation per 510(k) with method comparison studies is estimated to range from $215,457 to $279,157, with a primary estimate of $247,307.
FDA also anticipates that laboratories may seek to utilize FDA’s 510(k) Third Party Review Program. Multiple Third Party Review Organizations (3P510k Review Organizations) are accredited to conduct reviews of 510(k) submissions for certain IVDs. Manufacturers who submit to 3P510k Review Organizations pay the 3P510k Review Organization but do not pay FDA user fees for those submissions. Each 3P510k Review Organization sets their own rates, which are generally comparable to FDA user fees. Due to lack of data, we assume that laboratories will pay the same amount of FDA user fees to 3P510k Review Organizations. FDA assumes that at least 50% of the IVDs offered as LDTs being submitted for 510(k) review will be reviewed under the 510(k) Third Party Review Program.
Multiplying by the numbers of modified and new IVDs per year and IVDs from new entities that are subject to 510(k) with method comparison studies, excluding those that would be under enforcement discretion policies per year yields the recurring submission and preparation costs for 510(k)s with method comparison studies is estimated between $142.10 million and $732.21 million, with a primary estimate of $325.15 million. See Table 33.
**Table 33. Costs to Industry of 510(k)s (Method Comparison Study)**
| Cost of Submission and Preparation | Primary | Low | High |
|------------------------------------|-----------|----------|----------|
| Identify predicate device | | | |
| Hours | 1.5 | 1 | 2 |
| Wage | $133.66 | $133.66 | $133.66 |
| Develop necessary SOPs | $37,688 | $37,688 | $37,688 |
| Hold pre-submission meeting with FDA| $2,136 | $1,759 | $2,513 |
| Prepare indications for use | $25,125 | $25,125 | $25,125 |
| Perform method comparison | $62,813 | $62,813 | $62,813 |
| Preparing labeling | $25,125 | $25,125 | $25,125 |
| Prepare regulatory submission | $94,220 | $62,813 | $125,626 |
| **Subtotal cost per submission** | $247,307 | $215,457 | $279,157 |
| No. 510(k) submissions with method comparison study per year for affected tests | 1,286 | 643 | 2,572 |
| **Subtotal (millions)** | **$317.98** | **$138.52** | **$717.87** |
| **Fees to 3P510k Review Organizations** | | | |
| MDUFA Review Fee | $21,760 | $21,760 | $21,760 |
| (Adjusted fee for small entities) | ($5,440) | ($5,440) | ($5,440) |
| IVDs Affected, non-small* | 225 | 113 | 450 |
| IVDs affected, small* | 418 | 209 | 836 |
| **Subtotal (millions)** | $7.17 | $3.58 | $14.34 |
| **Total Recurring Costs (millions)** | **$325.15** | **$142.10** | **$732.21** |
||
*Notes:*
Unless otherwise specified, line-item estimates are inflation-adjusted estimates from Eastern Research Group, Inc. 2012: Economic Analysis of CDRH Submission Requirements.
Totals may not add due to rounding.
The numbers of 510(k) submissions per year include currently marketed tests that would be modified and new tests from both affected entities currently on the market and new entities entering the market per year. Total recurring costs does not include costs to FDA. See section II.G for FDA review costs of Q-submissions and 510(k) submissions.
*We calculate subtotals by multiplying the subtotal cost per submission by the number of affected IVDs.*
Table 34 presents costs of 510(k) submissions with a moderately complex clinical study. We calculate the costs using the exact same methods as in Table 33. The estimated subtotal cost of submission and preparation per submission ranges from $466,709 to $530,410, with a primary estimate of $498,560. Multiplying the estimates by the numbers of modified and new IVDs per year and IVDs from new entities per year that are subject to 510(k) with moderately complex clinical studies, excluding those that would be under enforcement discretion policies, we expect recurring submission and preparation cost to range from $211.00 million to $957.82 million, with a primary estimate of $450.45 million.
**Table 34. Costs to Industry of 510(k)s (Moderately Complex Clinical Study)**
| Cost of Submission and Preparation | Primary | Low | High |
|------------------------------------|-----------|----------|----------|
| Identify predicate device | | | |
| Hours | 1.5 | 1 | 2 |
| Wage | $133.66 | $133.66 | $133.66 |
| Develop necessary SOPs | $37,688 | $37,688 | $37,688 |
| Hold pre-submission meeting with FDA| $2,136 | $1,759 | $2,513 |
| Prepare indications for use | $25,125 | $25,125 | $25,125 |
| Perform clinical study | $314,065 | $314,065 | $314,065 |
| Preparing labeling | $25,125 | $25,125 | $25,125 |
| Prepare regulatory submission | $94,220 | $62,813 | $125,626 |
| **Subtotal cost per submission** | $498,560 | $466,709 | $530,410 |
| No. 510(k) submissions with moderately complex clinical study per year | 894 | 447 | 1,787 |
| **Subtotal (millions)** | **$445.47** | **$208.51** | **$947.86** |
| **Fees to 3P510k Review Organizations** | | | |
| MDUFA Review Fee | $21,760 | $21,760 | $21,760 |
| (Adjusted fee for small entities) | ($5,440) | ($5,440) | ($5,440) |
| IVDs Affected, non-small* | 156 | 78 | 313 |
| IVDs affected, small* | 290 | 145 | 581 |
| **Subtotal (millions)** | $4.98 | $2.49 | $9.96 |
| **Total Recurring Costs (millions)** | **$450.45** | **$211.00** | **$957.82** |
||
*Notes:*
Unless otherwise specified, line-item estimates are inflation-adjusted estimates from Eastern Research Group, Inc. 2012: Economic Analysis of CDRH Submission Requirements.
Totals may not add due to rounding.
The numbers of 510(k) submissions per year include currently marketed tests that would be modified and new tests from both affected entities currently on the market and new entities entering the market per year. Total recurring costs does not include costs to FDA. See section II.G for FDA review costs of Q-submissions and 510(k) submissions.
*We calculate subtotals by multiplying subtotal cost per submission by the number of affected IVDs.*
Table 35 shows costs of a De Novo classification request. We use the ERG estimates of 510(k) with moderately complex clinical trial for upper bound and use the ERG estimates of 510(k) with a method comparison study for lower bound estimates (Ref. [61]). We assume that most De Novo requests would have data from clinical trials. We take 99% of the high and 1% of the low estimates to calculate primary estimates. We calculate costs of De Novo classification requests using the exact same methods as in Table 34. The estimated subtotal cost of submission and preparation per submission ranges from $216,211 to $530,410, with a primary estimate of $527,202. Multiplying the estimates by the numbers of modified and new IVDs per year and IVDs from new entities per year that are subject to De Novo, excluding those that would be under enforcement discretion policies, we expect recurring submission and preparation cost to range from $28.88 million to $283.39 million, with a primary estimate of $140.84 million.
**Table 35. Costs to Industry of De Novo Classification Request**
| Cost of Submission and Preparation | Primary | Low | High |
|------------------------------------|-----------|----------|----------|
| Determine that no predicate devices exist | | | |
| Hours | 1.50 | 1.00 | 2.00 |
| Wage | $133.66 | $133.66 | $133.66 |
| Develop necessary SOPs | $37,688 | $37,688 | $37,688 |
| Hold pre-submission meeting with FDA| $2,513 | $2,513 | $2,513 |
| Prepare indications for use | $25,125 | $25,125 | $25,125 |
| Perform method comparison or clinical study | $311,553 | $62,813 | $314,065 |
| Preparing labeling | $25,125 | $25,125 | $25,125 |
| Prepare regulatory submission | $124,998 | $62,813 | $125,626 |
| **Subtotal cost per submission** | **$527,202** | **$216,211** | **$530,410** |
| No. De Novo submissions per year for affected tests | 267 | 134 | 534 |
| **Total Recurring Costs (millions)\*** | **$140.84** | **$28.88** | **$283.39** |
||
Notes:
Unless otherwise specified, line-item estimates are inflation-adjusted estimates from Eastern Research Group, Inc. 2012: Economic Analysis of CDRH Submission Requirements. Totals may not add due to rounding. The numbers of De Novo submissions per year include currently marketed tests that would be modified and new tests from both affected entities currently on the market and new entities entering the market per year. Total recurring costs does not include costs to FDA. See section II.G for FDA review costs of Q-submissions and De Novo requests.
*We calculate subtotals by multiplying subtotal cost per submission by the number of affected IVDs.
###### 5. Summary of Costs
Table 36 summarizes our estimates of the one-time and recurring costs by stage of the phaseout policy. These include costs to FDA and costs to industry. We estimate the total one-time costs to range between $11.67 million and $85.30 million, with a primary estimate of $32.45 million. We estimate the total recurring costs to range between $0.72 billion and $4.54 billion, with a primary estimate of $1.65 billion.
**Table 36. Total Costs to FDA and Industry (millions 2022$)**
| | Primary | Low | High |
|---|---|---|---|
| **Stage 1** | | | |
| Reading and Understanding the Rule | $3.62 | $0.81 | $12.21 |
| Medical Device Reporting | $13.21 | $5.36 | $32.57 |
| Correction and Removal Reporting | $0.03 | $0.01 | $0.06 |
| Complaint Records | $2.11 | $0.60 | $6.04 |
| Registration and Listing Requirements | $0.41 | $0.20 | $0.82 |
| **Stage 2** | | | |
| Labeling Requirements | $4.22 | $0.54 | $14.69 |
| Investigational Use Requirements | $7.45 | $3.73 | $14.90 |
| **Stage 3** | | | |
| Quality System Requirements | $1.41 | $0.40 | $4.02 |
**Total One-time Costs (millions)** | **$32.45** | **$11.67** | **$85.30**
**Recurring Annual** | | | |
| **Stage 1** | | | |
| Reading and Understanding the Rule | $0.29 | $0.07 | $0.98 |
| Medical Device Reporting | $82.03 | $40.91 | $164.55 |
| Correction and Removal Reporting | $0.15 | $0.08 | $0.30 |
| Complaint Records | $0.02 | $0.01 | $0.05 |
| Registration and Listing Requirements | $0.17 | $0.08 | $0.34 |
| **Stage 2** | | | |
| Labeling Requirements | $0.34 | $0.04 | $1.18 |
| Investigational Use Requirements | $18.02 | $9.01 | $36.03 |
| **Stage 3** | | | |
| Quality System Requirements | $24.66 | $1.94 | $124.01 |
| **Stage 4** | | | |
| Premarket Approval Application | $503.91 | $238.82 | $2,005.97 |
| Premarket Approval Application Supplements | $14.76 | $6.98 | $59.71 |
| **Stage 5** | | | |
| 510(k) Submission | $825.47 | $378.03 | $1,789.77 |
| De Novo Classification Request | $177.50 | $47.21 | $356.72 |
**Total Recurring Costs (millions)** | **$1,647.32** | **$723.18** | **$4,539.61** |
||
Notes:
The estimated costs include both costs to industry and FDA. The MDRs review costs for Stage 1, the IDEs review costs for Stage 2, and the Q-submission and premarket review costs to FDA for Stages 4 and 5 are reported in section II.G.
Table 37 presents a summary of the estimated twenty-year stream of costs. We expect that total costs for Stage 1 associated with reading and understanding the rule, medical device reporting, correction and removal reporting, and complaint records would occur in the first year after publication of the final rule. In the first year after publication of the final rule, we estimate total costs to range from $47.85 million to $216.75 million, with a primary estimate of $101.46 million.
We expect that total costs for Stage 2 associated with registration and listing requirements, labeling requirements, and investigational use requirements would occur in the second year after publication of the final rule. In year 2, total costs are estimated to range between $54.67 million to $233.83 million, with a primary estimate of $113.09 million.
In the third year after publication of the final rule, we expect that costs for Stage 3 associated with Quality System requirements except for complaint files would occur. We also expect that half of costs for Stage 4 associated with premarket approval applications would occur in year 3. Total costs in year 3 are estimated to range between $175.44 million to $1.36 billion, with a primary estimate of $386.41 million.
In subsequent years, we expect that costs for Stages 4 and 5 associated with PMAs, PMA supplements, 510(k) submissions or De Novo classification requests would occur. The recurring cost for year 4 to year 20 is estimated to range between $723.18 million and $4.54 billion, with a primary estimate of $1.65 billion. We estimate the total costs over 20 years to range from $12.57 billion to $78.99 billion, with a primary estimate of $28.61 billion.
The present value of total estimated costs is $20.41 billion at a 3 percent discount rate and $13.64 billion at a 7 percent discount rate over 20 years. The annualized value of costs is $1.37 billion at a 3 percent discount rate and $1.29 billion at a 7 percent discount rate.
**Table 37. Twenty-Year Timing of the Costs (millions 2022$)**
| | Primary | Low | High |
|---|---|---|---|
| Year 1 | $101.46 | $47.85 | $216.75 |
| Year 2 | $113.09 | $54.67 | $233.83 |
| Year 3 | $386.41 | $175.44 | $1,364.29 |
| Year 4-20 (costs for each year) | $1,647.32 | $723.18 | $4,539.61 |
**Total Costs** | **$28,605.32** | **$12,571.97** | **$78,988.22**
**Present Value of Total Costs (3%)** | **$20,407.00** | **$8,972.00** | **$56,376.49**
**Present Value of Total Costs (7%)** | **$13,637.63** | **$5,999.18** | **$37,699.79**
**Annualized Value of Costs (3%)** | **$1,371.67** | **$603.06** | **$3,789.39**
**Annualized Value of Costs (7%)** | **$1,287.30** | **$566.28** | **$3,558.59**
||
###### 6. Other Unquantified Costs
Other unquantified social costs associated with the phaseout policy (or consequences of the costs that have been quantified) may include the impact on prices, access to diagnostics if many laboratories exit the market or discontinue offering certain IVDs rather than incur the costs of compliance with FDA requirements, and/or a decrease in the number of new LDTs due to the
increased operation costs of the phaseout policy. There may be instances in which a laboratory may choose to exit the market or discontinue certain IVDs offered as LDTs due to compliance costs. Without information on the revenues or costs of production of IVDs offered as LDTs, however, we are unable to estimate the impact associated with compliance costs on the prevalence of laboratories exiting the market or discontinuing manufacturing of certain IVDs offered as LDTs.
Our analysis in section III (Final small entity analysis) shows that 22% of estimated receipts from IVDs offered as LDTs come from small laboratories (laboratories with annual receipts of less than $41,500,000), which are more likely to reduce operations or exit the market than large laboratories. However, the enforcement discretion policies discussed here -and in the preamble- make it less likely that these smaller laboratories would reduce operations or exit the market.
However, to the extent that some small laboratories might reduce operations or exit the market, it is possible that larger laboratories might take over the production of certain IVDs offered as LDTs, reducing potential impacts on IVD availability. This might concentrate production in a few large laboratories. Under this scenario, prices for certain IVDs offered as LDTs could increase, reducing overall net social benefits. According to economic theory, production concentration under a few laboratories could increase the risk of supply chain contractions, risking shortages for certain IVDs offered as LDTs and therefore affecting prices and access. Although under monopolistic competition, production of more IVDs offered as LDTs in large laboratories could also result in lower production costs due to the economies of scale associated with the operations of such laboratories, they do not produce at the minimum of their average costs curve and may charge prices higher than their marginal cost.
While we recognize that some laboratories might pass the costs of compliance to their customers by raising prices for IVDs offered as LDTs, increased FDA oversight might also help reduce social costs by helping to support coverage and reimbursement determinations and increasing patient accessibility to IVDs for which there is a reasonable assurance of safety and effectiveness.
We also understand that the increased cost to laboratories under the phaseout policy may reduce the amount of revenue a laboratory can invest in creating and/or modifying IVDs offered as LDTs. This could lead to a reduction in the number of new IVDs offered as LDTs and/or modifications of these which incorporate the most up-to-date scientific knowledge. While this may occur, the increased FDA oversight under the phaseout policy may provide more assurance that new and/or modified IVDs offered as LDTs will provide accurate results.
Finally, it is also possible that some laboratories might decide to switch from an IVD offered as an LDT to an FDA-authorized test or to outsource their testing to other laboratories. According to comments, an FDA-authorized test could cost an additional $6 to $35 per test performed. One comment also stated that outsourcing some testing instead of offering IVDs as LDTs could cost them an additional $3,000 to $6,000 per test, while another stated that outsourcing could cost an additional $760,000 annually. An unknown number of laboratories may pursue outsourcing their testing needs or switching to use of an FDA-authorized test rather than introducing a new test that does not fall within an enforcement discretion policy in the phaseout policy. However, we assume that the cost of switching to an FDA-authorized test when available, would cost less than the cost of submitting a premarket submission. We assume that a laboratory would switch to FDA-authorized tests or outsource their testing needs only if submitting a premarket submission was more costly than either of these alternatives. Either way, the decision would be a private decision made according to their business plan. To the extent that any number of laboratories switch to any number of FDA-authorized tests, or outsource their testing needs, our estimated costs for submitting a PMA or a 510(k) would be overestimated.
##### G. Budgetary Impacts
In addition to the cost to industry of preparing and submitting various submissions to FDA, including MDRs, IDEs, Q-submissions, PMAs, PMA supplements, 510(k)s, and De Novo requests, there would be incremental review costs for FDA to review these additional submissions. FDA is excluding from new review costs LDTs that are expected to be reviewed by NYS CLEP. For LDTs approved by NYS CLEP, FDA intends to exercise enforcement discretion and generally not enforce premarket review requirements. As discussed in appendix A, we estimate that 12.1% (ranging from 6.1% to 24%) of new submissions for IVDs offered as LDTs would not experience new review costs for FDA as a result of FDA’s general enforcement discretion policy with respect to the premarket review requirements for LDTs approved by NYS CLEP.
As mentioned in section II.F.4, FDA assumes that at least 50% of the IVDs offered as LDTs being submitted for 510(k) review will be reviewed under the 510(k) Third Party Review Program. Manufacturers who submit to 3P510k Review Organizations pay the 3P510k Review Organization but do not pay FDA user fees for those submissions. Under the MDUFA V agreement, FDA is currently working to enhance the program with the objective of eliminating routine re-review by FDA of third-party reviews.
To estimate the review costs for FDA, we first use average costs per-page based on premarket submission type used in a prior estimate from the Microbiology Devices; Reclassification of Nucleic Acid-Based Systems for Mycobacterium tuberculosis complex final regulatory impact analysis (Ref. [62]). The current estimate after adjustment for inflation is $864,057 per PMA and $20,565 per 510(k) (or per De Novo).[^81] We also use labor costs from estimated FTEs for FDA review of different submission types, including MDRs, Q-submissions, IDEs, and premarket submissions.[^82] The 3-year average cost of all personnel compensation and benefits paid per FTE at FDA is $315,403 (Ref. [63]). We then multiply this by the estimated FTEs by submission type to estimate the review cost per submission. We use an average of the two estimates for the premarket review cost per submission (we only use the FTEs information for the MDR review cost per listing, IDE cost per submission, and Q-submission cost per submission).
We expect MDR review cost would occur in Stage 1. Multiplying the MDR review cost per listing by the number of MDR submissions yields a total one-time review cost of MDRs between $0.22 million and $0.88 million, with a primary estimate of $0.44 million. Multiplying the review cost per listing by the number of MDR submissions per year yields a total recurring review cost of MDRs between $0.03 million and $0.11 million, with a primary estimate of $0.06 million.
Under stage 2, we expect IDE review cost would incur in year 2. Multiplying the IDE review cost per listing by the number of IDE submissions yields a total one-time review costs of IDEs between $1.16 million and $4.65 million, with a primary estimate of $2.32 million.
The estimated recurring review cost of IDEs range from $2.81 million and $11.24 million, with a primary estimate of $5.62 million.
We expect review costs of Q-submission, PMA, 510(k), and De Novo submissions would incur under stages 4 and 5. To estimate the review cost of Q-submissions, we calculate the number of modified and new IVDs per year subject to premarket review by adding the number of PMA, 510(k), and De Novo submissions.[^83] Multiplying the review cost per Q-submission by the number of new premarket submissions per year yields a total recurring review cost of Q-submissions between $18.63 million and $74.50 million, with a primary estimate of $37.25 million.
The total recurring review cost of PMAs is estimated to range between $29.33 million to $117.30 million, with a primary estimate of $58.65 million. The total recurring review cost of PMA supplements is estimated to range between $0.71 million and $2.82 million, with a primary estimate of $1.41 million. The total recurring review cost of 510(k)s is estimated to range from $11.02 million to $44.06 million, with a primary estimate of $22.03 million. The recurring review cost of De Novo classification requests is estimated to range from $14.92 million to $59.67 million, with a primary estimate of $29.84 million.
Overall, we estimate the total one-time FDA review costs to range between $1.38 million and $5.53 million, with a primary estimate of $2.77 million. We estimate the total recurring FDA review costs to range between $77.43 million and $309.72 million, with a primary estimate of $154.86 million. See Table 38.[^84]
**Table 38. FDA Review Costs by Submission Type**
| | Primary | Low | High |
|---|---|---|---|
| **MDR** | | | |
| FDA review costs using FTE | $5.58 | $5.58 | $5.58 |
| Affected IVDs offered as LDTs on the market | 79,114 | 39,557 | 158,227 |
| Subtotal, one-time (millions)* | $0.44 | $0.22 | $0.88 |
| MDR submissions per year for affected tests | 10,013 | 5,007 | 20,026 |
| Subtotal, recurring (millions)* | $0.06 | $0.03 | $0.11 |
| **IDE** | | | |
| FDA review costs using FTE | $21,763 | $21,763 | $21,763 |
| Affected IVDs offered as LDTs currently on the market | 107 | 53 | 214 |
| Subtotal, one-time (millions)* | $2.32 | $1.16 | $4.65 |
| New IDE submissions per year for affected tests | 258 | 129 | 516 |
| Subtotal, recurring (millions)* | $5.62 | $2.81 | $11.24 |
| **Q-submission** | | | |
| FDA review costs using FTE | $25,548 | $25,548 | $25,548 |
| Premarket submissions per year (PMAs, 510(k)s, and De Novos) for affected tests | 1,454 | 727 | 2,908 |
| Subtotal, recurring (millions)* | $37.14 | $18.57 | $74.28 |
| **PMA** | | | |
| FDA review costs using page numbers | $864,057 | $864,057 | $864,057 |
| FDA review costs using FTE | $294,429 | $294,429 | $294,429 |
| Average FDA review costs | $579,243 | $579,243 | $579,243 |
| PMA Submissions per year for affected tests | 101 | 51 | 203 |
| Subtotal, recurring (millions)* | $58.65 | $29.33 | $117.30 |
| **PMA Supplements** | | | |
| Average FDA review costs | $110,319 | $110,319 | $110,319 |
| Supplements per year for affected tests | 31 | 15 | 61 |
| Subtotal, recurring (millions)** | $1.41 | $0.71 | $2.82 |
| **510(k)** | | | |
| FDA review costs using page numbers | $20,565 | $20,565 | $20,565 |
| FDA review costs using FTE | $19,870 | $19,870 | $19,870 |
| Average FDA review costs | $20,218 | $20,218 | $20,218 |
| 510(k) submissions per year for affected tests | 1,090 | 545 | 2,179 |
| Subtotal, recurring (millions)* | $22.03 | $11.02 | $44.06 |
| **De Novo** | | | |
| FDA review costs using page numbers | $20,565 | $20,565 | $20,565 |
| FDA review costs using FTE | $202,804 | $202,804 | $202,804 |
| **Average FDA review costs** | **$111,685** | **$111,685** | **$111,685** |
| De Novo submissions per year for affected tests | 267 | 134 | 534 |
| **Subtotal, recurring (millions)** | **$29.84** | **$14.92** | **$59.67** |
| **Total one-time costs (millions)** | **$2.77** | **$1.38** | **$5.53** |
| **Total recurring costs (millions)** | **$154.86** | **$77.43** | **$309.72** |
||
Notes: The number of submissions per year include currently marketed tests that would be modified and new tests from both affected entities currently on the market and new entities entering the market per year. The number of premarket submissions per year for Q-submission review costs include all premarket submission types (PMA, 510(k), and De Novo). Totals may not add due to rounding.
*We calculate subtotals by multiplying average FDA review costs by the number of submissions per year.
**We multiply the average FDA review cost per PMA by the FTE weights to calculate the review cost per PMA supplement.
##### H. Transfers
With this phaseout policy, laboratories will pay fees to FDA for establishment registration, premarket submissions (where applicable), and periodic reporting for IVDs with a PMA. While these fees are paid by laboratories, they are revenue for FDA. The approach to estimating fee effects is distinct from the approaches for either benefits or costs, so they will be presented as transfers. Another perspective on the user fees is that they indicate industry bearing costs that are otherwise more simplistically presented as being experienced by FDA; hypothetically, adding the user fee estimates into the cost accounting would double-count effects on net social benefits.
See Table 39 for the estimated transfers associated with the phaseout policy. All anticipated fees are public information published by FDA. Each laboratory is expected to pay an annual registration fee, at a cost of $7,653 per laboratory. Laboratories will also pay for submission of a report annually to FDA for each IVD that has received premarket approval, which costs $16,925 per report. Laboratories will pay $483,560 to FDA for each PMA they submit. For PMA supplements, they will pay $72,534 for each 180-day supplement, $386,848 for each panel-track supplement, and $33,849 for each real-time supplement they submit. They will pay $21,760 for each 510(k) they submit and $145,068 for each De Novo request they submit.
As mentioned in sections II.F.4 and II.G, we assume that at least 50% of the IVDs offered as LDTs being submitted for 510(k) review will be reviewed under the 510(k) Third Party Review Program. We consider the fees paying to 3P510k Review Organizations as costs to industry, as described in section II.F.4 (see Table 33 and Table 34).
Small businesses that have gross receipts or sales of $100 million or less for the most recent tax year (including their affiliates) are eligible to pay a reduced fee for certain submissions, including:
- 510(k) submissions ($5,440 per submission),
- De Novo requests ($36,267 per submission),
- PMAs ($120,890 per submission),
- PMA supplements ($18,134 for each 180-day supplement, $96,712 for each panel-track supplement, and $8,462 for each real-time supplement), and
- PMA annual reports ($4,231 per submission).
Small businesses with sales of $30 million or less are eligible to have the fee waived on their first PMA.
We assume 40 to 90 percent of the laboratories would have gross receipts or sales of $100 million or less, and we use 65 percent (average of 40 and 90 percent) to estimate the number of small business IVDs. Multiplying these fees by the relevant number of laboratories and IVDs, we expect total annual transfers to range from $34.13 million to $137.09 million, with a primary estimate of $68.54 million.
**Table 39. Transfers**
| | Primary | Low | High |
|--------------------------------------|---------|------|-------|
| **Recurring Annual** | | | |
| Registration Annual Fee | $7,653 | $7,653 | $7,653 |
| Entities affected | 1,275 | 638 | 2,551 |
| **Subtotal (millions)** | $9.76 | $4.88 | $19.52 |
| Annual reporting on PMA | | | |
| Fee (Adjusted fee for small entities)| $16,925 | $16,925 | $16,925 |
| ( $4,231) | ($0) | ($4,231) | ($0) |
| IVDs affected, non-small* | 35 | 18 | 71 |
| IVDs affected, small* | 66 | 33 | 132 |
| **Subtotal (millions)** | $0.88 | $0.30 | $1.76 |
| **One-time/Annual** | | | |
| PMA | | | |
| MDUFA Review (Adjusted fee for small entities) | $483,560 | $483,560 | $483,560 |
| ($120,890) | ($120,890) | ($120,890) | ($120,890) |
| IVDs affected, non-small* | 35 | 18 | 71 |
| IVDs affected, small* | 66 | 33 | 132 |
| **Subtotal (millions)** | $25.09 | $12.55| $50.19 |
| PMA Supplements –180-day track | | | |
| MDUFA Review (Adjusted fee for small entities) | $72,534 | $72,534 | $72,534 |
| ($18,134) | ($18,134) | ($18,134) | ($18,134) |
| IVDs affected, non-small* | 2 | 1 | 4 |
| IVDs affected, small* | 4 | 2 | 7 |
| **Subtotal (millions)** | $0.20 | $0.10| $0.40 |
| PMA Supplements – Panel-track | | | |
| MDUFA Review (Adjusted fee for small entities) | $386,848 | $386,848 | $386,848 |
| ($96,712) | ($96,712) | ($96,712) | ($96,712) |
| IVDs affected, non-small* | 1 | 0 | 1 |
| IVDs affected, small* | 1 | 1 | 2 |
| **Subtotal (millions)** | $0.36 | $0.18| $0.71 |
| PMA Supplements – Real-Time | | | |
| MDUFA Review (Adjusted fee for small entities) | $33,849 | $33,849 | $33,849 |
| ($8,462) | ($8,462) | ($8,462) | ($8,462) |
| IVDs affected, non-small* | 5 | 2 | 10 |
| IVDs affected, small* | 9 | 4 | 18 |
| **Subtotal (millions)** | $0.24 | $0.12| $0.48 |
| 510(k) | | | |
| MDUFA Review (Adjusted fee for small entities) | $21,760 | $21,760 | $21,760 |
| ($5,440) | ($5,440) | ($5,440) | ($5,440) |
| IVDs Affected, non-small* | 381 | 191 | 763 |
| IVDs affected, small* | 708 | 354 | 1,417 |
| **Subtotal (millions)** | $12.15 | $6.08| $24.30 |
| De Novo | | | |
| MDUFA Review (Adjusted fee for small entities) | $145,068 | $145,068 | $145,068 |
| ($36,267) | ($36,267) | ($36,267) | ($36,267) |
| IVDs affected, non-small* | 94 | 47 | 187 |
| IVDs affected, small* | 174 | 87 | 347 |
| Subtotal (millions) | $19.86 | $9.93 | $39.72 |
| Total Recurring Transfers (millions) | $68.54 | $34.13 | $137.09 |
||
*The numbers of tests include currently marketed tests that would be modified in such a way as to require premarket review as well as new tests subject to premarket review from existing and new entities per year.
##### I. Stream of Benefits, Costs, and Transfers
We describe how we estimate the benefits, costs, and transfers in sections II.E, II.F, II.G and II.H. See Table 40 for a summary of the timing of expected benefits, costs, and transfers over a twenty-year time frame, in millions of 2022 U.S. dollars. Only primary estimates are presented. For each year, we present the undiscounted benefits, costs to industry, costs to FDA, and transfers.
**Table 40. Undiscounted Twenty-year Flow of Benefits, Costs, and Transfers (millions 2022 USD)**
| Year | Benefits VSLY based on 3% discounting | VSLY based on 7% discounting | Costs to Industry | Costs to FDA | Transfers |
|------|--------------------------------------|------------------------------|------------------|-------------|-----------|
| 1 | $0.00 | $0.00 | $101 | $0 | $0 |
| 2 | $0.00 | $0.00 | $105 | $8 | $10 |
| 3 | $3,111 | $2,725 | $332 | $54 | $23 |
| 4 | $3,151 | $2,760 | $1,492 | $155 | $68 |
| 5 | $4,420 | $3,871 | $1,492 | $155 | $69 |
| 6 | $4,613 | $4,041 | $1,492 | $155 | $69 |
| 7 | $4,786 | $4,192 | $1,492 | $155 | $69 |
| 8 | $4,939 | $4,326 | $1,492 | $155 | $69 |
| 9 | $5,075 | $4,446 | $1,492 | $155 | $69 |
| 10 | $5,197 | $4,552 | $1,492 | $155 | $69 |
| 11 | $5,305 | $4,647 | $1,492 | $155 | $69 |
| 12 | $5,403 | $4,732 | $1,492 | $155 | $69 |
| 13 | $5,490 | $4,808 | $1,492 | $155 | $69 |
| 14 | $5,568 | $4,877 | $1,492 | $155 | $69 |
| 15 | $5,638 | $4,938 | $1,492 | $155 | $69 |
| 16 | $5,701 | $4,994 | $1,492 | $155 | $69 |
| 17 | $5,758 | $5,044 | $1,492 | $155 | $69 |
| 18 | $5,810 | $5,089 | $1,492 | $155 | $69 |
| 19 | $5,856 | $5,130 | $1,492 | $155 | $69 |
| 20 | $5,899 | $5,167 | $1,492 | $155 | $69 |
||
Table 40 shows that for most years in the twenty-year time horizon, FDA review costs are greater than transfers. The total annualized values of FDA review costs, transfers, and the differences are presented in Table 41. These estimates are conducted using our current fiscal year 2024 Medical Device User Fee program (MDUFA) fee structure. We note that user fee payments are only intended to cover a portion of FDA review costs for premarket submissions.
Under the phaseout policy, FDA does not intend to phase out the general enforcement discretion approach for premarket review requirements for high risk IVDs offered as LDTs (Stage 4) before October 1, 2027, or for other IVDs offered as LDTs that require a premarket submission (Stage 5) before April 1, 2028. October 1, 2027, is the start of the next medical device user fee program (i.e., MDUFA VI).^87
**Table 41. Summary of FDA Review Costs and Transfers (Annualized over 20 years, in millions 2022 USD)**
| Discount rate | Primary | Low | High |
|---------------|----------|--------|---------|
| FDA Review Costs 3% | $129.30 | $64.65 | $258.59 |
| FDA Review Costs 7% | $121.39 | $60.69 | $242.77 |
| Transfers 3% | $57.50 | $28.65 | $115.05 |
| Transfers 7% | $40.60 | $20.24 | $81.27 |
| Difference (3%) | $71.80 | $36.00 | $143.54 |
| Difference (7%) | $80.78 | $40.45 | $161.51 |
||
After calculating the expected benefits, costs, and transfers for each year in a twenty-year time horizon, we calculate the present and annualized values using three and seven percent discount rates. See Table 42.
**Table 42. Summary of Present and Annualized Values (in millions 2022$)**
| | Benefits | Costs* | Transfers |
|--------------------------------|-------------|------------|-----------|
| Present Value 7% | $37,176.54 | $13,637.63 | $430.15 |
| Present Value 3% | $64,583.82 | $20,407.00 | $855.46 |
| Annualized Value 7% | $3,509.20 | $1,287.30 | $40.60 |
| Annualized Value 3% | $4,341.05 | $1,371.67 | $57.50 |
||
*The estimated costs include both costs to industry and FDA.
##### J. Analysis of Regulatory Alternatives to the Final Phaseout Policy
We consider four different regulatory alternatives as described below. In our analysis of alternatives, we compare total costs, benefits, and transfers with two options that would be more stringent and one option that would be less stringent. We also consider one alternative of taking no new action. Table 43 summarizes our analysis of the alternatives of the phaseout policy.
*** BERT STOPPED HERE ***
**Table 43. Annualized Values of Regulatory Alternatives Over a 20 Year Period (in billions 2022$)**
| | Final Phaseout Policy | | Alternative 2 | | Alternative 3 | | Alternative 4 | |
|-|---------------------|--|--------------|--|--------------|--|--------------|--|
| | 3% | 7% | 3% | 7% | 3% | 7% | 3% | 7% |
| Total Benefits | $4.34 | $3.51 | $4.39 | $3.57 | $3.94 | $3.10 | $5.14 | $4.21 |
| Total Costs | $1.37 | $1.29 | $1.45 | $1.39 | $1.20 | $1.09 | $5.58 | $5.83 |
| Net Benefits | $2.97 | $2.22 | $2.94 | $2.18 | $2.74 | $2.01 | -$0.44 | -$1.62 |
| Transfers | $0.06 | $0.04 | $0.06 | $0.06 | $0.05 | $0.03 | $0.28 | $0.23 |
||
*Notes: We report primary estimates. There would be no additional costs or benefits under Alternative 1.*
1. We treat one alternative of taking no new action as the baseline for determining the costs and benefits of other alternatives. Under this option, there will be no additional costs or benefits relative to the status quo.
2. The second regulatory alternative reduces the phaseout period to three years following the publication date of the final rule:
- **Stage 1**: beginning 1 year after the publication date of this final rule, FDA will expect compliance with MDR requirements, correction and removal reporting requirements, and QS requirements under § 820.198 (complaint files).
- **Stage 2**: beginning 2 years after the publication date of this final rule, FDA will expect compliance with requirements not covered during other stages of the phaseout policy, including registration and listing, labeling, investigational use requirements, and QS requirements under part 820 (other than requirements under § 820.198 (complaint files), which are already addressed in stage 1).
- **Stage 3**: beginning 3 years after the publication date of this final rule, FDA will expect compliance with premarket review requirements for high-risk IVDs and other premarket review requirements (for moderate-risk and low-risk IVDs that require premarket submissions).
Under this alternative, we assume that one-time and recurring costs of the QS requirements would occur in year 2 and costs of the PMA, 510(k), and De Novo submissions would occur in year 3. The estimated annualized costs of this alternative would be $1.39 billion, which is $99 million higher than the estimated costs associated with the phaseout policy. The estimated annualized transfers of this alternative would be $58 million, which is $17 million higher than the estimated transfers associated with the phaseout policy. The shorter phaseout period would result in higher annualized benefits because they would begin earlier than under the phaseout policy. The estimated annualized benefits of this alternative would be $3.57 billion, which is $56 million higher than the benefits associated with the phaseout policy. However, a shorter phaseout period means that, among other things, affected laboratories, including small laboratories, would have less time to prepare and it might be less feasible for them to come into compliance.
3. The third alternative extends the phaseout period to ten years for small entities (i.e., laboratories that have their annual receipts and sales less than $100 million) and six years for other entities:
- **Stage 1**: beginning 1 year after the publication date of this final rule, FDA will expect compliance with MDR requirements, correction and removal reporting requirements, and QS requirements under § 820.198 (complaint files).
- **Stage 2**: beginning 4 years after the publication date of this final rule, FDA will expect compliance with requirements other than MDR, correction and removal reporting, and QS requirements under part 820 (other than requirements under § 820.198 (complaint files), which are already addressed in stage 1).
- **Stage 3**: beginning 5 years (7 years for small laboratories) after the publication date of this final rule, FDA will expect compliance with respect to premarket review requirements for high-risk IVDs.
- **Stage 4**: beginning 6 years (10 years for small laboratories) after the publication date of this final rule, FDA will expect compliance with respect to premarket review requirements for moderate risk and low risk IVDs that require premarket submissions.
Compared to the final phaseout policy, having a longer phaseout period would reduce the burden on the affected laboratories by shifting costs into the future. Costs for Stage 2 under the phaseout policy (including compliance with registration and listing, labeling, and investigational use requirements) would occur in year 2, and costs for Stage 3 under the phaseout policy (relating to compliance with QS requirements) would occur in year 3, but we assume that costs for Stage 2 under this alternative (which would include the costs for Stage 2 and Stage 3 under the phaseout policy) would occur in year 4. We assume that costs for Stage 3 under this option would occur in year 5 (year 7 for small entities). We finally assume that costs for Stage 4 under this option would occur in year 6 (year 10 for small entities). The affected laboratories would thus have lower costs under Stages 2 to 4, except that the costs for Stage 1 would still occur in the first year after issuance of the final phaseout policy. The estimated annualized costs of this alternative would be approximately $1.09 billion, which is $202 million less than the estimated costs associated with the phaseout policy. Out of the estimated annualized costs, the estimated annualized costs to FDA would be approximately $96 million under this alternative, which is $25 million less than the estimated FDA review costs with the phaseout policy. In addition, the longer phaseout period for small laboratories would mean that these entities would have more time to prepare premarket submissions, potentially making it more feasible for them to come into compliance. However, this option would also reduce annualized benefits by $411 million because extending the phaseout period to six years (and ten years for small laboratories) will reduce the number of avoided harms from problematic IVDs.
4. In the fourth alternative, we assume the same phaseout policy as proposed in the preamble to the proposed rule. Under this alternative, there would be one-time costs of the QS requirements and premarket review requirements because FDA would be phasing out the general enforcement discretion approach for currently marketed IVDs offered as LDTs under stages 3 through 5.
The affected laboratories would thus have higher total costs. The estimated annualized costs of this alternative would be approximately $5.83 billion, which is $4.55 billion higher than the estimated costs associated with the final phaseout policy. This alternative would also increase annualized transfers by $194 million. Since this alternative does not consider premarket reviews by third parties or NYSDOH, the costs to FDA would be higher than the estimated costs of the final phaseout policy. We estimate that costs to FDA with this alternative would increase by $552 million, from $121 million to $673 million.
The benefits would increase because the number of affected tests under stages 3 through 5 would be higher than under the final phaseout policy. We estimate that the benefits associated with this alternative would be approximately $4.21 billion, which is $703 million higher than the estimated benefits of the final phaseout policy. Table 44 below summarizes primary estimates of the costs by stage of the phaseout policy and alternative 4. The cost reduction of the final phaseout policy compared to this alternative is primarily due changes in stages 3 through 5 due to the enforcement discretion policies. See Table 19 for the impact of the enforcement discretion policies on the benefits.
**Table 44. Costs of the Final Phaseout Policy and Alternative 4 (millions 2022$)**
| Stage | Description | Final Phaseout Policy | Alternative 4 |
|--------|--------------------------------------------------------|-----------------------|----------------|
| Stage 1 | Reading and Understanding the Phaseout Policy | $3.91 | $3.91 |
| | Medical Device Reporting | $95.24 | $95.24 |
| | Correction and Removal Reporting | $0.18 | $0.18 |
| | Complaint Records | $2.13 | - |
| Stage 2 | Registration and Listing Requirements | $0.58 | $0.58 |
| | Labeling Requirements | $4.55 | $4.55 |
| | Investigational Use Requirements | $25.47 | $25.47 |
| Stage 3 | Quality System Requirements | $26.06 | $472.19 |
| Stage 4 | Premarket Approval Application | $503.91 | $21,589.11 |
| | Premarket Approval Application Supplements | $14.76 | $289.24 |
| Stage 5 | 510(k) Submission | $825.47 | $13,746.59 |
| | De Novo Classification Request | $177.50 | $2,882.49 |
||
*Notes: We only report primary estimates. The estimated costs include one-time costs and recurring costs per year. The estimated costs include both costs to industry and FDA.*
##### K. Distributional Effects
Phasing out the general enforcement discretion approach for LDTs might generate benefits and costs that accrue differentially to establishments and segments of society. In this section, we discuss health equity effects for populations on which IVDs offered as LDTs are used. We address differential effects for small entities in section III of this analysis.
As described in section II.E, we expect the phaseout policy to increase the accuracy of laboratory test results, reducing the incidence of patient diagnostic error and resulting in more appropriate treatments and improved health outcomes, among other benefits. While we would not expect the benefits of the phaseout policy – in isolation – to differentially affect certain population segments, existing inequities in healthcare access might result in differential accrual of benefits across the general population. For example, there is evidence of disparities in access to tests (Ref. [64]) which might impact the patient populations that the benefits of the phaseout policy would reach. FDA also recognizes that IVDs offered as LDTs might serve communities in rural, medically underserved areas with disparities in access to diagnostic tests.
However, the benefits of test access depend on the ability of tests to work as intended, and the harms of unsafe or ineffective IVDs offered as LDTs might disproportionately occur among medically underserved patient populations that such tests might aim to reach. Without appropriate oversight, IVDs offered as LDTs might exacerbate health disparities. Research reports higher rates of inaccurate results among underrepresented patient populations, particularly racial and ethnic minorities undergoing genetic tests (Refs. [65, 66, 67, 68, 69]).
Additionally, some IVDs offered as LDTs have not been validated for use in all patient populations who may have the relevant health condition, across ages or ethnicities, meaning that it is unknown how well the test might perform across diverse patient populations expected to use the test, and tests might be less accurate in underrepresented patient populations, which could contribute to health disparities (Ref. [70]).
The role of IVDs offered as LDTs in either ameliorating or exacerbating existing health inequity ultimately depends on the safety and effectiveness of IVDs offered as LDTs, which the phaseout policy is intended to help assure. By increasing its oversight, FDA might better prevent and mitigate harms disproportionately realized among underrepresented, medically underserved populations. As such, the benefits of phasing out the general enforcement discretion approach for LDTs might differentially reach these populations.
When IVDs are subject to increased FDA oversight, FDA will help ensure that information is available pertaining to device safety and effectiveness for specific demographic characteristics if performance differs within the target population, through the enforcement of applicable labeling requirements. In addition, when FDA conducts premarket review of a device, FDA may ask that sponsors provide data for different intended patient populations. With new FDA authorities under the Food and Drug Omnibus Reform Act of 2022 (FDORA), sponsors will generally be required to submit diversity action plans to FDA, including the sponsor’s goals for enrollment in device clinical studies, to help improve the generalizability of the results to the intended use population. In contrast, with limited oversight over these IVDs, FDA does not know whether validation studies for these IVDs include diverse patient populations. FDA believes increased oversight for these IVDs will help ensure adequate representation of the intended use population in validation studies and transparency regarding potential differential performance, helping to advance health equity.
Nonetheless, while phasing out the general enforcement discretion approach for LDTs might help to advance health equity, we have no specific data showing that increased FDA oversight of IVDs offered as LDTs will necessarily reduce health disparities.
As described in section II.F.6, pass-through of costs to provide IVDs offered as LDTs might in turn create additional costs to society. If laboratories pass through the cost of compliance to the costs of IVDs offered as LDTs, test frequency might decrease for areas that rely on IVDs offered as LDTs for easy, rapid access to tests. If laboratories or healthcare facilities respond to increased compliance costs by increasing the prices of IVDs offered as LDTs or reducing the availability of IVDs offered as LDTs, there might thus be an increase in health inequity. Vulnerable populations that rely on IVDs offered as LDTs for diagnosis might have less access to diagnostic tests in general after the implementation of the phaseout policy.
However, in the absence of assurances about the safety and effectiveness of these tests, the value of access is uncertain. We further note that in the event any currently marketed tests for underserved populations are withdrawn from the market due to their inability to meet regulatory requirements, other manufacturers may fill the need with appropriately designed and validated tests.
We do not expect the phaseout policy to result in an increase in health inequity in isolation. Though we do have evidence of existing health inequities in diagnostic tests and clinical trials across sociodemographic populations, we lack the evidence to quantify the effect of the phaseout policy on these existing health inequities, and thus cannot determine whether the phaseout policy will ameliorate or exacerbate health inequity. By increasing oversight over IVDs offered as LDTs, FDA may better prevent and mitigate harm to patients that might result from inaccurate and unreliable tests, including patients in underserved populations.
##### L. International Effects
While the phaseout policy will generate benefits that accrue to the domestic population, some laboratories that are located outside the United States would be expected to comply with applicable device requirements, as a result of the phaseout of the general enforcement discretion approach for LDTs, if those laboratories offer IVDs as LDTs to patients within the United States. This section estimates the cost of compliance for international laboratories. These costs are not included in section II.F, which only assesses domestic costs.
As of January 2024, there are 74 international laboratories certified under CLIA to perform non-waived testing. Based on available information and professional judgment, we assume that 100% of CLIA-certified international laboratories are performing high complexity testing and have IVDs offered as LDTs. While our historical experience indicates that these laboratories likely offer a smaller number of IVDs offered as LDTs, as they are typically offering more specialized tests, for the cost estimates, we use the same assumption described in section II.D that each laboratory would have 67 IVDs offered as LDTs, and thus we expect 496 (= 74 x 67) international IVDs offered as LDTs to be affected by the phaseout policy. We also assume 592 (74 x (6+2)) modified (an additional 2 annually) and new (an additional 6 annually) international IVDs offered as LDTs to be affected annually, consistent with assumptions in section II.D.
We also adjust wages to reflect the fact that international laboratories may not offer the same wages as those in the United States. Specifically, we create a list of the unique countries that appear in our data on the 74 international laboratories, then search the National Bureau of Economic Research (NBER) Occupational Wages around the World (OWW) database for wage information for the relevant countries. The most recent year with complete data is 2007. We observe the average hourly wage rate across all sectors for the relevant countries in U.S. dollars, then divide by the same measure for U.S. wages to get a relative measure of wages as percent deviation from the U.S. hourly wage rate for the same period. We then take the average percent deviation across the relevant countries and find that wages for the relevant international countries are 73% that of U.S. wages for the same time period. We therefore adjust the wages we use in the domestic cost analysis by 0.73 to assess international costs.
Aside from coverage and wage rates, the costs for international laboratories are calculated using the exact same methods as in section II.F. Because there are significantly fewer laboratories and tests, and wages are slightly lower, international costs are much lower than domestic costs of compliance. See Table 45 for a summary of international costs, organized by stage and part of the phaseout policy.
**Table 45. International Costs**
| | Primary | Low | High |
|--|---------|-----|------|
| One-time | | | |
| Stage 1 | | | |
| Reading and Understanding the Rule | $165,541 | $74,494 | $279,351 |
| Medical Device Reporting | $612,171 | $498,064 | $752,796 |
| Correction and Removal Reporting | $1,850 | $1,850 | $1,850 |
| Complaint Records | $96,644 | $55,225 | $138,062 |
| Stage 2 | | | |
| Registration and Listing Requirements | $18,669 | $18,669 | $18,669 |
| Labeling Requirements | $192,916 | $49,785 | $336,048 |
| **Investigational Use Requirements** | $466,943 | $466,943 | $466,943 |
| Stage 3 | | | |
| Quality System Requirements | $96,644 | $55,225 | $138,062 |
| **Total One-time Costs** | **$1,651,379** | **$1,220,255** | **$2,131,781** |
| **Recurring Annual** | | | |
| Stage 1 | | | |
| Medical Device Reporting | $3,707,098 | $3,707,090 | $3,707,106 |
| Correction and Removal Reporting | $6,845 | $6,845 | $6,845 |
| Re-registration | $6,223 | $6,223 | $6,223 |
| Stage 2 | | | |
| Investigational Use | $1,129,027 | $1,129,027 | $1,129,027 |
| Premarket Approval Application | $59,172,917 | $56,088,281 | $117,781,004 |
| Stage 4 | | | |
| Premarket Approval Application Supplements | $1,733,605 | $1,640,318 | $3,506,047 |
| Stage 5 | | | |
| 510(k) Submission | $104,382,781 | $96,222,502 | $112,543,060 |
| De Novo Classification Request | $20,842,241 | $11,086,707 | $20,942,297 |
| **Total Recurring Costs** | **$190,980,737** | **$169,886,993** | **$259,621,610** |
||
See Table 46 for a summary of the expected timing and annualized value of international costs. At a three percent discount rate, we expect the annualized value of international costs to range from $140.29 million to $214.98 million, with a primary estimate of $157.50 million. At a seven percent discount rate, we expect the annualized value of international costs to range from $131.23 million to $201.26 million, with a primary estimate of $147.26 million.
**Table 46. Twenty-Year Timing of International Costs (millions 2022$)**
| | Primary | Low | High |
|--------------------------|---------|---------|---------|
| Year 1 | $4.59 | $4.34 | $4.89 |
| Year 2 | $5.53 | $5.38 | $5.67 |
| Year 3 | $35.40 | $33.77 | $65.63 |
| Year 4-20 (costs for each year) | $190.98 | $169.89 | $259.62 |
| **Total Costs of the Phaseout Policy** | **$3,292.19** | **$2,931.58** | **$4,489.76** |
| Present Value of Total Costs (3%) | $2,343.16 | $2,087.14 | $3,198.30 |
| Present Value of Total Costs (7%) | $1,560.07 | $1,390.28 | $2,132.20 |
| **Annualized Value of Costs (3%)** | **$157.50** | **$140.29** | **$214.98** |
| **Annualized Value of Costs (7%)** | **$147.26** | **$131.23** | **$201.26** |
||
#### III. Final Small Entity Analysis
The Regulatory Flexibility Act requires agencies to analyze regulatory options that would minimize any significant impact of a rule on small entities. Because most facilities that will be affected by the phaseout of the general enforcement discretion approach for LDTs are defined as small businesses and the phaseout policy is likely to impose a substantial burden on the affected small entities, we find that the phaseout policy will have a significant economic impact on a substantial number of small entities. This analysis, as well as other sections in this document and the final rule, serves as the Final Regulatory Flexibility Analysis, as required under the Regulatory Flexibility Act.
##### A. Description and Number of Affected Small Entities
We used detailed data from 2017 Statistics of U.S. Businesses on U.S. 6-digit NAICS detailed employment sizes and revenues to analyze the potential impacts of the phaseout policy on small entities. The Small Business Administration (SBA) considers Medical Laboratories (NAICS code 621511) to be small if their annual receipts are less than $41.5 million. Since not all laboratories in this NAICS code offer IVDs as LDTs, we use the number of affected laboratories and distribute them proportionally across the revenue distribution from the Economic Census to estimate breakdown of the laboratories by revenue size (see Table 47). Of the 1,181 laboratories, 1,085 laboratories (those with less than $41.5 million in annual receipts), or 92 percent of the total, would be small according to the 2023 SBA size standard. We estimate that small businesses also manufacture 22% of IVDs offered as LDTs currently on the market. We provide more detail on these estimates in Appendix B.
**Table 47. Distribution of Revenues for Laboratories Offering IVDs as LDTs**
| Receipts Size ($1,000) | Number of Laboratories Under NAICS Code 621511 | Number of Laboratories Offering IVDs as LDTs | Number of IVDs offered as LDTs |
|------------------------|-----------------------------------------------|---------------------------------------------|----------------------------------|
| < $150 | 438 | 166 | 56 |
| $151 - $999 | 933 | 327 | 625 |
| $1000 - $1,999 | 413 | 145 | 754 |
| $2,000 - $3,999 | 481 | 169 | 1,948 |
| $4,000 - $5,999 | 343 | 120 | 3,061 |
| $6,000 - $9,999 | 146 | 51 | 2,150 |
| $10,000 - $14,999 | 77 | 27 | 1,489 |
| $15,000 - $19,999 | 115 | 40 | 3,114 |
| $20,000 - $24,999 | 79 | 28 | 2,920 |
| $25,000 - $29,999 | 21 | 7 | 951 |
| $30,000 - $39,999 | 43 | 15 | 2,270 |
| $40,000 - $49,999 | 15 | 5 | 1,151 |
| $50,000 - $99,999 | 67 | 24 | 5,475 |
| $100,000 + | 194 | 68 | 63,163 |
| **Total** | 3,365 | 1,193 | 89,127 |
| < $41.5 million | 3,091 | 1,097 | 19,510 |
| **Percent Small** | **92%** | **92%** | **22%** |
||
##### B. Description of the Potential Impacts of the Phaseout Policy on Small Entities
We compiled the costs and transfers associated with the phaseout policy and compared them to the estimated share of annual receipts of the laboratories offering IVDs as LDTs. In Table 48, we estimate the total annualized costs per entity at a 7 percent discount rate over 20 years and the costs as a percent of revenue by receipts size. The estimated annualized cost per small entity ranges from $4,395 to $3,045,766 per laboratory, depending on its size.
As shown in Table 48, the annualized costs per small entity averages $232,618 represent 5.8 percent of receipts for the small laboratories (with annual receipts of less than $41,500,000). Because we don’t know how costs would be distributed across entities, we estimate average costs per laboratory by their receipt size categories using the assumption that costs are distributed proportionally to receipts and for this reason costs as a percent of receipts appear to be constant across all receipt size categories.
The extent in which smaller laboratories may be disproportionately impacted by the phaseout of the general enforcement discretion approach for LDTs, is dependent on the number of IVD's offered as LDTs per lab. FDA anticipates that the enforcement discretion policies discussed in the preamble of the final rule will moderate these concerns and help to avoid complete disruption to the test market. As noted in Appendix B-Table 8, the average costs per LDT are smallest for stages 1 through 3 of the phaseout policy representing 10% of costs and up to 59% of affected tests, whereas average costs per LDT for stages 4 and 5 represent 90% of costs affecting 3% of tests. The percentage of tests that may experience costs under stages 4 and 5 will increase as new laboratories and tests enter the market during and after stages 4 and 5, as they will fall within the enforcement discretion policy for currently marketed tests. However, they may still fall within the scope of other enforcement discretion policies described in the preamble to the final rule, including those for unmet needs and LDTs approved by NYS CLEP. However, in the event that a new lab does not fall within the scope of other enforcement discretion policies, costs under stages 4 and 5 could present as a potential barrier to entry in the LDT market for new laboratories. In Table B7 of Appendix B, total costs and transfers of the phaseout policy are estimated to be on average anywhere between about 2.54, 5.8 and 16 percent for all entities. We do not have the information about labs to determine how the average estimates are distributed among the firms according to their size categories. Depending on profit margins with respect to revenue, the costs of this rule may be prohibitive for some small labs, making it likely for some small entities in this size category to exit the market, reduce operations, sell the business, be subject to acquisitions by larger firms or not enter the market. If profit margins were too small for many small firms considering the costs, it is possible that selling to large entities, would further cause industry consolidation and contribute to the growth of monopolies in the industry which would hinder competition.
While we do not have the data on profit margins to properly estimate the number of labs that would be adversely impacted by this rule, we estimate that small laboratories make fewer IVDs offered as LDTs than large firms. We estimate that small labs make up 92 percent of all labs, and that they also hold a 24 percent share of IVDs offered as LDTs. With the low number of IVDs offered as LDTs per small lab, it is more likely that the percent of costs over receipts per lab would be closer to our low average estimate 2.5 percent. Furthermore, for the final rule, as explained in comments 17 and 18, FDA intends to exercise enforcement discretion with respect to premarket review and QS requirements (except for applicable requirements under 21 CFR 820, subpart M (Records)) for currently marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of the final rule and that are not modified, or that are modified as described in the preamble and for LDTs developed by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system (as described in section V.B.3 of the preamble), we do not expect significant market concentration or market exit to result from the phaseout policy.
Small businesses that have gross receipts or sales of $100 million or less for the most recent tax year (including their affiliates) are eligible to pay a reduced fee for certain submissions, including 510(k) submissions, De Novo classification requests, PMAs, and PMA annual reports. The estimated average recurring transfer for small businesses is $4,069. As seen in Table 48, the percentage of receipts that are additional transfers associated with the phaseout policy are estimated to be 0.10 percent for 166 laboratories (15 percent of the small entities) with their annual receipts less than $150,000.
**Table 48. Small Business Costs and Transfers as a Percentage of Receipts**
| Receipts Size ($1,000) | Labs | Average Receipts | Total Costs per Lab | Costs as a % of Receipts | Total Transfers per Lab | Transfers as a % of Receipts |
|------------------------|------|------------------|---------------------|--------------------------|------------------------|-----------------------------|
| < $150 | 166 | $75,755 | $4,395 | 5.8% | $76 | 0.10% |
| $151 - $999 | 327 | $430,532 | $24,978 | 5.8% | $434 | 0.10% |
| $1000 - $1,999 | 145 | $1,172,533 | $68,026 | 5.8% | $1,181 | 0.10% |
| $2,000 - $3,999 | 169 | $2,601,807 | $150,947 | 5.8% | $261 | 0.10% |
| $4,000 - $5,999 | 120 | $5,733,410 | $332,631 | 5.8% | $5,775 | 0.10% |
| $6,000 - $9,999 | 51 | $9,459,407 | $548,799 | 5.8% | $9,528 | 0.10% |
| $10,000 - $14,999 | 27 | $12,425,958 | $720,908 | 5.8% | $12,516 | 0.10% |
| $15,000 - $19,999 | 40 | $17,395,652 | $1,009,231 | 5.8% | $17,521 | 0.10% |
| $20,000 - $24,999 | 28 | $23,750,766 | $1,377,930 | 5.8% | $23,922 | 0.10% |
| $25,000 - $29,999 | 7 | $29,082,108 | $1,687,235 | 5.8% | $29,292 | 0.10% |
| $30,000 - $39,999 | 15 | $33,924,383 | $1,968,166 | 5.8% | $34,169 | 0.10% |
| $40,000 - $49,999 | 5 | $49,317,674 | $2,861,227 | 5.8% | $92,157 | 0.19% |
| $50,000 - $99,999 | 24 | $52,498,495 | $3,045,766 | 5.8% | $106,083 | 0.20% |
| $100,000 + | 68 | $209,184,656 | $12,136,110 | 5.8% | $422,695 | 0.20% |
| Total | 1,193| $16,841,846 | $977,101 | 5.8% | $30,296 | 0.18% |
| < $41.5 M | 1,097| $4,009,525 | $232,618 | 5.8% | $4,069 | 0.10% |
| Percent small | 92% | 24% | 24% | 100% | 13% | 56.42% |
||
##### C. Alternatives to Minimize the Burden on Small Entities
Regulatory alternative 3, described in section II.J, would reduce costs for all laboratories by extending the phaseout period to ten years for small entities and six years for other entities. Below we show how the reduction in cost under the alternative would reduce the cost on small laboratories, if it were implemented.
The alternative that could reduce the impact to small entities would be an extended phaseout policy from 4 years to 10 years for small laboratories as discussed in section II.J.3 ("third alternative"). Compared with the final phaseout policy, small laboratories would have lower one-time and recurring costs for Stage 2 of the third alternative because they generally would have an additional one to two years before FDA would expect compliance with these requirements (e.g., labeling, registration and listing, investigational use, and QS requirements). There would also be an additional 3.5 years for the compliance expectations for PMA requirements and 6 years for the compliance expectations for 510(k) and De Novo requirements. The costs associated with Stage 1 would be unimpacted by the extended phaseout policy as the costs would still occur in the first year after issuance of the final phaseout policy.
We estimate this option would reduce total costs by $690 to $478,302 per small entity. For all laboratories, total recurring costs are estimated to be 4.9 percent of their average receipts. This alternative would also reduce transfers for all laboratories offering IVDs as LDTs from an average of $4,069 to $2,055 per entity for laboratories with their annual receipts below $41.5 million, which is $2,014 less than the estimated transfers of the phaseout policy. For the smallest laboratories (with annual receipts lower than $150,000), total transfers would be 0.05% percent of receipts. See Table 49.
**Table 49. Small Business Costs and Transfers as a Percentage of Receipts under Regulatory Alternative 3**
| Receipts Size ($1,000) | Labs | Average Receipts | Costs Per Lab (7%) | Costs as a % of Receipts | Transfers Per Lab (7%) | Transfers as a % of Receipts |
|------------------------|------|------------------|--------------------|--------------------------|------------------------|------------------------------|
| < $150 | 166 | $75,755 | $3,705 | 4.9% | $38 | 0.05% |
| $151 - $999 | 327 | $430,532 | $21,055 | 4.9% | $217 | 0.05% |
| $1000 - $1,999 | 145 | $1,172,533 | $57,343 | 4.9% | $591 | 0.05% |
| $2,000 - $3,999 | 169 | $2,601,807 | $127,243 | 4.9% | $1,312 | 0.05% |
| $4,000 - $5,999 | 120 | $5,733,410 | $280,395 | 4.9% | $2,890 | 0.05% |
| $6,000 - $9,999 | 51 | $9,459,407 | $462,617 | 4.9% | $4,769 | 0.05% |
| $10,000 - $14,999 | 27 | $12,425,958 | $607,697 | 4.9% | $6,264 | 0.05% |
| $15,000 - $19,999 | 40 | $17,395,652 | $850,743 | 4.9% | $8,769 | 0.05% |
| $20,000 - $24,999 | 28 | $23,750,766 | $1,161,542 | 4.9% | $11,973 | 0.05% |
| $25,000 - $29,999 | 7 | $29,082,108 | $1,422,274 | 4.9% | $14,660 | 0.05% |
| $30,000 - $39,999 | 15 | $33,924,383 | $1,659,088 | 4.9% | $17,101 | 0.05% |
| $40,000 - $49,999 | 5 | $49,317,674 | $2,411,904 | 4.9% | $71,741 | 0.15% |
| $50,000 - $99,999 | 24 | $52,498,495 | $2,567,464 | 4.9% | $85,176 | 0.16% |
| $100,000 + | 68 | $209,184,656 | $10,230,325 | 4.9% | $339,391 | 0.16% |
| Total | 1,193| $16,841,846 | $823,658 | 68.5% | $23,202 | 0.14% |
| < $41.5 M | 1,097| $4,009,525 | $196,088 | 4.9% | $2,055 | 0.05% |
||
#### IV. References
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#### Appendix A. Estimation of the Number of Affected Labs and Tests
##### Number of Affected Labs
To obtain the number of laboratories and tests affected by the phaseout policy, we use data from the Centers for Medicare & Medicaid Services (CMS) that shows the number of laboratories by laboratory type (column A in Table A.1).[^96] Only laboratories that are certified under CLIA and meet the regulatory requirements under CLIA to perform high complexity testing are affected by the phaseout policy since LDTs are high complexity. To determine the number of affected high complexity laboratories, we must first determine the number of non-waived laboratories (column C in Table A.1) and then estimate how many of those can perform high complexity testing versus only moderate complexity testing. We determine the number of non-waived laboratories by excluding the number of laboratories whose certificate type is microscopy or waiver (column B in Table A.1). Since laboratories are certified only as waived or non-waived, without specific notation on whether they meet the regulatory requirements for high complexity testing or only moderate complexity testing, the estimate for how many of the non-waived laboratories can perform high complexity testing is based on FDA professional judgement and historical knowledge. Therefore, we estimated the percent of each laboratory type that was likely to be high complexity to determine the high complexity rate (column D). We then estimate the number of high complexity laboratories affected by the phaseout policy by multiplying column C times high complexity rate in column D (column E). We estimate that there are 11,808 high complexity CLIA laboratories. This is close to our original estimate of 12,000 used in the preliminary analysis (Ref. [1]) and a 2021 report from the Pew Charitable Trust (Ref. [12]) that also estimated that there are approximately 12,000 CLIA-certified laboratories performing high complexity testing.
As explained in section II.D.1, we rely on the information about laboratories and tests in NYS to estimate the percent of high complexity laboratories that make IVDs offered as LDTs. From the NYSDOH data, we calculate that approximately 10% of laboratories located in NYS that are certified under CLIA and that meet the regulatory requirements under CLIA to perform high complexity testing are developing IVDs offered as LDTs. We assume that NYS is representative of the U.S. laboratory community. We therefore estimate that approximately 10% of 11,808 (or 1,181) laboratories in the U.S. that are certified under CLIA and that meet the regulatory requirements under CLIA to perform high complexity testing currently manufacture IVDs offered as LDTs. To account for potential variability across the country, we estimate the proportion of high complexity laboratories making IVDs offered as LDTs to vary from 5% of 11,808 (or 590) laboratories to a high estimate of 20% of 11,808 (or 2,362) affected laboratories by reducing the primary estimate by 50% and doubling the primary estimate, respectively. In addition, we assume that there would be new laboratories entering the market every year (approximately 8 percent of the affected high complexity laboratories making IVDs offered as LDTs, ranging from 47 to 189, with a primary estimate of 94). While there are also likely laboratories that exit the market each year, we have not subtracted expected departing laboratory numbers from our cost estimates.
**Table A.1 Number of Affected Laboratories by Laboratory Type**
| Laboratory Type | (A) Total | (B) Waiver and Microscopy | (C) Difference (A) - (B) | (D) High Complexity Rate | (E) No. HC Labs (C) x (D) | (F) Integrated Healthcare System Rate | (G) No. HC Labs within Healthcare System (E) x (F) |
|---------------------|-----------|---------------------------|--------------------------|--------------------------|--------------------------|-------------------------------------|-----------------------------------------------|
| Physician Office ** | 123,726 | 108,696 | 15,030 | 0 | - | - | - |
| Other ** | 39,524 | 36,162 | 3,362 | 0.5 | 1,681 | 0 | - |
| Pharmacy** | 29,120 | 29,110 | 10 | 0 | - | - |
| Intermediate Care Facility | 28,758 | 28,705 | 53 | 0 | - | - |
| Skilled Nursing/Nursing Facility | 15,154 | 15,109 | 45 | 0 | - | - |
| Home Health Agency | 13,824 | 13,809 | 15 | 0 | - | - |
| Assisted Living Facility | 12,019 | 12,015 | 4 | 0 | - | - |
| Hospital | 9,399 | 2,599 | 6,800| 0.5 | 3,400 | 1 | 3,400 |
| Independent | 9,198 | 3,602 | 5,596| 0.75 | 4,197 | 0 | - |
| Community Clinic | 8,165 | 6,686 | 1,479| 0.5 | 740 | 0.66 | 488 |
| End Stage Renal Disease Dialysis | 7,301 | 7,294 | 7 | 0 | - | - |
| Ambulatory Surgery Center | 7,150 | 6,719 | 431 | 0.75 | 323 | 0.5 | 162 |
| Other Practitioner | 6,688 | 6,653 | 215 | 0 | - | - |
| School/Student Health Service | 6,729 | 6,599 | 130 | 0 | - | - |
| Ambulance | 5,968 | 5,917 | 51 | 0 | - | - |
| Hospice | 5,100 | 5,091 | 9 | 0 | - | - |
| Federally Qualified Health Center | 4,556 | 4,332 | 224 | 0.5 | 112 | 0 | - |
| Ancillary Test Site | 3,700 | 2,811 | 889 | 0.75 | 667 | 0.5 | 333 |
| Mobile Lab | 3,219 | 3,131 | 88 | 0.25 | 22 | 0.75 | 17 |
| Rural Health Care Clinic | 2,726 | 2,512 | 214 | 0.25 | 54 | 0.25 | 13 |
| Industrial | 1,771 | 1,751 | 20 | 0.5 | 10 | 0 | - |
| Comprehensive Outpatient Rehab | 1,230 | 1,214 | 16 | 0.5 | 8 | 0.5 | 4 |
| Prison | 1,204 | 1,168 | 36 | 0.5 | 18 | 0 | - |
| Public Health Laboratory | 1,015 | 777 | 238 | 1 | 238 | 0 | - |
| Health Maintenance Org | 695 | 536 | 159 | 0.5 | 80 | 0.5 | 40 |
| Health Fair | 617 | 608 | 9 | 0 | - | - |
| Blood Banks | 426 | 167 | 259 | 1 | 259 | 0.5 | 130 |
| Insurance | 45 | 42 | 3 | 0 | - | - |
| **Total** | **349,207** | **313,815** | **35,392** | | **11,808** | **4,586** |
||
##### Number of Affected Tests
We estimate the number of affected tests using information from NYSDOH. We then estimate the number of affected tests subject to different requirements and that would fall under different enforcement policies by adjusting the number of tests to account for the number that are currently marketed, the number expected to be impacted by potential reclassification of Class III IVDs to Class II IVDs, the number of LDTs expected to be for unmet needs in an integrated health care system, and the number of LDTs estimated to be reviewed by NYS CLEP each year.
1) Using NYSDOH Information
Using the NYSDOH information, FDA calculates that each laboratory that manufactures IVDs offers an average of 67 IVDs as LDTs and introduces an average of 6 new IVDs offered as LDTs per year (see section II.D.1 for details of the calculation). Multiplying 67 IVDs per lab by the number of affected laboratories, it is estimated that the number of affected currently marketed IVDs offered as LDTs ranges from 39,557 (=590 x 67) to 158,227 (=2,362 x 67), with a primary estimate of 79,114 (=1,181 x 67). Multiplying 6 new IVDs offered as LDTs per laboratory by the number of affected laboratories, we estimate 3,542, 7,085, or 14,170 new IVDs offered as LDTs may be affected per year. We also estimate new IVDs offered as LDTs from new laboratories entering the market every year (8 percent of affected laboratories). The total number of new IVDs offered as LDTs per year is estimated to range from 3,826 to 15,303, with a primary estimate of 7,652.
FDA generally intends to exercise enforcement discretion with respect to premarket review requirements for currently marketed IVDs offered as LDTs and LDTs manufactured and performed by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system. To estimate the number of high complexity laboratories within integrated healthcare systems which may fall under the enforcement discretion policy for unmet needs (column G in Table A.1 above), we first multiply the number of high complexity laboratories in each laboratory type in each row in Column E by the estimated rate of integrated healthcare system in Column F for that laboratory type. As with the high complexity rate, to determine the estimated rate of integrated healthcare system laboratories, we used professional judgment and historical knowledge to estimate the percent of high complexity laboratories we expect would be part of an integrated healthcare system for each laboratory type. We estimate that there are approximately 4,586 high complexity laboratories that may be part of an integrated healthcare system. Applying the proportion of high complexity laboratories making IVDs offered as LDTs (5%, 10%, 20%) to this estimate, we estimate the number of high complexity laboratories with LDTs within integrated healthcare systems to range from 229 (=5% x 4,586) to 917 (=20% x 4,586), with a primary estimate of 459 (=10% x 4,586). We assume that about 40 to 70 percent of LDTs from these high complexity laboratories integrated within healthcare systems are likely to be for unmet needs. The estimated number of LDTs that are likely to be for unmet needs range from 10,755 to 24,582, with a primary estimate of 16,900 (see Table A.2).
**Table A.2 Number of Affected Laboratories and LDTs For Unmet Needs**
| Number of affected labs and tests | Primary | Low | High | Calculation |
|----------------------------------|---------|------|-------|---------------------|
| Affected labs (A) | 1,181 | 590 | 2,362 | 11,808 * 5-20% |
| Affected IVDs offered as LDTs on the market (B) | 79,114 | 39,557 | 158,227 | A * 67 |
| New IVDs offered as LDTs per year (C) | 7,652 | 3,826 | 15,303 | A * 1.08 * 6 |
| Affected labs for unmet needs (D) | 459 | 229 | 917 | 4,586 * 5-20% |
| Affected LDTs on the market for unmet needs (E) | 16,900 | 10,755 | 24,582 | D * 67 * 40-70% |
| New LDTs for unmet needs (F) | 1,635 | 1,040 | 2,377 | D * 1.08 * 6 * 40-70% |
| Affected IVDs offered as LDTs excluding LDTs for unmet needs | 62,213 | 28,802 | 133,645 | B - E |
| New IVDs offered as LDTs excluding LDTs for unmet needs | 6,017 | 2,786 | 12,926 | C - F |
||
*Note: Product across table may not be exact due to rounding.*
Table A.3 shows the number of affected IVDs offered as LDTs by submission type, excluding tests for unmet needs, using the primary estimates from Table A.2. As explained in section II.D.1, we also expect that among currently-marketed IVDs offered as LDTs that were first marketed prior to the date of issuance of the rule, 2 IVDs will be modified per laboratory per year in a manner that falls outside of the enforcement discretion policy for currently marketed IVDs offered as LDTs and will thus be expected to undergo premarket review (2,362 = 1,181 affected labs * 2). We then add this number to the number of new tests (10,013 = 2,362 + 7,652) to estimate total number of new tests in column A of Table A.3. We further break down these estimates by submission type to estimate compliance costs. As mentioned in section II.F.2, we estimate that approximately 50 percent of IVDs currently undergo premarket review (5,007 = 10,013 * 0.5). In addition, we assume that about 40 percent are offered after 510(k) clearance (4,005 = 10,013 * 0.40), 5 percent after De Novo classification (501 = 10,013 * 0.05), and 5 percent after premarket approval (501 = 10,013 * 0.05). We assume these estimated percentages also apply to IVDs offered as LDTs and apply these shares to the estimated total number of affected tests, minus the number of affected tests expected to be offered under an enforcement policy without premarket submission, to estimate the number of IVDs offered as LDTs by submission type. For 2,139 LDTs for unmet needs (2,139 = 459 * 2 * 55% + 1,635)98, we estimate that approximately 10 percent are offered after premarket approval (214 = 2,139 * 0.10), 80 percent after 510(k) clearance (1,711 = 2,139 * 0.80), and 10 percent after De Novo classification (214 = 2,139 * 0.10). We then subtract the number of new LDTs for unmet needs (column B of Table A.3) from the number of new IVDs offered as LDTs (column A of Table A.3) to calculate the number of new IVDs offered as LDTs excluding LDTs for unmet needs.
**Table A.3 Number of IVDs offered as LDTs Per Year Excluding LDTs For Unmet Needs**
|| No. IVDs offered as LDTs, total (A) | No. LDTs for unmet needs (B) | No. IVDs offered as LDTs excluding LDTs for unmet needs (A - B) |
|-------------------------------------|-----------------------------|-------------------------------------------------------------|-------------------------------------------------------------|
| Total | 10,013 | 2,139 | 7,874 |
| Exempt | 5,007 | - | 5,007 |
| PMA | 501 | 214 | 287 |
| 510 (k) | 4,005 | 1,711 | 2,294 |
| De Novo | 501 | 214 | 287 |
||
2) **Reclassification adjustment**
On January 31, 2024, FDA announced its intent to initiate the reclassification process for most IVDs that are currently Class III into Class II. The majority of these tests are infectious disease and companion diagnostic IVDs. Reclassification would allow manufacturers of certain types of tests to seek marketing clearance through the less burdensome 510(k) pathway rather than the PMA pathway. FDA also intends to continue taking a risk-based approach in the initial classification of IVDs to determine the appropriate level of regulatory controls and whether a new test may be classified into Class II through De Novo classification (and special controls established), rather than being class III and subject to the PMA pathway. Based on our experience, we believe that special controls could be developed that, along with general controls, could provide a reasonable assurance of safety and effectiveness for most future companion diagnostic and infectious disease IVDs. As such, first of a kind submission for such tests would be expected to submit a De Novo, with follow-on IVDs submitting 510(k) notifications. Therefore, our estimates for the number of affected IVDs that will be subject to certain requirements were adjusted based on the anticipated number of submissions following the potential reclassifications and considering that most future companion diagnostic and infectious disease IVDs would be reviewed through the De Novo and 510(k) pathways.
To estimate anticipated rates of submissions going forward, we rely on historical data for total IVD original and supplemental PMA submissions where FDA review started in the last ten fiscal years (FY 2014-2023). We use information for IVD PMA submissions received per fiscal year for certain CDRH-regulated infectious disease and companion diagnostic tests that have either been recently down classified or for which FDA intends to propose reclassification (Table A.4). The number of estimated De Novo submissions per year going forward is estimated based on the number of “first of a kind (FOAK)” original PMA submissions since, going forward, we would expect new FOAK tests to submit a De Novo instead of a PMA. The number of estimated 510(k) submissions per year going forward is estimated by considering the number of non-FOAK original PMA submissions as well as PMA supplements since, going forward, we would expect these submissions to be 510(k)s instead. (We excluded “135-Day Review Track for 30-Day Notice” and “Special CBE” PMA supplement types from our counts since no 510(k) would be expected for these types of modifications for Class II devices).
We use these data to calculate the reduction in anticipated PMA submissions and the increase in anticipated De Novo and 510(k) submissions going forward, following potential reclassification and considering that most future companion diagnostic and infectious disease IVDs would be Class II. This is represented by the last three columns of Table A.4, showing the rate of remaining PMAs, the rate of new De Novos, and the rate of new 510(k)s anticipated per year, respectively. Then we use these rates to determine the new estimates, as shown in Table A.5. For example, we multiply the remaining PMA rate (Column F of Table A.4) of 0.40 by the estimated number of PMAs before potential reclassification (Table A.5) to obtain the number of PMAs expected after potential reclassification (287 * 0.40 = 115) (Table A.5). We then multiply the De Novo rate of 0.06 (Column G of Table A.4) by the number of PMAs before potential...
reclassification and add to the number of De Novo submissions before potential reclassification to estimate the number of De Novo submissions after potential reclassification (287 * 0.06 + 287 = 304) (Table A.5).
**Table A.4 Rate of Potential Reclassification of PMA Submission Per Fiscal Year (FY 2014-2023)**
| Review Track | (A) Average Historical IVD submissions per Year | (B) # from column A that fall into proceeds considered for reclassification | (C) Average FOAK used to estimate future # De Novo per Year | (D) Average non-FOAK used to estimate future # 510(k) per Year | (E) Estimated # Remaining PMA per year in future | (F) Remaining PMA Rate =(E)/(A) | (G) De Novo Rate =(C)/(A) | (H) 510(k) Rate =(D)/(A) |
|---------------------------------|-----------------------------------------------|-------------------------------------------------------------|-------------------------------------------------------------|-------------------------------------------------------------|---------------------------------|---------------------------|-----------------------------|---------------------------|
| PMA Original | 11.7 | 7.0 | 0.7 | 6.3 | 4.7 | 0.40 | 0.06 | 0.54 |
| 135 Review Track For 30-Day Notice | 13.7 | 5.3 | 0.0 | 0.0 | 8.4 | 0.61 | 0.00 | 0.00 |
| Normal 180 Day Track | 27.4 | 17.3 | 0.0 | 17.3 | 10.1 | 0.37 | 0.00 | 0.63 |
| Normal 180 Day Track No User Fee| 15.8 | 9.4 | 0.0 | 9.4 | 6.4 | 0.41 | 0.00 | 0.59 |
| Panel Track | 7.7 | 4.8 | 0.0 | 4.8 | 2.9 | 0.38 | 0.00 | 0.62 |
| Real-Time Process | 53.3 | 25.9 | 0.0 | 25.9 | 27.4 | 0.51 | 0.00 | 0.49 |
| Special CBE | 11.3 | 5.5 | 0.0 | 0.0 | 5.8 | 0.51 | 0.00 | 0.00 |
||
**Table A.5 Number of Submissions for IVDs offered as LDTs Before and After Potential Reclassification**
| Submission Type | Before Potential Reclassification | After Potential Reclassification |
|--------------------|-----------------------------------|----------------------------------|
| | Primary | Low | High | Primary | Low | High |
| PMA | 287 | 143 | 574 | 115 | 58 | 230 |
| 510(k) | 2,294 | 1,147| 4,588 | 2,479 | 1,239| 4,958 |
| De Novo | 287 | 143 | 574 | 304 | 152 | 608 |
| PMA supplements | 67 | 33 | 133 | 35 | 17 | 70 |
||
3) **NYS CLEP review adjustment**
As discussed in the preamble, FDA intends to exercise enforcement discretion and generally not enforce premarket review requirements for LDTs that are approved by NYS CLEP. Therefore, we reduce the estimated number of premarket submissions to FDA by the number of premarket submissions expected to go to NYS CLEP. We use an estimate of the number of premarket submissions expected to be reviewed by NYS CLEP, rather than an estimate of the number of LDTs expected to be approved by NYS CLEP, due to the assumption that neither NYS CLEP nor FDA will approve/authorize 100% of the submissions reviewed, and workload costs are based on the number of submissions reviewed, not the number approved/authorized.
NYSDOH provided information indicating that they review an average of 888 LDTs per year, including high risk, moderate risk, low risk, and clinical trial IVDs based on NYSDOH criteria. Accounting for FDA’s assumption that 50% of IVDs offered as LDTs will be low risk and not subject to premarket review and that 21% of new IVDs offered as LDTs per year will fall within the enforcement discretion policy for unmet needs (0.21 = 1,635 new LDTs for unmet needs per year / 7,652 new IVDs offered as LDTs per year; see Table A.2), we estimate that an average of 351 (= [100% - 21%] x 50% x 888) new IVDs offered as LDTs per year that would normally be submitted to FDA for premarket review would not undergo FDA premarket review as a result of the enforcement discretion policy with respect to LDTs approved by NYS CLEP.
We then estimate that 12.1% of premarket submissions for IVDs offered as LDTs would be reviewed by NYS CLEP (and that these would not be submitted to FDA for review) by dividing 351 by 2,898 (the total number of new PMAs, 510(k)s, and De Novo submissions per year for affected tests, see Table A.5), excluding those that would be under the unmet needs enforcement discretion policy (0.121 = 351 / 2,898).
We thus exclude 12.1% from the number of affected tests after potential reclassification (Table A.5). Table A.6 below shows the final number of premarket submissions for IVDs offered as LDTs, excluding tests for unmet needs and submissions for LDTs expected to be reviewed by NYS CLEP, when estimating the costs of Stages 4 and 5 in section II.F.4. For example, we estimate the number of PMAs to be 101 (=115 - 115*0.121).
**Table A.6 Number of IVD Submissions After Potential Reclassification and Excluding Tests for Unmet Needs and LDTs Reviewed by NYS CLEP**
| Submission Type | Primary | Low | High |
|--------------------|---------|------|------|
| PMA | 101 | 51 | 203 |
| 510(k) | 2,179 | 1,090| 4,359|
| De Novo | 267 | 134 | 534 |
| PMA supplements | 31 | 15 | 61 |
||
### Appendix B. Final Small Entity Analysis Estimates
The purpose of this Appendix is to explain the steps for calculating the number of laboratories and existing IVDs offered as LDTs per receipt size category that was used for Section III. Final Small Entity Analysis. In Table 48 of Section III. Final Small Entity Analysis, we used detailed data from 2017 Statistics of U.S. Businesses on U.S. 6-digit NAICS detailed employment sizes and revenues to analyze the potential impacts of the phaseout policy on small entities. We initially use our estimated total market revenue for IVDs offered as LDTs of $14 billion in the bottom of column E in Table B.1 as our total annual receipts and extrapolate the share of annual receipt by enterprise size from the 2017 Census data corresponding to NAICS code 621511. This estimate is based on the assumption that 35% of revenue for this NAICS category is from IVDs offered as LDTs. ^99^ We also re-classify enterprise size categories given our new estimated average receipts per lab (Table B.2).
|**Table B.1 Growth Adjusted Annual Receipts from IVDs Offered as LDTs by Enterprise Size (2022, U.S. Dollars)**| ||
|----|--------------------------|-------|
| Number of Firms and Receipts by Enterprise Receipt Size 2017 | Receipts Only IVDs Offered as | Calculation |
||
| I | Enterprise Size ($1,000) | Firms | Receipts ($1,000) D | LDTs ($1,000) in 2022 dollars adjusted for growth since 2017 E | |
|---|---------------------|-------|-----------------|------------------------------------------|---------------------------|
| 1 | < $150 | 438 | $22,315 | $12,575 | E Total * D1/D Total |
| 2 | $151 - $999 | 933 | $250,134 | $140,954 | E Total * D2/D Total |
| 3 | $1000 - $1,999 | 413 | $301,551 | $169,929 | E Total * D3/D Total |
| 4 | $2,000 - $3,999 | 481 | $779,302 | $439,148 | E Total * D4/D Total |
| 5 | $4,000 - $5,999 | 343 | $1,224,596 | $690,078 | E Total * D5/D Total |
| 6 | $6,000 - $9,999 | 146 | $860,008 | $484,627 | E Total * D6/D Total |
| 7 | $10,000 - $14,999 | 77 | $595,808 | $335,747 | E Total * D7/D Total |
| 8 | $15,000 - $19,999 | 115 | $1,245,731 | $701,988 | E Total * D8/D Total |
| 9 | $20,000 - $24,999 | 79 | $1,168,397 | $658,409 | E Total * D9/D Total |
| 10 | $25,000 - $29,999 | 21 | $380,304 | $214,307 | E Total * D10/D Total |
| 11 | $30,000 - $39,999 | 43 | $908,377 | $511,884 | E Total * D11/D Total |
| 12 | $40,000 - $49,999 | 15 | $460,659 | $259,588 | E Total * D12/D Total |
| 13 | $50,000 - $99,999 | 67 | $2,190,319 | $1,234,278 | E Total * D13/D Total |
| 14 | $100,000 + | 194 | $25,270,700 | $14,240,421 | E Total * D14/D Total |
| | Total | 3,365 | $35,658,201 | $20,093,935 | |
||
We estimate the number of labs by receipt size category by the same proportion as the number of firms by receipt category from the Census data. For example, for firms with annual receipts less than <$150,000 we divided 438 by 3,365 and multiply by 1,275 (total LDT labs) to obtain 166 (438/3,365*1,275 = 166). We repeat this calculation for the rest of the rows. We then estimate the average receipts per laboratory by receipt size category.
**Table B.2 Estimated Number of LDT Laboratories and Average Annual Receipts per Laboratory (2022 U.S. dollars)**
| i | Enterprise Size ($1,000) | Firms | Receipts ($1,000) | Receipts IVDs Offered as LDTs Only ($1,000) in 2022 dollars adjusted for growth since 2017 | LDT Labs (1,181) | Average Receipts per lab |
|----|--------------------------|-------|------------------|------------------------------------------------------------------------------------------|------------------|--------------------------|
| 1 | < $150 | 438 | $22,315 | $12,575 | 166 | $76 |
| 2 | $151 - $499 | 933 | $250,134 | $140,954 | 354 | $399 |
| 3 | $500 - $999 | 413 | $301,551 | $169,929 | 157 | $1,086 |
| 4 | $1,000 - $2,999 | 481 | $779,302 | $439,148 | 182 | $2,409 |
| 5 | $3,000 - $5,999 | 343 | $1,224,596 | $690,078 | 130 | $5,309 |
| 6 | $6,000 - $7,999 | 146 | $860,008 | $484,627 | 55 | $8,759 |
| 7 | $8,000 - $9,999 | 77 | $595,808 | $335,747 | 29 | $11,506 |
| 8 | $10,000 - $14,999 | 115 | $1,245,731 | $701,988 | 44 | $16,107 |
| 9 | $15,000 - $19,999 | 79 | $1,168,397 | $658,409 | 30 | $21,991 |
| 10 | $20,000 - $23,999 | 21 | $380,304 | $214,307 | 8 | $26,928 |
| 11 | $24,000 - $29,999 | 43 | $908,377 | $511,884 | 16 | $31,411 |
| 12 | $30,000 - $35,999 | 15 | $460,659 | $259,588 | 6 | $45,665 |
| 13 | $36,000 - $99,999 | 67 | $2,190,319 | $1,234,278 | 25 | $48,610 |
| 14 | $100,000 + | 194 | $25,270,700 | $14,240,421 | 74 | $193,689 |
| Total | 3,365 | $35,658,201 | $20,093,935 | 1,275 | $15,757 |
||
We obtain the number of IVDs offered as LDTs per receipts size category in column D by multiplying column C times 79,114 (which is our estimated number of affected IVDs offered as LDTs currently on the market, as described in section II.D.1). See Table B.3.
**Table B.3 Share of LDTs Offered as LDTs and IVDs Offered as LDTs per Receipt Category**
| i | Enterprise Size ($1,000) | Percent Firms by Receipt Size A | LDT LABS B = A x 1,181 | Percent Receipts by Receipt Size C | IVDs offered as LDTs per receipt category * D |
|----|--------------------------|--------------------------------|------------------------|-----------------------------------|-----------------------------------------------|
| 1 | < $150 | 13% | 166 | 0.06% | 56 |
| 2 | $151 - $999 | 28% | 354 | 0.70% | 625 |
| 3 | $1000 - $1,999 | 12% | 157 | 0.85% | 754 |
| 4 | $2,000 - $3,999 | 14% | 182 | 2.19% | 1,948 |
| 5 | $4,000 - $5,999 | 10% | 130 | 3.43% | 3,061 |
| 6 | $6,000 - $9,999 | 4% | 55 | 2.41% | 2,150 |
| 7 | $10,000 - $14,999 | 2% | 29 | 1.67% | 1,489 |
| 8 | $15,000 - $19,999 | 3% | 44 | 3.49% | 3,114 |
| 9 | $20,000 - $24,999 | 2% | 30 | 3.28% | 2,920 |
| 10 | $25,000 - $29,999 | 1% | 8 | 1.07% | 951 |
| 11 | $30,000 - $39,999 | 1% | 16 | 2.55% | 2,270 |
| 12 | $40,000 - $49,999 | 0% | 6 | 1.29% | 1,151 |
| 13 | $50,000 - $99,999 | 2% | 25 | 6.14% | 5,475 |
| 14 | $100,000 + | 6% | 74 | 70.87% | 63,163 |
| Total | 100% | 1,275 | | | 89,127 |
||
\* Column D is the product of each row in Column C and 79,114.
The following four tables show detailed calculations leading to estimating cost as a percent of receipts using the primary, low and high estimates.
**Table B.4 Detailed Calculations for Percent Receipts and Average Receipts per Lab**
| i | Enterprise Size ($1,000) | LDT Labs A | Receipts by Size Category B | Percent Receipts by Receipt Category C = B / B_total | Average Receipts per Lab D = B / A |
|----|--------------------------|------------|-----------------------------|-----------------------------------------------------|-----------------------------------|
| 1 | < $150 | 166 | $12,574,839 | 0.06% | $75,755 |
| 2 | $151 - $999 | 327 | $140,954,286 | 0.70% | $430,532 |
| 3 | $1000 - $1,999 | 145 | $169,928,542 | 0.85% | $1,172,533 |
| 4 | $2,000 - $3,999 | 169 | $439,148,446 | 2.19% | $2,601,807 |
| 5 | $4,000 - $5,999 | 120 | $690,078,339 | 3.43% | $5,733,410 |
| 6 | $6,000 - $9,999 | 51 | $484,627,495 | 2.41% | $9,459,407 |
| 7 | $10,000 - $14,999 | 27 | $335,746,086 | 1.67% | $12,425,958 |
| 8 | $15,000 - $19,999 | 24 | $701,988,231 | 3.49% | $17,395,652 |
| 9 | $20,000 - $23,999 | 28 | $658,409,354 | 3.28% | $23,750,766 |
| 10 | $25,000 - $29,999 | 7 | $214,307,047 | 1.07% | $29,082,108 |
| 11 | $30,000 - $39,999 | 15 | $511,884,157 | 2.55% | $33,924,383 |
| 12 | $40,000 - $49,999 | 5 | $259,588,803 | 1.29% | $49,317,674 |
| 13 | $50,000 - $99,999 | 24 | $1,234,277,833 | 6.14% | $52,498,495 |
| 14 | $100,000 + | 68 | $14,240,421,072 | 70.87% | $209,184,656 |
| | Total | 1,193 | $20,093,934,751 | | $16,841,846 |
||
**Table B.5 Annualized Costs by Receipt Category - Primary, Low and High Estimates**
| i | Enterprise Size ($1,000) | Annualized Cost by Receipt Category Primary, Low and High Estimates (7%) |||
|----|--------------------------|----------------------------------------------------------------------------|--------------------------|----------------------------------------------------------------------------|
| | Calculation | E (primary) = $1,165,774,775 x C_i | E (low) = $510,386,965 x C_i | E (high) = $3,222,662,070 x C_i |
| 1 | $151 - $999 | $729,545 | $319,402 | $2,016,751 |
| 2 | $1000 - $1,999 | $8,177,639 | $3,580,246 | $22,606,226 |
| 3 | $2,000 - $3,999 | $9,858,617 | $4,316,194 | $27,253,113 |
| 4 | $4,000 - $5,999 | $25,477,747 | $11,154,393 | $70,430,558 |
| 5 | $6,000 - $9,999 | $40,035,759 | $17,528,025 | $110,674,655 |
| 6 | $10,000 - $14,999 | $28,116,271 | $12,309,563 | $77,724,481 |
| 7 | $15,000 - $19,999 | $19,478,771 | $8,527,986 | $53,847,019 |
| 8 | $20,000 - $24,999 | $40,726,726 | $17,830,537 | $112,584,761 |
| 9 | $25,000 - $29,999 | $38,198,443 | $16,723,631 | $105,595,588 |
| 10 | $30,000 - $39,999 | $12,433,292 | $5,443,410 | $34,370,530 |
| 11 | $40,000 - $49,999 | $29,697,600 | $13,001,884 | $82,095,900 |
| 12 | $50,000 - $99,999 | $15,060,340 | $6,593,556 | $41,632,731 |
| 13 | $100,000 + | $71,608,173 | $31,350,720 | $197,953,283 |
| 14 | Total | $826,175,853 | $361,707,420| $2,283,876,474|
| | Total | $1,165,774,775| $510,386,965| $3,222,662,070
||
**Table B.6 Annualized Costs per Lab Receipt Category - Primary, Low and High Estimates**
| Enterprise Size ($1,000) | Annualized Cost per lab by Receipt Category | Primary, Low and High Estimates (7%) |||
|--------------------------|---------------------------------------------|--------------------------------------|---------------------------------------------|--------------------------------------|
| i | Calculation | F (primary) = F (low) = F (high) = |
| | | E (primary) / Aᵢ | E (low) / Aᵢ | E (high) / Aᵢ |
| 1 | <$150 | $4,395 | $1,924 | $12,150 |
| 2 | $151 - $999 | $24,978 | $10,936 | $69,049 |
| 3 | $1000 - $1,999 | $68,026 | $29,782 | $188,051 |
| 4 | $2,000 - $3,999 | $150,947 | $66,086 | $417,277 |
| 5 | $4,000 - $5,999 | $332,631 | $145,629 | $919,523 |
| 6 | $6,000 - $9,999 | $548,799 | $240,269 | $1,517,098|
| 7 | $10,000 - $14,999 | $720,908 | $315,620 | $1,992,873|
| 8 | $15,000 - $19,999 | $1,009,231 | $441,850 | $2,789,912|
| 9 | $20,000 - $24,999 | $1,377,930 | $603,271 | $3,809,144|
| 10 | $25,000 - $29,999 | $1,687,235 | $738,687 | $4,664,184|
| 11 | $30,000 - $39,999 | $1,968,166 | $861,681 | $5,440,787|
| 12 | $40,000 - $49,999 | $2,681,227 | $1,252,671 | $7,909,561|
| 13 | $50,000 - $99,999 | $3,045,766 | $1,333,464 | $8,419,700|
| 14 | $100,000 + | $12,136,110 | $5,313,301 | $33,549,002|
| | Total | $977,101 | $427,784 | $2,701,093 |
||
**Table B.7 Costs as a Percent of Receipts - Primary, Low and High Estimates**
| Enterprise Size ($1,000) | Annualized Cost as a Percent of Receipts per lab | Primary, Low and High Estimates (7%) | ||
|--------------------------|-------------------------------------------------|--------------------------------------|-------------------------------------------------|--------------------------------------|
| i | Calculation | G (primary) = F (primary) / Dᵢ | G (low) = F (low) / Dᵢ | G (high) = F (high) / Dᵢ |
| 1 | $151 - $999 | 5.80% | 2.54% | 16.04% |
| 2 | $1000 - $1,999 | 5.80% | 2.54% | 16.04% |
| 3 | $2,000 - $3,999 | 5.80% | 2.54% | 16.04% |
| 4 | $4,000 - $5,999 | 5.80% | 2.54% | 16.04% |
| 5 | $6,000 - $9,999 | 5.80% | 2.54% | 16.04% |
| 6 | $10,000 - $14,999 | 5.80% | 2.54% | 16.04% |
| 7 | $15,000 - $19,999 | 5.80% | 2.54% | 16.04% |
| 8 | $20,000 - $24,999 | 5.80% | 2.54% | 16.04% |
| 9 | $25,000 - $29,999 | 5.80% | 2.54% | 16.04% |
| 10 | $30,000 - $39,999 | 5.80% | 2.54% | 16.04% |
| 11 | $40,000 - $49,999 | 5.80% | 2.54% | 16.04% |
| 12 | $50,000 - $99,999 | 5.80% | 2.54% | 16.04% |
| 13 | $100,000 + | 5.80% | 2.54% | 16.04% |
| | Total | 5.80% | 2.54% | 16.04% |
||
Table B.8 below, describes total discounted costs to industry along with the percent share of costs by stage, LDTs affected, costs per LDT along with percent affected tests, entities affected and cost per lab.
**Table B.8 Discounted Costs to Industry and Percentage, by affected LDTs, by Entity and by Stage**
| Stage | Discounted Costs ($ Millions, 7%, 20 years) | Percent Costs | LDTs Affected | Costs per LDT | Percent Tests Affected | Entities Affected | Costs per Lab |
|--------|--------------------------------------------|---------------|---------------|---------------|------------------------|-------------------|---------------|
| Stage 1 | $83 | 7% | 10,013 | $8,335 | 11% | 1,275 | $65,457 |
| Stage 2 | $12 | 1% | 10,013 | $1,187 | 11% | 1,275 | $9,326 |
| Stage 3 | $21 | 2% | 52,641 | $391 | 59% | 849 | $24,216 |
| Stage 4 | $361 | 31% | 132 | $2,735,305 | 0.1% | 849 | $424,763 |
| Stage 5 | $689 | 59% | 2,446 | $281,807 | 3% | 849 | $812,045 |
| Total | $1,166 | 100% | | $3,027,025 | | | $1,335,807 |
||
## CIVIL COVER SHEET
The JS 44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law, except as provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet. (SEE INSTRUCTIONS ON NEXT PAGE OF THIS FORM.)
I:
(a) PLAINTIFFS: American Clinical Laboratory Association, et al.
DEFENDANTS: US Food and Drug Administration, et al.
(b) County of Residence of First Listed Plaintiff: Washington, DC
(EXCEPT IN U.S. PLAINTIFF CASES)
County of Residence of First Listed Defendant: [blank]
(IN U.S. PLAINTIFF CASES ONLY)
NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LAND INVOLVED.
(c) Attorneys (Firm Name, Address, and Telephone Number):
King & Spalding LLP, 500 W 2nd Street, Ste 1800, Austin, TX 78701, (512) 457-2000
Attorneys (If Known): [blank]
II. BASIS OF JURISDICTION (Place an "X" in One Box Only):
□ 1 U.S. Government Plaintiff
[X] 2 U.S. Government Defendant
□ 3 Federal Question (U.S. Government Not a Party)
□ 4 Diversity (Indicate Citizenship of Parties in Item III)
III. CITIZENSHIP OF PRINCIPAL PARTIES (Place an "X" in One Box for Plaintiff and One Box for Defendant):
PTF DEF
□ 1 □ 1 Citizen of This State
□ 2 □ 2 Citizen of Another State
□ 3 □ 3 Citizen or Subject of a Foreign Country
□ 4 □ 4 Incorporated or Principal Place of Business In This State
□ 5 □ 5 Incorporated and Principal Place of Business In Another State
□ 6 □ 6 Foreign Nation
IV. NATURE OF SUIT (Place an "X" in One Box Only):
CONTRACT:
□ 110 Insurance
□ 120 Marine
□ 130 Miller Act
□ 140 Negotiable Instrument
□ 150 Recovery of Overpayment & Enforcement of Judgment
□ 151 Medicare Act
□ 152 Recovery of Defaulted Student Loans (Excludes Veterans)
□ 153 Recovery of Overpayment of Veteran's Benefits
□ 160 Stockholders' Suits
□ 190 Other Contract
□ 195 Contract Product Liability
□ 196 Franchise
REAL PROPERTY:
□ 210 Land Condemnation
□ 220 Foreclosure
□ 230 Rent Lease & Ejectment
□ 240 Torts to Land
□ 245 Tort Product Liability
□ 290 All Other Real Property
TORTS
PERSONAL INJURY:
□ 310 Airplane
□ 315 Airplane Product Liability
□ 320 Assault, Libel & Slander
□ 330 Federal Employers' Liability
□ 340 Marine
□ 345 Marine Product Liability
□ 350 Motor Vehicle
□ 355 Motor Vehicle Product Liability
□ 360 Other Personal Injury
□ 362 Personal Injury - Medical Malpractice
PERSONAL INJURY:
□ 365 Personal Injury - Product Liability
□ 367 Health Care/Pharmaceutical Personal Injury Product Liability
□ 368 Asbestos Personal Injury Product Liability
PERSONAL PROPERTY:
□ 370 Other Fraud
□ 371 Truth in Lending
□ 380 Other Personal Property Damage
□ 385 Property Damage Product Liability
CIVIL RIGHTS:
□ 440 Other Civil Rights
□ 441 Voting
□ 442 Employment
□ 443 Housing/Accommodations
□ 445 Amer. w/Disabilities - Employment
□ 446 Amer. w/Disabilities - Other
□ 448 Education
PRISONER PETITIONS:
Habeas Corpus:
□ 463 Alien Detainee
□ 510 Motions to Vacate Sentence
□ 530 General
□ 535 Death Penalty
Other:
□ 540 Mandamus & Other
□ 550 Civil Rights
□ 555 Prison Condition
□ 560 Civil Detainee - Conditions of Confinement
FORFEITURE/PENALTY:
□ 625 Drug Related Seizure of Property 21 USC 881
□ 690 Other
LABOR:
□ 710 Fair Labor Standards Act
□ 720 Labor/Management Relations
□ 740 Railway Labor Act
□ 751 Family and Medical Leave Act
□ 790 Other Labor Litigation
□ 791 Employee Retirement Income Security Act
BANKRUPTCY:
□ 422 Appeal 28 USC 158
□ 423 Withdrawal 28 USC 157
INTELLECTUAL PROPERTY RIGHTS:
□ 820 Copyrights
□ 830 Patent
□ 835 Patent - Abbreviated New Drug Application
□ 840 Trademark
□ 880 Defend Trade Secrets Act of 2016
SOCIAL SECURITY:
□ 861 HIA (1395ff)
□ 862 Black Lung (923)
□ 863 DIWC/DIWW (405(g))
□ 864 SSID Title XVI
□ 865 RSI (405(g))
FEDERAL TAX SUITS:
□ 870 Taxes (U.S. Plaintiff or Defendant)
□ 871 IRS—Third Party 26 USC 7609
IMMIGRATION:
□ 462 Naturalization Application
□ 465 Other Immigration Actions
OTHER STATUTES:
□ 375 False Claims Act
□ 376 Qui Tam (31 USC 3729(a))
□ 400 State Reapportionment
□ 410 Antitrust
□ 430 Banks and Banking
□ 450 Commerce
□ 460 Deportation
□ 470 Racketeer Influenced and Corrupt Organizations
□ 480 Consumer Credit (15 USC 1681 or 1692)
□ 485 Telephone Consumer Protection Act
□ 490 Cable/Sat TV
□ 850 Securities/Commodities Exchange
□ 890 Other Statutory Actions
□ 891 Agricultural Acts
□ 893 Environmental Matters
□ 895 Freedom of Information Act
□ 896 Arbitration
[X] 899 Administrative Procedure Act/Review or Appeal of Agency Decision
□ 950 Constitutionality of State Statutes
Here is the complete text extraction from the image, going through each section:
V. ORIGIN (Place an "X" in One Box Only)
[X] 1 Original Proceeding
□ 2 Removed from State Court
□ 3 Remanded from Appellate Court
□ 4 Reinstated or Reopened
□ 5 Transferred from Another District (specify)
□ 6 Multidistrict Litigation - Transfer
□ 8 Multidistrict Litigation - Direct File
VI. CAUSE OF ACTION
"Cite the U.S. Civil Statute under which you are filing (Do not cite jurisdictional statutes unless diversity):"
5 U.S.C. § 701 et seq., 21 U.S.C. § 301 et seq.
"Brief description of cause:"
Challenge to FDA final rule under Administrative Procedure Act
VII. REQUESTED IN COMPLAINT:
□ CHECK IF THIS IS A CLASS ACTION UNDER RULE 23, F.R.Cv.P.
DEMAND $
CHECK YES only if demanded in complaint:
JURY DEMAND: □ Yes □ No
VIII. RELATED CASE(S) IF ANY
(See instructions):
□ JUDGE _________________________ DOCKET NUMBER _________________________
DATE: 05/29/2024
SIGNATURE OF ATTORNEY OF RECORD: /s/Edward F. Fernandes
FOR OFFICE USE ONLY:
RECEIPT #
AMOUNT
APPLYING IFP
JUDGE
MAG. JUDGE
---
[^1]: "A laboratory developed test (LDT) is a type of in vitro diagnostic test that is designed, manufactured and used within a single laboratory." https://www.fda.gov/medical-devices/vitro-diagnostics/laboratory-developed-tests (Sept. 27, 2018).
[^2]: Given that FDA has not expressed its view in a rule subject to notice and comment rulemaking, its determination that an LTD is a medical device would not enjoy Chevron deference, but rather lesser Skidmore deference.
[^3]: 21st Century Cures: Examining the Regulation of Laboratory Developed Tests, Before the H. Comm. on Energy and Commerce Health Subcomm. 113 Cong. 91 (2014) (preliminary transcript) ("21st Century Cures hearing") (statement of Dr. Jeffrey Shuren, Director, CDRH. FDA); see also id. at 68.
[^4]: Pursuant to a delegation of authority from the Secretary of HHS, FDA is delegated limited authority under CLIA, to "implement CLIA's complexity categorization provisions as they apply to commercially available tests . . ." https://www.govinfo.gov/content/pkg/FR-2004-04-27/pdf/04-9527.pdf (emphasis added). This authority pertains to categorizing the complexity of such tests for purposes of CLIA. As discussed below, this involves physical test kits that are "commercially available" in interstate commerce, and not the type of laboratory developed testing at issue in this memorandum. This delegation of authority was recognized in statutory language in section 3057 of the 21st Century Cures Act. The Centers for Disease Control and Prevention (CDC) also provides analysis, research, and technical assistance with respect to CLIA and manages the Clinical Laboratory Improvement Advisory Committee (CLIAC).
[^3]: The new estimate of 69 IVDs offered as LDTs per affected entity was derived using comments and the initial PRIA estimate of 67. Specifically, we weighted together a maximum estimate of 310, a high estimate of 192, a middle estimate of 67, a low estimate of 13, and a minimum estimate of 1.
[^4]: FDA - CDRH Announces Intent to Initiate the Reclassification Process for Most High Risk IVDs. [https://www.fda.gov/medical-devices/medical-devices-news-and-events/cdrh-announces-intent-initiate-reclassification-process-most-high-risk-ivds](https://www.fda.gov/medical-devices/medical-devices-news-and-events/cdrh-announces-intent-initiate-reclassification-process-most-high-risk-ivds). As discussed in the preamble to the final rule, FDA notes that the reclassification process will include opportunities for public comment and FDA aims to complete the process before stage 4 of the phaseout policy.
[^5]: Statements in preamble which are not mirrored in the text of the rule are treated as interpretive rules, at best. See Wyeth v. Levine, 555 U.S. 555 (2009).
[^6]: See: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/vitro-diagnostic-multivariate-index-assays-draft-guidance-industry-clinical-laboratories-and-fda. In addition, in 2010, FDA held a widely-attended public meeting to solicit feedback from stakeholders on LDTs.
[^7]: See FDA Notification and Medical Device Reporting for Laboratory Developed Tests (LDTs) (Oct. 3, 2014) and Framework for Regulatory Oversight of Laboratory Developed Tests (LDTs) (Oct. 3, 2014).
[^8]: The regulation would not reach state public health laboratories or state university laboratories, since they are not "persons" within the meaning of the law. See FDCA § 201(e). 14 The term “person” is defined in the Agency’s premarket application rules as including “any individual, partnership, corporation, association, scientific or academic establishment, Government agency, or organizational unit thereof or any other legal entity.” 21 C.F.R. § 814.2. Inasmuch as the regulation is inconsistent with the definition of “person” in the Act, as including governmental entities, we believe that definition is invalid. 15 Counties and local governmental entities are “persons” under the FDCA. See, e.g., *Cook County, Ill. v. U.S. ex rel. Chandler*, 538 U.S. 119 (2003) (holding that a county is a “person” under the False Claims Act).
[^8]: Throughout this document, FDA uses the phrase “LDTs approved by NYS CLEP” to refer to LDTs that are approved, conditionally approved, or within an approved exemption from full technical documentation, under NYS CLEP. These three categories of LDTs are discussed further in section V.B.2 of the preamble. Other LDTs, including “LDTs used in Clinical Trials” and “Tests Not Subject to Evaluation” which are described on NYS CLEP’s website, are not considered “LDTs approved by NYS CLEP” and are not within the enforcement discretion policy with respect to premarket review requirements described in section V.B.2 of the preamble. For additional discussion of the NYS CLEP premarket review program, see section V.B.2 of the preamble.
[^9]: Memorandum to File from Elizabeth Hillebrenner, Associate Director for Scientific and Regulatory Programs, RE: Summary of 2020 Assessment of the First 125 EUA Requests from Laboratories for Molecular Diagnostic Tests for SARS-CoV-2 (September 22, 2023), available in Docket No. FDA-2023-N-2177.
[^12]: These requests resulted in review because FDA did not generally exercise enforcement discretion for LDTs intended for emergencies/potential emergencies/material threats declared under section 564 of the FD&C Act.
[^13]: Memorandum to File from Elizabeth Hillebrenner, Associate Director for Scientific and Regulatory Programs, RE: Summary of 2020 Assessment of the First 125 EUA Requests from Laboratories for Molecular Diagnostic Tests for SARS-CoV-2 (September 22, 2023), available in Docket No. FDA-2023-N-2177
[^14]: See Complaint, _In re Myriad Genetics, Inc. Sec. Litig._, No. 2:19-cv-00707-DBB (D. Utah 2019); Complaint, _Hickok v. Capone_, No. 2021-0686 (Del. Ch. 2021); Complaint, _Davis v. Natera, Inc._, No. 3:22-cv-00985 (N.D. Cal. 2022); Complaint, _Carroll v. Myriad Genetics Inc._, No. 4:22-CV-00739 (N.D. Cal. 2022); _Biesterfeld v. Ariosa Diagnostics, Inc._, No. 1:21-cv-03085, 2022 WL 972281 (N.D. Ill. 2022); and Complaint, _Kogus v. Capone_, No. 2022-0047-SG (Del. Ch. 2022).
15 Market distortions may be associated with events, decisions, or interventions taken by governments, companies, or other agents that influence the market in ways that undermine optimal allocation as modeled under the First Fundamental Theorem of Welfare Economics. Related concepts include market failure, government failure or behavioral bias (Ref. [71]).
[^16]: Social costs are costs incurred from the viewpoint of society (including external costs), beyond just stakeholders (private costs). When laboratories avoid paying for external costs arising from their actions (such as costs to manufacture tests with a reasonable assurance of safety and effectiveness, and if borne by individuals not involved in the decision to order such tests—for example, taxpayers funding government health insurance), the costs to society as a whole (such as non-internalized worsened health outcomes from inaccurate test results) remain. External costs, along with private costs, affect whether society is operating at a socially efficient rate of output (Ref. [72]).
[^17]: This includes laboratories operating under State licensure programs deemed exempt from CLIA.
[^18]: This discussion concerns only laboratories that are certified under CLIA and that meet the regulatory requirements under CLIA to perform high complexity testing (including laboratories operating under State licensure programs deemed exempt from CLIA), as other laboratories would be out of compliance with CLIA regulations if they were developing and performing tests that are not FDA-authorized. As noted in the preamble to the final rule, tests offered by such laboratories have never fallen within FDA’s general enforcement discretion approach.
[^19]: According to its website, CMS regulates all laboratory testing (except research) performed on humans in the U.S. through CLIA. In total, CLIA covers approximately 320,000 laboratories, but we do not know how many of these laboratories meet the regulatory requirements under CLIA to perform high complexity testing. It is worth noting that the number of CLIA certified laboratories, including laboratories that meet the requirements under CLIA for high complexity testing, can vary over time as new laboratories acquire certifications and others may close or lose their certification (Ref. [18]).
[^20]: We also examined census data. According to 2017 Statistics of U.S. Businesses (SUSB) data from the U.S. Census there are 3,365 Medical Laboratories (represented by NAICS code 621511). While data from the Census does not provide information on the number of laboratories under NAICS code 621511 that specifically manufacture IVDs offered as LDTs, if we assumed half of the entities were IVD manufacturers and the other half were laboratories, we would get 1,683 laboratories. The difference between this estimate and our primary estimate (502-[1,683-1,181]) is less than 5% of our primary estimate. We also consider varying our estimates by -5% and +10% to be sufficient for estimating the range of variability between our low and high estimate.
[^27]: From Newman-Toker (2023), annual US incidence was 6.0 M vascular events, 6.2 M infections and 1.5 M cancers. Per ‘Big Three’ dangerous disease case, weighted mean error and serious harm rates were 11.1% and 4.4%, respectively. Extrapolating to all diseases (including non-‘Big Three’ dangerous disease categories), the authors estimated 795,000 total serious harms annually in the USA (plausible range 598 000–1 023 000). Sensitivity analyses using other assumptions estimated 549 000 serious harms. Results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care (Ref. [34]).
[^28]: In general, the phaseout policy may reduce the risk of dying earlier or at a certain age (also referred to as the hazard function). This change in the hazard function can be expressed as a reduction in the expected number of deaths in a specified time period (less than one for an individual) or as an increase in the expected number of years lived (Ref. [74]).
[^29]: As noted above, per Newman-Toker et al. (2023), annual US incidence was 6.0 M vascular events, 6.2 M infections and 1.5 M cancers.
[^30]: According to the Census Bureau as of July 1, 2022, the population of NY was 19,677,151, and the population of the U.S. was 333,287,557. We thus assume that about 5.9% (= 19,677,151 / 333,287,557) of new U.S. cancers are in NY. For the population estimates used, refer to: [https://www.census.gov/quickfacts/fact/table/US/PST045222](https://www.census.gov/quickfacts/fact/table/US/PST045222).
[^33]: Calculated from Table 1 “Life table for the total population: United States, 2020” in the report “United States Life Tables, 2020,” available at: [CDC Life Tables](https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-01.pdf)
[^34]: The approach for valuing mortality risk reductions is generally based on estimates of the value per statistical life (VSL), from which a value per statistical life year (VSLY) is derived. The VSLY values presented are updated to 2022 dollars per HHS guidance (Ref. [42]).
[^35]: We note that the HHS estimates of VSLY depend on the choice of discount rate.
37 Available at: [https://aspe.hhs.gov/sites/default/files/documents/796080c2812365443347c1cea347188/standard-ria-values-2024.xlsx](https://aspe.hhs.gov/sites/default/files/documents/796080c2812365443347c1cea347188/standard-ria-values-2024.xlsx)
[44](https://www.bls.gov/oes/current/naics4_621500.htm)
[45] NAICS code: 621500
[46] We use several sources to estimate costs associated with the phaseout policy. We use input from ICR packages for correction and removal reporting under Stage 1, but we rely on other sources such as previous RIAs or ERG reports to estimate costs for the other requirements. A major distinction between regulatory impact analysis (RIA) and Information Collection Request (ICR) is that the RIA bases estimates on external factors as yet unknown to FDA while ICR captures real-time data of the elements prescribed in regulations. In addition, the RIA considers affected entities according to specific requirements of regulations while the ICR includes a broader range for the number of respondents. Our estimates, therefore, may be different from the ICR package estimates because the RIA estimates costs of the rule in a different way compared as the costs of burden in the ICR package.
[47] In this section, when we use the word “laboratories,” we refer to manufacturers who offer IVDs as LDTs that are within the scope of the phaseout policy.
[^56]: The ICR package of QS regulation (OMB control number 0910-0073) is available at: [https://www.reginfo.gov/public/do/PRAViewDocument?ref_nbr=202309-0910-003](https://www.reginfo.gov/public/do/PRAViewDocument?ref_nbr=202309-0910-003)
[^57]: We assume half of the labor hours would be for complaint files and the other half of the labor hours would be for other activities under subpart M.
[^58]: We anticipate that costs for compliance with any other requirements under Stage 2 such as mandatory recall orders under section 518(e) of the FD&C Act, or notification orders under section 518(a) of the FD&C Act would only be triggered under certain circumstances. Therefore, the costs are likely to be minimal compared to the costs for compliance with the requirements listed below. In addition, if requirements listed below are appropriately satisfied, these other requirements generally should not become applicable.
[^59]: The ICR package of registration and listing (OMB control number 0910-0625) is available at: [https://www.reginfo.gov/public/do/PRAViewDocument?ref_nbr=202206-0910-003](https://www.reginfo.gov/public/do/PRAViewDocument?ref_nbr=202206-0910-003)
[^60]: We assume that each affected laboratory will list an average number of 67 product listings and an average number of 6 new product listings per year, based on our estimates discussed in section II.D.1.
[^61]: NAICS code 621500, occupation codes 11-1021 for general and operations managers. Available from: [https://www.bls.gov/oes/current/naics4_621500.htm](https://www.bls.gov/oes/current/naics4_621500.htm)
[^62]: The ICR package of medical device labeling requirements (OMB control number 0910-0485) is available at: [https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202308-0910-004](https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202308-0910-004)
[^63]: As discussed in section II.D.1, we assume each affected laboratory offers 67 IVDs as LDTs and will offer 6 new IVDs as LDTs per year.
[^64]: The ICR package of investigational device exemptions (OMB control number 0910-0078) is available at: [https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202210-0910-013](https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202210-0910-013)
[^65]: IDE requirements in 21 CFR part 812 include certain requirements distinct from the requirement for approval of an IDE application, such as certain recordkeeping and labeling requirements. We anticipate that costs for compliance with these other requirements, where applicable, would be minimal compared to the costs discussed in this subsection for preparing and submitting an IDE application. These costs may be overestimated as the cited source reflects costs of IDE applications for all devices.
[^66]: Investigations of certain categories of devices are exempt from most requirements in 21 CFR part 812. See 21 CFR 812.2(c). Moreover, certain categories of investigations are considered to have an approved IDE application. See 21 CFR 812.2(b).
[^67] All wage rates are doubled to account for overhead costs. Available from: [https://www.bls.gov/oes/current/naics4_621500.htm](https://www.bls.gov/oes/current/naics4_621500.htm)
[^68] As discussed in section II.D.1, we assume each affected laboratory offers 67 IVDs as LDTs and will offer 6 new IVDs as LDTs per year.
[^70]: Another study by ERG used the same source for an analytical framework for examining the value of antibacterial products: [ASPE Report](https://aspe.hhs.gov/reports/analytical-framework-examining-value-antibacterial-products-0).
[^71]: We may under- or over-estimate the costs of premarket preparation since the estimates by ERG are not specific to IVDs. We have revised some of the estimates based on FDA professional judgement and historical knowledge.
[^72]: The ICR package of premarket approval of medical devices (OMB control number 0910-0231) is available at: [Reginfo](https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202211-0910-010).
[^73]: See the following page for a list of changes that would require a PMA supplement: [https://www.fda.gov/medical-devices/premarket-approval-pma/pma-supplements-and-amendments](https://www.fda.gov/medical-devices/premarket-approval-pma/pma-supplements-and-amendments).
[^74]: As of June 2023, the estimated number of active PMAs for all IVDs is 187 and total number of supplements over 7 years is 928. We divide the total number of supplements by the number of active PMAs and 7 years to calculate the number of PMA supplement per active PMA per year, which is 0.71 (= 928 supplements / 187 active PMAs / 7 years). We assume that the same rates for IVDs overall will apply to IVDs offered as LDTs.
[^75]: We use the FDA internal information on the total number of supplement submissions received by FDA from 2017 to 2023, as of July 2023.
[^76]: This cost reflects hours spent in CDRH substantive review of devices, required to determine whether they meet the standard to be approved. It does not include some of the steps required to complete review of a submission, such as management or time spent on such reviews by staff outside CDRH.
[^77]: The ICR package of premarket notification submission 510(k) (OMB control number 0910-0120) is available at: [https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202308-0910-018](https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202308-0910-018)
[^78]: Distinctions of the estimates used in Table 33 and Table 34 are based on the type of study supporting clinical validation of these tests due to differing costs.
[^79]: In the absence of more detailed information on De Novo costs, we extrapolate 510(k) costs to estimate De Novo costs.
[^81]: We extrapolate 510(k) costs to estimate De Novo costs, noting however that De Novo costs are likely higher than 510(k) costs. However, in the absence of more detailed information, we sometimes rely on such extrapolations to arrive at estimates due to uncertainty.
[^82]: This cost reflects hours spent in CDRH substantive review of devices, required to determine whether they meet the standard to be approved, cleared, or granted marketing authorization. It does not include some of the steps required to complete review of a submission, such as management or time spent on such reviews by staff outside CDRH.
[^83]: Our estimates of review costs of Q-submissions are uncertain as we assume every premarket submission will have a Q-submission, which is unlikely, and we do not account for the fact that some premarket submissions have multiple Q-submissions or that we receive some Q-submissions that are not tied to a premarket submission. Further, we do not account for the likelihood of receiving Q-submissions prior to Stage 3 as laboratories prepare in advance for premarket submissions.
[^84]: The costs could be spread over time depending on the time of submission and review.
[^87]: Note that under the phaseout policy, FDA intends to phase out the general enforcement discretion approach for establishment registration requirements during the current MDUFA V program, such that user fee payments for establishment registrations (which are distinct from user fee payments for premarket submissions) will be subject to the current MDUFA V fee structure.
[^93]: The average annualized cost per small entity ranges from $4,395 per laboratory with annual receipts that are less than $150,000 and to $3,045,766 per laboratory with annual receipts between $40 and $49.99 million.
[^94]: Although businesses with gross receipts of $100 million or less are eligible to pay a reduced fee, we estimate the transfers per firm by receipts size category using the total transfers paid proportional to the share of IVDs offered as LDTs per receipt category in Table B.3 column D in Appendix B. For example, for firms making less than $150,000 in annual revenues, their share of total annual fees would be equivalent to 0.12% or $95 divided by $81,816 of the low estimate of total annualized fees of $2331 million.
# 824 2024-05-29_ACLA Website - ACLA Challenges FDAs Final Rule.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2024-05-29_ACLA Website - ACLA Challenges FDAs Final Rule.md
file_date: 2024-05-29
title: ACLA Website - ACLA Challenges FDAs Final Rule
category: regulatory
subcategory: ldts
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source_file_type: website
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conversion_input_file_type: docx
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license: Public Domain
tokens: 824
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notes: date converted 2024-06-03
web_url: https://www.acla.com/acla-challenges-fdas-final-rule-to-regulate-laboratory-developed-testing-services-as-medical-devices/
summary_short: ACLA Challenges FDA’s Final Rule announces ACLA and HealthTrackRx’s May 29, 2024 lawsuit in the Eastern District of Texas contesting FDA’s May 6, 2024 Final Rule that treats laboratory-developed testing services as medical devices. It argues FDA lacks statutory authority because lab testing services are regulated under CLIA by CMS, and claims the rule is arbitrary and capricious under the Administrative Procedure Act and would disrupt patient access, costs, and innovation in clinical laboratory services.
CONTENT
Washington, D.C. – Today the American Clinical Laboratory Association (ACLA) and its member company, HealthTrackRx, [filed a lawsuit](https://www.acla.com/acla-challenge-to-fdas-final-rule-regulating-laboratory-developed-testing-services-as-medical-devices/) against the U.S. Food and Drug Administration (FDA) in the United States District Court for the Eastern District of Texas, challenging the Agency’s May 6, 2024, [Final Rule](https://public-inspection.federalregister.gov/2024-08934.pdf), which inappropriately seeks to regulate professional laboratory testing services as medical devices under the Federal Food, Drug, and Cosmetics Act (FDCA).
Congress has never granted FDA authority to regulate the professional testing services that laboratories provide, which are federally regulated by the Centers for Medicare & Medicaid Services (CMS) under the Clinical Laboratory Improvement Amendments (CLIA).
For years, ACLA has worked collaboratively with Congress, FDA and other stakeholders to develop legislation that would establish an appropriate regulatory framework for diagnostics. Rather than continue that dialogue, FDA chose instead to act unilaterally and impose an ill-fitting device regime on laboratory testing services. Given the far-reaching negative impacts on our nation’s laboratory community, ACLA believes it must bring this lawsuit to clarify that FDA’s Final Rule exceeds its authority. The lawsuit challenges the Final Rule because FDA has exceeded its statutory authority and acted arbitrarily and capriciously in violation of the Administrative Procedure Act.
“FDA’s Final Rule is the wrong approach, both as a matter of law and public policy, and represents regulatory overreach,” said ACLA President Susan Van Meter. “The medical device framework is inappropriate and ill-suited for regulating laboratory-developed tests, which are services provided by trained professionals rather than manufactured products. These professional services incorporate the latest scientific advances to offer innovative testing solutions to physicians and the patients they serve. The Rule will disrupt this paradigm, creating negative consequences for the entire health care system, including millions of vulnerable patients who depend on the essential clinical testing services that only laboratory professionals can provide.”
Laboratory testing services are often created to address unmet patient needs. They provide patients and physicians with diagnostic information to inform clinical care, power precision medicine, contribute to the discovery of novel therapeutics, and lead the fight against emerging pathogens. Forcing them into the rigid regulatory framework designed for manufactured medical devices will undermine the dynamic and patient-centered nature of clinical laboratory services.
ACLA maintains that legislation is the right – and only – approach for FDA to regulate professional testing services offered by laboratories. The industry remains committed to working with Congress, FDA, and other stakeholders to advance appropriate legislation that preserves the critical role of laboratory diagnostics and ensures that patients continue to have access to lifesaving tests.
Below are links to ACLA’s previous statements, comments on the Proposed Rule, and testimony to Congress:
[ACLA’s Statement on the Final Rule](https://www.acla.com/acla-statement-on-fda-final-rule-to-regulate-laboratory-developed-testing-services-as-medical-devices/)
[ACLA’s Comments on FDA’s Proposed Regulation of Laboratory Developed Tests as Medical Devices](https://www.acla.com/aclas-comments-on-fdas-proposed-regulation-of-laboratory-developed-tests-as-medical-devices/)
[FDA Proposed Rule to Regulate LDTs as Medical Devices Would Slow Development of Critical Lab Tests and Should Be Withdrawn, ACLA Urges](https://www.acla.com/fda-proposed-rule-to-regulate-ldts-as-medical-devices-would-slow-development-of-critical-lab-tests-and-should-be-withdrawn-acla-urges/)
[ACLA Statement on LDT Proposed Rule Comments by FDA and CMS](https://www.acla.com/acla-statement-on-ldt-proposed-rule-comments-by-fda-and-cms/)
[ACLA President to Testify on Regulation of Diagnostic Tests](https://www.acla.com/acla-president-to-testify-on-regulation-of-diagnostic-tests/)
# 10,416 2024-06-25_FDA Guidance - Laboratory Developed Tests Small Entity Compliance Guide.md
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summary_short: The FDA “Laboratory Developed Tests: Small Entity Compliance Guide” (June 25, 2024) explains how the May 6, 2024 LDT Final Rule makes explicit that IVDs are regulated as medical devices even when manufactured by a laboratory and outlines FDA’s staged phaseout of its general LDT enforcement discretion. It summarizes key compliance milestones from 2025–2028 (MDR/complaints; registration/labeling/IDE; quality system; then premarket review) and highlights targeted enforcement discretion categories such as 1976-type LDTs, NYS CLEP–approved LDTs, certain modifications to cleared tests, “currently marketed” IVDs offered as LDTs, and LDTs for unmet needs.
CONTENT
***INTERNAL TITLE:*** Laboratory Developed Tests: Small Entity Compliance Guide
Guidance for Laboratory Manufacturers and Food and Drug Administration Staff
Document issued on June 25, 2024.
For questions about this document, contact [LDTFinalRule@fda.hhs.gov](mailto:LDTFinalRule@fda.hhs.gov)
U.S. Department of Health and Human Services
Food and Drug Administration
Center for Devices and Radiological Health
Center for Biologics Evaluation and Research
## Preface
### Public Comment
You may submit electronic comments and suggestions at any time for Agency consideration to [https://www.regulations.gov](https://www.regulations.gov). Submit written comments to the Dockets Management Staff, Food and Drug Administration, 5630 Fishers Lane, Room 1061, (HFA-305), Rockville, MD 20852-1740. Identify all comments with the docket number FDA-2023-N-2177. Comments may not be acted upon by the Agency until the document is next revised or updated.
### Additional Copies
**CDRH**
Additional copies are available from the Internet. You may also send an email request to [CDRH-Guidance@fda.hhs.gov](mailto:CDRH-Guidance@fda.hhs.gov) to receive a copy of the guidance. Please include the document number GUI00007036 and complete title of the guidance in the request.
**CBER**
Additional copies are available from the Center for Biologics Evaluation and Research (CBER), Office of Communication, Outreach, and Development (OCOD), 10903 New Hampshire Ave., Bldg. 71, Room 3128, Silver Spring, MD 20993-0002, or by calling 1-800-835-4709 or 240-402-8010, by email, [ocod@fda.hhs.gov](mailto:ocod@fda.hhs.gov), or from the Internet at [https://www.fda.gov/vaccines-blood-biologics/guidance-compliance-regulatory-information-biologics/biologics-guidances](https://www.fda.gov/vaccines-blood-biologics/guidance-compliance-regulatory-information-biologics/biologics-guidances).
## Table of Contents
I. Introduction................................................................................................................... 1
II. Background.................................................................................................................... 2
III. Overview....................................................................................................................... 3
IV. Scope............................................................................................................................ 4
A. General Scope of Amendment and Phaseout Policy................................................ 4
B. Enforcement Discretion Policies for Certain IVDs .................................................. 5
V. Amendment and Phaseout Policy ................................................................................ 8
A. 21 CFR 809.3(a) Definition of in vitro diagnostic products...................................... 8
B. Phaseout Policy........................................................................................................ 8
C. Summary of FDA Compliance Expectations.......................................................... 10
VI. Additional Resources.................................................................................................. 10
A. Requirements related to Complaints, Medical Device Reports, and Correction and Removal Reports.......................................................................................................... 10
B. Registration and Listing Requirements................................................................... 11
C. Device Labeling Requirements............................................................................... 11
D. Investigational Use Requirements ......................................................................... 11
E. Quality System Requirements................................................................................ 12
F. Premarket Review Requirements............................................................................ 13
G. General Information............................................................................................... 13
## I. Introduction
On May 6, 2024, FDA published a final rule in the Federal Register entitled “Medical Devices; Laboratory Developed Tests” ([89 FR 37286](https://www.federalregister.gov/documents/2024/05/06/2024-08986/medical-devices-laboratory-developed-tests)) (“LDT Final Rule”). This final rule amends FDA regulations to make explicit that in vitro diagnostic products (IVDs) are devices under the Federal Food, Drug, and Cosmetic Act (FD&C Act) including when the manufacturer of the IVD is a laboratory. This amendment reflects that the device definition in the FD&C Act does not differentiate between entities manufacturing the device. In conjunction with the amendment, FDA is phasing out its general enforcement discretion approach for laboratory developed tests (LDTs) so that IVDs manufactured by a laboratory will generally fall under the same enforcement approach as other IVDs (i.e., FDA’s expectations for compliance will generally be the same). This phaseout policy is more fully described in the preamble to the LDT Final Rule and includes enforcement discretion policies for specific categories of IVDs manufactured by a laboratory, including currently marketed IVDs offered as LDTs and LDTs for unmet needs.
This phaseout policy is intended to better protect the public health by helping to assure the safety and effectiveness of IVDs offered as LDTs, while also accounting for other important public health considerations such as patient access and reliance. FDA has prepared this Small Entity Compliance Guide to assist small entities in complying with the requirements established in FDA regulations as they apply to IVDs, including LDTs.
FDA's guidance documents, including this guidance, do not establish legally enforceable responsibilities. Instead, guidances describe the Agency’s current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word *should* in Agency guidance means that something is suggested or recommended, but not required.
## II. Background
In 1976, the Medical Device Amendments of 1976 (the MDA) amended the FD&C Act to create a comprehensive system for the regulation of devices intended for human use. In implementing the MDA, FDA has exercised enforcement discretion such that it generally has not enforced applicable requirements with respect to most LDTs, including requirements related to establishment registration and product listing, medical device reporting to FDA, current good manufacturing practices (CGMPs), and premarket review of an IVD by FDA prior to use of the LDT in patient care, among others. The rationale for this approach was that, at the time of passage of the MDA, LDTs were mostly manufactured in small volumes by laboratories that served their local communities. They were typically intended for use in diagnosing rare diseases or for other uses to meet the needs of a local patient population, or were generally similar to well-characterized, standard IVDs. They also tended to employ manual techniques (and did not use automation) and were performed by laboratory personnel with specialized expertise; to be used and interpreted by physicians or pathologists in a single institution responsible for the patient (and who were actively involved in patient care); and to be manufactured using components legally marketed for clinical use, such as general purpose reagents or immunohistochemical stains marketed in compliance with FDA requirements. Due to these and other factors, FDA exercised enforcement discretion such that it generally has not enforced applicable requirements for most LDTs.
However, the LDT landscape has evolved significantly since 1976. Today, many LDTs increasingly rely on high-tech or complex instrumentation and software to generate results and clinical interpretations. They are often used in laboratories outside of the patient’s healthcare setting and are often run in high volume for large and diverse populations. Many LDTs are manufactured by laboratory corporations that market the IVDs nationwide, as they accept specimens from patients across the country and run their LDTs in very large volumes in a single laboratory. Today’s LDTs are also more commonly manufactured with instruments or other components not legally marketed for clinical use and are more often used to inform or direct critical treatment decisions, to widely screen for common diseases, to predict personal risk of developing certain diseases, and to diagnose serious medical conditions such as cancer and heart disease. The risks associated with most LDTs today are therefore much greater than they were at the time FDA began implementing the MDA, and most LDTs today are similar to other IVDs that have not been under FDA’s general enforcement discretion approach. In addition, FDA is concerned that firms are offering IVDs as “LDTs” even when they are not LDTs as defined on FDA’s website, because they are not actually designed, manufactured, and used within a single laboratory.
As LDTs increasingly rely on high-tech instrumentation and software, the potential for cybersecurity vulnerabilities is growing. Many LDTs are connected to Laboratory Information Management Systems and other IT infrastructure, making them a potential conduit for those looking to access information in such systems. This may include patient genetic information, among other things, which could have national security implications. Further, it has been demonstrated that hackers can modify medical test results. Through premarket review, FDA works with manufacturers to ensure cybersecurity is appropriately considered, mitigating the potential for future problems. Through medical device reporting (MDR) and corrections and removals reporting requirements, FDA helps to ensure that any problems are appropriately addressed. In fact, FDA has seen cybersecurity problems with certain instruments and issued two safety communications where laboratories may not have otherwise been aware that the research use only (RUO) versions of the instruments used as part of their LDTs had the same vulnerabilities.
As a result of these evolutions in the testing landscape, FDA has long recognized the need for a change in the Agency’s general enforcement discretion approach for LDTs. Over the past few years, FDA has accumulated even more information supporting the need for a change, as noted in the preamble to the LDT Final Rule. In light of these developments, FDA has issued a final rule to amend FDA’s regulations to make explicit that IVDs are devices under the FD&C Act including when the manufacturer is a laboratory. The preamble to the LDT Final Rule describes how FDA is: (1) phasing out its general enforcement discretion approach for LDTs so that IVDs manufactured by a laboratory will generally fall under the same enforcement approach as other IVDs and (2) adopting targeted enforcement discretion policies for specific categories of IVDs manufactured by a laboratory.
## III. Overview
FDA has issued a rule to amend its regulations to make explicit that IVDs are devices under the FD&C Act including when the manufacturer of the IVD is a laboratory. This amendment reflects that the device definition in the FD&C Act does not differentiate between entities manufacturing the device.
As amended, 21 CFR 809.3(a) reads:
**In vitro diagnostic products** are those reagents, instruments, and systems intended for use in the diagnosis of disease or other conditions, including a determination of the state of health, in order to cure, mitigate, treat, or prevent disease or its sequelae. Such products are intended for use in the collection, preparation, and examination of specimens taken from the human body. These products are devices as defined in section 201(h)(1) of the Federal Food, Drug, and Cosmetic Act (the act) and may also be biological products subject to section 351 of the Public Health Service (PHS) Act, including when the manufacturer of these products is a laboratory.
The preamble to the LDT Final Rule also includes a policy under which FDA is phasing out its general enforcement discretion approach for LDTs in stages so that, following a 4-year phaseout period, as described in Section V.B. of this Small Entity Compliance Guide, IVDs manufactured by a laboratory will generally fall under the same enforcement approach as other IVDs (i.e., FDA’s expectations for compliance will generally be the same). This phaseout policy includes enforcement discretion policies for specific categories of IVDs manufactured by a laboratory, including “currently marketed IVDs offered as LDTs” and “LDTs for unmet needs,” as described below.
## IV. Scope
### A. General Scope of Amendment and Phaseout Policy
The LDT Final Rule amends FDA’s regulations to make explicit that IVDs are devices under the FD&C Act including when the manufacturer of the IVD is a laboratory.
The preamble to the LDT Final Rule includes a phaseout policy, which applies to IVDs that are *manufactured* and *offered* as LDTs by laboratories that are certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) and that meet the regulatory requirements under CLIA to perform high complexity testing, and used within such laboratories, even if those IVDs do not fall within FDA’s traditional understanding of an LDT because they are not designed, manufactured, and used within a single laboratory (“IVDs offered as LDTs”). FDA adopted this scope because it recognizes that not all laboratories have understood the limited nature of FDA’s general enforcement discretion approach and have been offering IVDs based on the approach even when those IVDs do not fit what FDA generally considers to be an LDT.
As discussed in the preamble to the LDT Final Rule, “IVDs offered as LDTs” does not include IVDs manufactured or used *outside* of a laboratory, including collection devices.
The phaseout policy does not apply to certain tests that were excluded from our general enforcement discretion approach. FDA continues to generally expect that tests within the following categories will comply with applicable device requirements:
- Tests that are intended as blood donor screening or human cells, tissues, and cellular and tissue-based products (HCT/P) donor screening tests required for infectious disease testing under 21 CFR 610.40 and 1271.80(c), respectively, or required for determination of blood group and Rh factors under 21 CFR 640.5;
- Tests intended for emergencies, potential emergencies, or material threats declared under section 564(b) of the FD&C Act; and
- Direct to consumer (DTC) tests, intended for consumer use without meaningful involvement by a licensed healthcare professional.
Tests manufactured and offered for use exclusively for public health surveillance are also not affected by the phaseout policy. Public health surveillance tests are tests: (1) intended solely for use on systematically collected samples for analysis and interpretation of health data in connection with disease prevention and control; and (2) for which results are not reported to patients or their healthcare providers. The results of these tests are generally used for trending on a population basis or public health outbreaks, where the test results are not intended for clinical decision making.
Finally, we note that the amended regulation and phaseout policy do not change requirements for laboratories, including requirements under CLIA, which we note are separate from requirements under the FD&C Act.
### B. Enforcement Discretion Policies for Certain IVDs
As discussed in the preamble to the LDT Final Rule, for certain IVDs, FDA intends to exercise enforcement discretion and generally not enforce all or some applicable requirements. These enforcement discretion policies do not apply to any IVDs identified in section V.A.2 of the preamble to the LDT Final Rule as falling outside the scope of the phaseout policy or as discussed in section V.B of the preamble to the LDT Final Rule. As with any enforcement discretion policy, FDA may update any of these policies as circumstances warrant or if the circumstances that inform these policies change, consistent with FDA’s good guidance practices (section 701(h) of the FD&C Act, 21 CFR 10.115). Regardless of the phaseout timeline and enforcement discretion policies for certain IVDs discussed below, FDA retains discretion to pursue enforcement action for violations of the FD&C Act at any time and intends to do so when appropriate. This small entity compliance guide does not introduce new or different enforcement discretion policies from those discussed in the preamble to the LDT Final Rule.
For several categories of tests, FDA intends to continue the general enforcement discretion approach and generally not enforce any applicable requirements because tests in these categories are, in our experience, unlikely to pose significant risks or are conducted in circumstances that themselves will mitigate the risks. The categories of tests are:
- **1976-Type LDTs.** These tests have the following characteristics common among LDTs offered in 1976: (1) use of manual techniques (without automation) performed by laboratory personnel with specialized expertise; (2) use of components legally marketed for clinical use; and (3) design, manufacture, and use within a single CLIA-certified laboratory that meets the requirements under CLIA for high complexity testing. These tests might include, for example, immunohistochemistry tests that involve no automated preparation or interpretation, but would not include, for example, lateral flow tests, as they do not generally rely on laboratory personnel expertise.
- **Certain Human Leukocyte Antigen (HLA) Tests for Transplantation.** These tests are designed, manufactured, and used within a single laboratory certified under CLIA that meets the requirements to perform high-complexity histocompatibility testing when used in connection with organ, stem cell, and tissue transplantation to perform HLA allele typing, for HLA antibody screening and monitoring, or for conducting real and “virtual” HLA crossmatch tests (“HLA tests for transplantation”). This enforcement discretion policy does not include HLA tests used for blood transfusion, which are highly standardized across institutions.
- **Forensic Tests.** These tests are intended solely for forensic (law enforcement) purposes.
- **DoD and VHA LDTs.** These are LDTs manufactured and performed within the Veterans Health Administration (VHA) or the Department of Defense (DoD). This policy applies only to LDTs used for patients that are being tested and treated within the DoD or VHA.
FDA generally intends to exercise enforcement discretion with respect to premarket review requirements for:
- **LDTs Approved by NYS CLEP.** LDTs that are approved by New York State Department of Health’s Clinical Laboratory Evaluation Program (NYS CLEP). This policy applies only to the approved version of the test. (FDA is aware that some laboratories may offer different versions of an LDT depending on whether a patient specimen comes from NYS or from elsewhere.)
- **Certain Modified Versions of Another Manufacturer’s 510(k) Cleared or De Novo Authorized Test.** This policy applies when a laboratory certified under CLIA and meeting the regulatory requirements under CLIA to perform high complexity testing modifies another manufacturer’s 510(k) cleared or De Novo authorized test, following design controls and other quality system requirements for which FDA expects compliance (as described in stage 3 of the phaseout policy), in a manner that could not significantly affect the safety or effectiveness of the test and does not constitute a major change or modification in intended use, and where the modified test is performed only in the laboratory making the modification. Under the policy, FDA would expect premarket submissions from laboratories modifying a third party’s 510(k) cleared or De Novo authorized test for the same types of changes for which FDA would expect a premarket submission from the original manufacturer making changes to its own IVD. For a description of changes that could significantly affect the safety or effectiveness of the test or constitute a major change or modification in intended use under this policy, see FDA’s regulations at 21 CFR 807.81(a)(3) and further discussion in the final guidance “Deciding When to Submit a 510(k) for a Change to an Existing Device.” If the modification (individually or in the aggregate) could significantly affect the safety or effectiveness of the test or does constitute a major change or modification in intended use (and the modified test does not fall within another enforcement discretion policy), FDA expects laboratories to submit the applicable premarket submission. If the laboratory modification is so significant that the IVD is no longer substantially equivalent to the original IVD and requires a PMA, FDA expects the PMA to be submitted either by stage 4 of the phaseout policy or before the modified test is marketed, whichever comes later.
FDA intends to exercise enforcement discretion and generally not enforce premarket review and quality system (QS) requirements (except for requirements under 21 CFR part 820, subpart M (Records)) for:
- **LDTs for Unmet Needs.** These are LDTs manufactured and performed by a laboratory integrated within a healthcare system to meet an unmet need of patients receiving care within the same healthcare system. This enforcement discretion policy is discussed in more detail in section V.B.3. of the preamble to the LDT Final Rule. FDA also intends to provide additional guidance on this enforcement discretion policy, which would be issued in accordance with good guidance practices (see 21 CFR 10.115).
- **Currently Marketed IVDs offered as LDTs.** These are currently marketed IVDs offered as LDTs that were first marketed prior to May 6, 2024 (the date of publication of the LDT Final Rule), as long as they are not modified after that date, or are modified but only in certain limited ways, as described in section V.B.3 of the preamble to the LDT Final Rule. Under this policy, FDA generally expects compliance with premarket review and QS requirements for currently marketed IVDs offered as LDTs when a laboratory’s modifications (individually or in aggregate) change the indications for use of the IVD, alter the operating principle of the IVD (e.g., changes in critical reaction components), include significantly different technology in the IVD (e.g., addition of artificial intelligence/machine learning to the test algorithm, a change from targeted sequencing to whole genome sequencing, a change from immunoassay to mass spectrometry, or a change from manual to automated procedures), or adversely change the performance or safety specifications of the IVDs.8
- **Non-Molecular Antisera LDTs for Rare Red Blood Cell (RBC) Antigens for Transfusion Compatibility.** These are non-molecular antisera LDTs for rare RBC antigens, when such tests are manufactured and performed by blood establishments, including transfusion services and immunohematology laboratories, and when there is no alternative IVD available to meet the patient’s need for a compatible blood transfusion. This policy does not apply to molecular tests used for genotyping RBC antigens.
The enforcement discretion policies described above are more fully described and discussed in sections V.B and V.C of the preamble to the LDT Final Rule. We also intend to publish additional guidance documents on these policies as appropriate. Table 2 in Section V.C of this Small Entity Compliance Guide provides a high-level summary of FDA’s compliance expectations for certain categories of IVDs, including those that fall within the targeted enforcement discretion policies listed above.
## V. Amendment and Phaseout Policy
### A. 21 CFR 809.3(a) Definition of in vitro diagnostic products
21 CFR 809.3(a), as amended, makes explicit that IVDs are devices under the FD&C Act including when the manufacturer is a laboratory. The amendment to 21 CFR 809.3(a) reflects that the device definition in the FD&C Act does not differentiate between entities manufacturing the device.
FDA’s intent is that following a 4-year phaseout period, described in the preamble to the LDT Final Rule, IVDs offered as LDTs generally will be expected to meet applicable requirements, with several enforcement discretion policies for certain categories of IVDs manufactured by a laboratory.
In this section, Section V, of this Small Entity Compliance Guide, we discuss these targeted enforcement discretion policies, which are described in the preamble to the LDT Final Rule. In the next section, Section VI, of this Small Entity Compliance Guide, we provide additional resources on the applicable requirements to assist manufacturers in understanding these requirements.
### B. Phaseout Policy
FDA has had a general enforcement discretion approach for most LDTs. As discussed in the preamble to the LDT Final Rule, FDA is phasing out this general enforcement discretion approach so that IVDs manufactured by a laboratory will generally fall under the same enforcement approach as other IVDs. The phaseout is intended to help assure the safety and effectiveness of IVDs offered as LDTs, while also accounting for other important public health considerations such as patient access and reliance. Following a four-year phaseout period, FDA will no longer have a general enforcement discretion approach for LDTs. The phaseout policy includes the following five stages for IVDs offered as LDTs:
- **Stage 1:** Beginning May 6, 2025, FDA will expect compliance with MDR requirements, corrections and removals reporting requirements, and QS requirements under 21 CFR 820.198 (complaint files).
- **Stage 2:** Beginning May 6, 2026, FDA will expect compliance with requirements not covered during other stages of the phaseout policy, including registration and listing requirements under section 510 of the FD&C Act, 21 CFR part 607, and 21 CFR part 807 (excluding subpart E); labeling requirements under section 502 of the FD&C Act and 21 CFR parts 801 and 809, subpart B; and investigational use requirements under section 520(g) of the FD&C Act and 21 CFR part 812.
- **Stage 3:** Beginning May 6, 2027, FDA will expect compliance with QS requirements under part 820 (21 CFR part 820) (other than requirements under 21 CFR 820.198 (complaint files), which are already addressed in stage 1).9
- **Stage 4:** Beginning November 6, 2027, FDA will expect compliance with premarket review requirements for high-risk IVDs offered as LDTs (IVDs that may be classified into class III or that are subject to licensure under section 351 of the PHS Act), unless a premarket submission has been received by the beginning of this stage in which case FDA intends to continue to exercise enforcement discretion for the pendency of its review.
- **Stage 5:** Beginning May 6, 2028, FDA will expect compliance with premarket review requirements for moderate-risk and low-risk IVDs offered as LDTs (that require premarket submissions), unless a premarket submission has been received by the beginning of this stage in which case FDA intends to continue to exercise enforcement discretion for the pendency of its review.
**Table 1. Stages of Final Phaseout Policy**
| Stage | Compliance Expectations | Timeline |
|---------|--------------------------------------------------------------------------|------------------------|
| Stage 1 | Medical device reporting, reporting of corrections and removals, and complaint files | Beginning May 6, 2025 |
| Stage 2 | Registration, listing, labeling, investigational use, and other applicable requirements that are not a part of Stages 1, 3, 4, or 5 | Beginning May 6, 2026 |
| Stage 3 | Quality system requirements not addressed in earlier stages | Beginning May 6, 2027 |
| Stage 4 | Premarket submission requirements for high-risk IVDs offered as LDTs | Beginning November 6, 2027 |
| Stage 5 | Premarket submission requirements for low- and moderate-risk IVDs offered as LDTs, unless exempt | Beginning May 6, 2028 |
||
For IVDs offered as LDTs on the market prior to Stage 4 or 5 (as applicable), FDA also generally does not intend to enforce against IVDs offered as LDTs for lacking premarket authorization after a complete PMA, Humanitarian Device Exemption application, 510(k), BLA or De Novo request has been submitted to FDA (by the corresponding stage of the phaseout policy) until FDA completes review of the submission, so as not to interrupt access to IVDs that are already on the market and available to patients.
As discussed in Section IV of this Small Entity Compliance Guide and summarized below, FDA intends to exercise enforcement discretion for specific categories of IVDs manufactured by a laboratory, such as “currently marketed IVDs offered as LDTs” and “LDTs for unmet needs.” Additionally, other enforcement discretion policies not addressed in this phaseout policy may apply to certain IVDs. For example, FDA issued final guidance documents with enforcement discretion policies for certain COVID-19 and mpox tests at the beginning of each declared emergency. Concurrent with the LDT Final Rule, FDA issued a draft guidance document with a proposed enforcement policy for certain IVDs for immediate response to a chemical, biological, radiological, or nuclear (CBRN) agent in the absence of a declaration under section 564 of the FD&C Act.10 FDA has adopted and intends to continue adopting enforcement discretion policies for certain types of IVDs in certain circumstances, as appropriate.
Although FDA is phasing out its current general enforcement discretion approach over a period of years, the phaseout policy does not in any way alter the fact that it is illegal to offer IVDs without complying with applicable requirements. Regardless of the phaseout timeline and enforcement discretion policies for certain IVDs discussed below, FDA retains discretion to pursue enforcement action for violations of the FD&C Act at any time and intends to do so when appropriate.
### C. Summary of FDA Compliance Expectations
As discussed in the preamble to the LDT Final Rule, FDA intends to exercise enforcement discretion and generally not enforce some or all applicable requirements for certain categories of IVDs manufactured by a laboratory, as summarized in the table below. Some IVDs may fall into more than one enforcement discretion policy. We note that an IVD is not excluded from an enforcement discretion policy in the preamble to the final rule simply because it falls within another enforcement discretion policy in such preamble, and so either policy may apply. As noted in the preamble to the final rule, the targeted enforcement discretion policies included in the preamble do not apply to any IVD identified in section V.A.2 of the preamble to the LDT Final Rule as falling outside the scope of the phaseout policy (e.g., donor screening tests for infectious diseases and certain blood typing tests, Direct-to-Consumer tests) or as discussed in section V.B of the preamble.
The table below is intended to provide a high-level overview of certain key categories of IVDs covered in the preamble to the final rule. This table does not address all IVDs (e.g., tests for 564 declarations). Please refer to the preamble to the rule for additional details and policies.
**Table 2: FDA Compliance Expectations**
| Category of IVD | Stage 1 Medical Device Reporting (21 CFR pt. 803) Reporting of Corrections and Removals (21 CFR pt. 806) Complaint Files (21 CFR 820.198) | Stage 2 Requirements Not Covered In Other Stages, Including: Establishment Registration & Device Listing (21 CFR pts. 807, 807 subpts. A-D) Labeling (21 CFR pts. 801, 809) Investigational Use Requirements (21 CFR pt. 812) | Stage 3 Quality System Requirements Other than Complaint Files (21 CFR pt. 820 other than 820.198) | Stages 4 & 5 Premarket Review (21 CFR pt. 807, subpt. E; 21 CFR pt. 860, subpt. D; 21 CFR 814; 21 CFR pt. 601) |
|----------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------|
| **Donor screening tests for infectious diseases and certain blood typing tests** Section V.A.2.a of preamble | compliance currently expected | compliance currently expected | compliance currently expected | compliance currently expected |
| **Direct-to-Consumer (DTC) tests** Section V.A.2.c of preamble | compliance currently expected | compliance currently expected | compliance currently expected | compliance currently expected |
| **Public Health Surveillance tests** Section V.A.2 of preamble | compliance generally not expected | compliance generally not expected | compliance generally not expected | compliance generally not expected |
| **1976 type LDTs** Section V.B.1 of preamble | compliance generally not expected | compliance generally not expected | compliance generally not expected | compliance generally not expected |
| **HLA tests for transplantation** Section V.B.1 of preamble | compliance generally not expected | compliance generally not expected | compliance generally not expected | compliance generally not expected |
| **Forensic tests** Section V.B.1 of preamble | compliance generally not expected | compliance generally not expected | compliance generally not expected | compliance generally not expected |
| **LDTs manufactured and performed within DoD and VHA** Section V.B.1 of preamble | compliance generally not expected | compliance generally not expected | compliance generally not expected | compliance generally not expected |
| **LDTs for unmet needs manufactured and performed by labs integrated in the healthcare system treating the patient** Section V.B.3 of preamble | compliance generally expected beginning May 6, 2025 | compliance generally expected beginning May 6, 2026 | compliance with 21 CFR 820.180-820.186 generally expected beginning May 6, 2027; compliance generally not expected with other QS requirements (except for complaint files) | compliance generally not expected |
| **Currently marketed IVDs offered as LDTs first marketed prior to rule publication date and not modified beyond scope described in preamble** Section V.B.3 of preamble | compliance generally expected beginning May 6, 2025 | compliance generally expected beginning May 6, 2026 | compliance with 21 CFR §20.180-820.186 generally expected beginning May 6, 2027;
compliance generally not expected with other QS requirements (except for complaint files) | compliance generally not expected |
| **Non-molecular antisera LDTs for rare red blood cell antigens** Section V.B.3 of preamble | compliance generally expected beginning May 6, 2025 | compliance generally expected beginning May 6, 2026 | compliance with 21 CFR §20.180-820.186 generally expected beginning May 6, 2027;
compliance generally not expected with other QS requirements (except for complaint files) | compliance generally not expected |
| **LDTs approved by NYS CLEP** Section V.B.2 of preamble | compliance generally expected beginning May 6, 2025 | compliance generally expected beginning May 6, 2026 | compliance* generally expected beginning May 6, 2027 | compliance generally not expected |
| **Modified version of another manufacturer's 510(k) cleared or De Novo authorized test within the scope described in the preamble** Section V.C.4 of preamble | compliance generally expected beginning May 6, 2025 | compliance generally expected beginning May 6, 2026 | compliance* generally expected beginning May 6, 2027 | compliance generally not expected |
| **IVDs offered as LDTs within scope of phaseout policy, but that do not fall within a targeted enforcement discretion policy summarized above** Section V.C of preamble | compliance generally expected beginning May 6, 2025 | compliance generally expected beginning May 6, 2026 | compliance** generally expected beginning May 6, 2027 | compliance generally expected beginning November 6, 2027 for high-risk tests
compliance generally expected beginning May 6, 2028 for moderate-risk and low-risk tests |
||
\* Because these tests are LDTs, FDA generally will not expect compliance with 21 CFR part 820 requirements other than design controls, purchasing controls, acceptance activities, CAPA, and records requirements.
\** For tests that are LDTs, FDA generally will not expect compliance with 21 CFR part 820 requirements other than design controls, purchasing controls, acceptance activities, CAPA, and records requirements.
## VI. Additional Resources
FDA understands that, for some entities, complying with applicable FDA requirements for IVDs will be new. Below is a list of resources available on FDA’s website to assist IVD manufacturers with understanding and complying with applicable requirements. This list is not exhaustive; IVD manufacturers should evaluate the characteristics of each device to determine which requirements apply to a specific device.
### A. Requirements related to Complaints, Medical Device Reports, and Correction and Removal Reports
FDA regulations require that device manufacturers establish and maintain complaint files, where a manufacturer documents and investigates any complaints it receives about its medical devices (21 CFR 820.198). A “complaint” is defined at 21 CFR 820.3(b) and means any written, electronic, or oral communication that alleges deficiencies related to the identity, quality, durability, reliability, safety, effectiveness, or performance of a device after it is released for distribution.
FDA regulations also require that device manufacturers submit an MDR when the manufacturer becomes aware of certain events, whether through a complaint or other sources (21 CFR part 803). A reportable event is any event that the manufacturer becomes aware of that reasonably suggests that their device may have caused or contributed to a death or serious injury, or has malfunctioned and would be likely to cause or contribute to a death or serious injury if the malfunction were to recur (see sections 519(a) through (c) of the FD&C Act and 21 CFR part 803).[^14]
Medical device recalls are usually conducted voluntarily by manufacturers and involve removing or correcting products that are in violation of laws administered by the FDA. Under section 519(g) of the FD&C Act and 21 CFR part 806, manufacturers and importers are generally required to report to FDA any correction or removal of a medical device if the correction or removal was initiated to reduce a risk to health posed by the device or to remedy a violation of the Act caused by the device which may present a risk to health.
FDA has several guidance documents and resources available to help manufacturers understand and comply with these requirements. They include:
- [Complaint Files (presentation)](https://www.fda.gov/media/109411/download)
- [Medical Device Reporting for Manufacturers, Guidance for Industry and Food and Drug Administration Staff](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/medical-device-reporting-manufacturers)
- [Recalls, Corrections and Removals (Devices)](https://www.fda.gov/medical-devices/postmarket-requirements-devices/recalls-corrections-and-removals-devices)
### B. Registration and Listing Requirements
Owners or operators of establishments that are involved in the production and distribution of medical devices intended for use in the U.S. generally are required to register annually with the FDA. This process is known as establishment registration. Generally, establishments that are required to register with the FDA are also required, under section 510 of the FD&C Act, to list the devices that are made there and the activities that are performed on those devices. FDA regulations on establishment registration and device listing are found at 21 CFR parts 607 (for devices subject to licensure under section 351 of the PHS Act) and 807. For licensed devices, information on registration and listing requirements under part 607 is available at [Blood Establishment Registration and Product Listing](https://www.fda.gov/vaccines-blood-biologics/biologics-establishment-registration/blood-establishment-registration-and-product-listing) and for other devices, registration and listing information is available at [Device Registration and Listing](https://www.fda.gov/medical-devices/how-study-and-market-your-device/device-registration-and-listing).
### C. Device Labeling Requirements
Medical devices must comply with general labeling requirements, including formatting and substantive requirements, found in section 502 of the FD&C Act and 21 CFR part 801. Labeling requirements under part 801 include unique device identification (UDI) requirements, as applicable (see part 801, subpart B). IVDs have additional labeling requirements found at 21 CFR part 809, subpart B. 21 CFR 801.119 exempts IVDs from most general labeling requirements if an IVD is compliant with UDI requirements and the specific IVD labeling requirements found at 21 CFR 809.10. As discussed in the preamble to the LDT Final Rule, for LDTs, the required labeling information could be encompassed in more than one document, such as the test protocol, test report template, and test menu. FDA provides additional information on these requirements on its web pages, [Device Labeling](https://www.fda.gov/medical-devices/overview-device-regulation/device-labeling) and [In Vitro Diagnostic Device Labeling Requirements](https://www.fda.gov/medical-devices/device-labeling/in-vitro-diagnostic-device-labeling-requirements).
### D. Investigational Use Requirements
An approved investigational device exemption (IDE) allows an investigational device to be shipped for use in a clinical investigation (a clinical study or research) for purposes of collecting safety and effectiveness data, without complying with other requirements of the FD&C Act. Investigational use also includes clinical evaluation of certain modifications or new intended uses of legally marketed devices. All clinical evaluations of significant risk devices used in an investigation, unless exempt, must have an approved IDE before the study is initiated under requirements found in section 520(g) of the FD&C Act and 21 CFR part 812. Investigations of diagnostic devices are exempt from most IDE requirements, provided that certain labeling requirements are met and the testing: is noninvasive, does not require an invasive sampling procedure that presents significant risk, does not by design or intention introduce energy into a subject, and is not used as a diagnostic procedure without confirmation of the diagnosis by another, medically established diagnostic product or procedure (21 CFR 812.2(c)(3)). Additionally, investigations of diagnostic devices that are not significant risk are deemed to have an approved IDE (without submission of an IDE application) if the conditions in 21 CFR 812.2(b) are met.
FDA provides more information on IDEs and how to comply with the Agency’s IDE regulations, as well the Agency’s regulations for informed consent (21 CFR part 50) and for institutional review boards (21 CFR part 56), on its web site at [Investigational Device Exemptions (IDE)](https://www.fda.gov/medical-devices/premarket-submissions-selecting-and-preparing-correct-submission/investigational-device-exemption-ide) and in its guidance document [In Vitro Diagnostic (IVD) Device Studies - Frequently Asked Questions](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/in-vitro-diagnostic-ivd-device-studies-frequently-asked-questions).
### E. Quality System Requirements
Manufacturers generally must establish and follow a quality system to help ensure that their devices consistently meet applicable requirements and specifications to assure that they are safe and effective and otherwise in compliance with the FD&C Act, as required by section 520(f) of the FD&C Act. The quality system requirements for FDA-regulated products are known as CGMPs and, for medical devices, CGMPs are found at 21 CFR part 820 (“the QS regulation”). The QS regulation provides the essential elements of a quality system without prescribing specific ways to establish these elements. Because the QS regulation covers a broad spectrum of devices, production processes, etc., it allows some leeway in the details of quality system elements.
In early 2024, FDA issued the Quality Management System Regulation Final Rule, which incorporates by reference into the QS regulation the International Organization for Standardization (ISO) 13485:2016 Medical devices – Quality management systems – Requirements for regulatory purposes, to promote consistency in the regulation of devices. This rule will take effect on February 2, 2026. The requirements found in 21 CFR part 820 remain in effect until then.
The phaseout of the general enforcement discretion approach for LDTs with respect to most QS requirements (except complaint files) will take place after the effective date of the QMS Regulation Final Rule. With respect to requirements regarding complaint files prior to the effective date of the amended QSR, as discussed in the preamble to the LDT Final Rule, FDA intends to exercise enforcement discretion and generally not enforce requirements under 21 CFR 820.198 for laboratories that are in compliance with Subclause 8.2.2 of ISO 13485.
FDA provides more information about the QS regulation and how to comply on its web site [QS Regulation/Medical Device Current Good Manufacturing Practices (CGMP)](https://www.fda.gov/medical-devices/postmarket-requirements-devices/quality-system-qs-regulationmedical-device-current-good-manufacturing-practices-cgmp). FDA anticipates providing to all its stakeholders, including laboratory manufacturers, timely guidance on compliance with the regulatory requirements in the amended QSR.
### F. Premarket Review Requirements
For most medical devices, the appropriate premarket submission type is based on the device classification. Moderate-risk (Class II) and some low-risk (Class I) devices are typically reviewed under a premarket notification under section 510(k) of the FD&C Act (referred to as “510(k)”), which involves an assessment of whether the new device is substantially equivalent to a legally marketed device, called a predicate device. FDA’s premarket notification requirements are found at 21 CFR part 807 subpart E. When no predicate device is available, manufacturers of moderate-risk and low-risk devices can submit a de novo classification request under section 513(f)(2) of the FD&C Act, following the requirements found at 21 CFR part 860 subpart D. Manufacturers of higher risk (Class III) devices submit a PMA under section 515 of the FD&C Act. FDA’s PMA requirements are found at 21 CFR part 814. Certain devices regulated by CBER may require a BLA under section 351 of the PHS Act. The regulations for BLAs are found at 21 CFR part 601. More information about these submissions can be found at [Information about the Biologics License Applications (BLA) Process](https://www.fda.gov/vaccines-blood-biologics/development-approval-process-cber/biologics-license-applications-bla-process-cber). FDA provides information on how to select and prepare the correct submission on its web site at [Premarket Submissions: Selecting and Preparing the Correct Submission](https://www.fda.gov/medical-devices/how-study-and-market-your-device/premarket-submissions-selecting-and-preparing-correct-submission).
### G. General Information
In addition to the above resources, FDA’s web pages for [Laboratory Developed Tests](https://www.fda.gov/medical-devices/in-vitro-diagnostics/laboratory-developed-tests) and [IVD Regulatory Assistance](https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/ivd-regulatory-assistance) provide additional resources and information about how FDA regulates devices. CDRH also offers two important resources for industry:
- **[CDRH Learn](https://www.fda.gov/training-and-continuing-education/cdrh-learn)**, a multi-media educational resource, featuring learning modules that address medical device laws, regulations, guidances, and policies, across the entire product life cycle; and
- **[Division of Industry and Consumer Education (DICE)](https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/contact-us-division-industry-and-consumer-education-dice)**, which answers questions by phone and email from the medical device industry and hosts [Device Advice: Comprehensive Regulatory Assistance](https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/contact-us-division-industry-and-consumer-education-dice), a web page for CDRH’s comprehensive regulatory education.
FDA’s Q-Submission program additionally offers manufacturers an opportunity to receive feedback on IDE applications, INDs, and premarket submissions for devices prior to FDA premarket review. More information can be found in the [Requests for Feedback and Meetings for Medical Device Submissions: The Q-Submission Program guidance document](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/requests-feedback-and-meetings-medical-device-submissions-q-submission-program). FDA’s web page for [Premarket Submissions: Selecting and Preparing the Correct Submission](https://www.fda.gov/medical-devices/how-study-and-market-your-device/premarket-submissions-selecting-and-preparing-correct-submission) also links to pages that provide additional information on each type of premarket submission, except information for BLAs, which can be found at [Biologics License Applications (BLA) Process (CBER)](https://www.fda.gov/vaccines-blood-biologics/development-approval-process-cber/biologics-license-applications-bla-process-cber).
---
[^10]: The draft guidance titled “Enforcement Policy for Certain In Vitro Diagnostic Devices for Immediate Public Health Response in the Absence of a Declaration under Section 564: Draft Guidance for Laboratory Manufacturers and Food and Drug Administration Staff” will reflect FDA’s current thinking when finalized.
[^11]: An IVD that is also a biological product and subject to licensure under section 351 of the PHS Act may be studied under an investigational new drug application (IND) and subject to the investigational use requirements in section 351(a)(3) of the PHS Act and 21 CFR part 312, instead of the IDE requirements in part 812.
[^12]: LDTs are IVDs that are intended for clinical use and that are designed, manufactured, and used within a single laboratory that is certified under the CLIA and meets the regulatory requirements under CLIA to perform high complexity testing.
[^13]: As discussed in the preamble to the final rule, FDA uses the phrase “LDTs approved by NYS CLEP” to refer to LDTs that are approved, conditionally approved by, or within an approved exemption from full technical documentation, under NYS CLEP.
[^14]: Reporting requirements for other entities are also set forth in 21 CFR part 803.
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CONTENT
# _archive-combined-files_open-euas_28k (6 files, 27,806 tokens)
# 12,968 _AI_open-euas-open-access-diagnostics-report.md
METADATA
last updated: 2026-03-02 RT
file_name: _AI_open-euas-open-access-diagnostics-report.md
file_date: 2026-03-02
title: FloodLAMP Open EUAs - Open-Source Protocol and Open-Access Authorization for Diagnostic Tests
category: regulatory
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tags: open-eua, open-source-diagnostics, salivadirect, fda-eua, cdc-test, open-access, ldt-oversight
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notes: Initially created by ChatGPT Pro 5.2 Extended, edited by Opus 4.6 and RT during archive preparation. **PARTIALLY HUMAN EDITED/VERIFIED - MAY CONTAIN ERRORS** Research report analyzing the "open EUA" concept (open-source protocol combined with open-access authorization) centered on SalivaDirect as the canonical example, with analysis of the CDC test, pre-pandemic antecedents, regulatory barriers to proliferation, and implications for future open-access diagnostics. Key sources include FDA authorization documents, SalivaDirect retrospective literature, policy analyses, and FloodLAMP archive materials.
summary_short: Research report on "open EUAs" -- the combination of open-source diagnostic protocols with open-access FDA authorization -- centered on SalivaDirect as the canonical example. Covers the regulatory mechanics of the steward/designation model, evidence of uptake in press and academia, pre-pandemic antecedents, reasons the model did not proliferate during COVID-19, a detailed analysis of the CDC test as a government "open" diagnostic with structural limitations, and a practical framework for future open-access diagnostics. Includes a comparative openness table across six COVID-19 EUA test categories.
CONTENT
***INTERNAL TITLE:*** Open EUAs for Diagnostic Tests (Open-Source Protocol + Open-Access Authorization)
**A research report centered on the SalivaDirect “open source protocol” EUA model and what happened to the concept (pre‑COVID → March 2026)**
**Archive Files included in context window:**
`regulatory/open-euas/Anne Wyllie Nomination for FDA Foundation 2022 Innovations in Regulatory Science Awards.md`
`regulatory/open-euas/2020-08-15_FDA Website - Press Release FDA Issues EUA for SalivaDirect.md`
Added during Opus 4.6 edits:
`regulatory/fda-euas/2020-12-01_CDC EUA IFU - CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel.md`
---
## Table of contents
1. [Executive summary](#executive-summary)
2. [What an “open EUA” actually means](#what-an-open-eua-actually-means)
3. [Case study: SalivaDirect as the canonical open‑protocol/open‑access EUA](#case-study-salivadirect-as-the-canonical-openprotocolopenaccess-eua)
4. [Evidence of uptake in press, academia, and FDA-facing discussions](#evidence-of-uptake-in-press-academia-and-fda-facing-discussions)
5. [Did FDA authorize *other* open‑protocol/open‑access EUAs?](#did-fda-authorize-other-openprotocolopenaccess-euas)
6. [Pre‑pandemic antecedents and “why this wasn’t obviously new”](#prepandemic-antecedents-and-why-this-wasnt-obviously-new)
7. [Why the open‑protocol/open‑access model didn’t proliferate in COVID‑19](#why-the-openprotocolopenaccess-model-didnt-proliferate-in-covid19)
8. [Where things stand now (2023–2026): open protocols vs open access](#where-things-stand-now-20232026-open-protocols-vs-open-access)
9. [A practical framework for future “open access diagnostics”](#a-practical-framework-for-future-open-access-diagnostics)
10. [The CDC test as the canonical "open" government diagnostic](#the-cdc-test-as-the-canonical-open-government-diagnostic)
11. [Comparative table: openness characteristics of COVID-19 EUA diagnostic tests](#comparative-table-openness-characteristics-of-covid-19-eua-diagnostic-tests)
12. [Appendices](#appendices)
13. [References](#references)
---
## Executive summary
### The core idea
An **“open EUA”** (as discussed here) is not merely publishing a protocol. It is an **institutional and legal pattern** that combines:
- **Open-source protocol**: the assay design and workflow are fully disclosed and implementable without proprietary equipment; and key components can be sourced from **multiple suppliers**.
- **Open-access authorization**: *multiple* independent clinical laboratories can legally run the test **under one authorization**, rather than each needing their own EUA/510(k)/De Novo, *because* a single steward (the EUA holder) **designates/authorizes participating labs** and maintains a “single source of truth” for validated configurations and updates.
SalivaDirect is the clearest widely-recognized example of this in FDA’s COVID‑19 test authorization corpus, and FDA itself explicitly described it as an “open source” protocol that *designated* labs could run ([1], [21]).
### What SalivaDirect contributed (beyond “saliva”)
Across public sources, SalivaDirect is repeatedly characterized as:
- **Extraction‑free** (skipping nucleic acid extraction), with supply‑chain benefits ([1], [8]).
- **Flexible validation** across multiple reagent/instrument combinations (“off‑the‑shelf” components) ([1], [7]).
- A **novel regulatory framework**: an EUA held centrally, with **quality oversight** by the steward and execution at **designated high‑complexity labs**, leading to a large national lab network and millions of tests ([2], [7]).
A 2024 retrospective paper from the SalivaDirect team describes a “novel regulatory framework” established with FDA—EUA to Yale, protocol offered to designated CLIA high‑complexity labs with quality oversight by Yale—and reports **>200 labs** and **>6.5 million tests as of May 2024** ([7]).
### Was the concept “picked up” in the press and academic retrospectives?
Yes—but unevenly.
- **Press**: Many stories emphasized *saliva* and *skipping extraction*; fewer centered the **regulatory novelty** (open protocol + designated-lab access). Still, multiple outlets explicitly called it “open source” and described designated labs using the protocol ([15]–[19]).
- **Academic / policy**: A citizen-science policy analysis (2022) framed COVID as revealing structural barriers to open-source diagnostics and argued U.S. approval models are poorly suited to them ([9]). A 2024 SalivaDirect retrospective explicitly positions the model as scalable and replicable for future outbreaks ([7]).
### Was this concept considered before COVID?
Elements existed, but the **exact combination** was unusual:
- **Open protocols** in diagnostics have long existed via publications and CLIA‑governed laboratory-developed tests (LDTs).
- **Networked testing under centralized authority** also existed in public-health contexts (e.g., reference lab networks), and EUA mechanisms existed pre‑COVID.
- What appears rarer is FDA’s explicit endorsement of an *“open source protocol”* framing **plus** a centralized steward role enabling broad adoption in many unaffiliated CLIA labs without the steward manufacturing a proprietary kit ([1], [7], [20]).
### Why didn’t the model proliferate?
Public evidence points to several interacting frictions:
1. **Regulatory incentives changed mid‑pandemic**: HHS policy changes in Aug/Oct 2020 reduced FDA review of COVID LDT EUAs, likely reducing the value of building an “open‑access EUA umbrella,” because labs could implement LDTs without EUA in that period ([6], [11]).
2. **Stewardship burden**: The steward must maintain validated “test systems” (not just “protocols”), manage amendments/bridging studies, and oversee a lab network with reporting obligations ([2], [7]).
3. **Commercial incentives**: many developers pursued proprietary kits/platforms; open protocols don’t create the same exclusivity.
4. **Market shift**: U.S. testing demand shifted toward rapid antigen and at‑home tests; an open PCR protocol for high‑complexity labs is not a direct substitute.
### Current state (through March 2026)
- SalivaDirect remains an ongoing example: by mid‑2024 SalivaDirect, Inc. held multiple EUAs and continued updating reagent/instrument options through amendments and bridging studies ([7]).
- The broader “open access” question is tightly linked to U.S. policy oscillations on **LDT oversight** (and legal challenges to FDA’s attempted expansions), which affect whether “open protocols” propagate via CLIA LDTs versus via centralized FDA authorizations ([6], [12]–[14]).
---
## What an “open EUA” actually means
### EUA reality: FDA authorizes **test systems**, not “ideas”
One of the central observations in the attached nomination letter is that FDA generally authorizes a **defined test system**: sample type, reagents, instruments, workflow, and performance claims must be specified; FDA does not simply approve a “protocol” in the abstract ([20]).
That has two consequences:
1. **Open publication ≠ open access.** Publishing a complete protocol does not automatically allow others to run it “as that FDA‑authorized test” unless they are legally covered under the authorization.
2. **Openness must be engineered into the regulatory wrapper.** To make a published protocol “open access,” you need a regulatory mechanism that authorizes execution by multiple independent entities.
### A simple taxonomy: “open” has at least 4 layers
| Layer | What’s “open”? | Typical mechanism | What it enables | What it *doesn’t* solve |
|---|---|---|---|---|
| 1. **Open science** | Paper/preprint describes workflow | Publication | Scientific replication | Legal authority to offer clinical testing under FDA authorization |
| 2. **Open protocol** | Step-by-step IFU-like protocol, implementable with commodity parts | Protocol repositories, publications, SOP sharing | Faster adoption by capable labs | A lab is still “on its own” for regulatory posture (LDT vs EUA) |
| 3. **Open supply chain** | Multiple validated suppliers of key reagents/instruments | Validation across alternatives; equivalence/bridging | Resilience against shortages; cost competition | Requires ongoing maintenance as suppliers change |
| 4. **Open access authorization** | Multiple labs can legally run under one authorization | Designated/authorized labs under an EUA held by a steward | Scaling without requiring each lab to submit full EUA | Governance, liability, quality control, and costs shift to steward |
In this framing, **SalivaDirect** is notable because it attempted to combine **all four layers** ([1], [7], [20]).
### Why “open source” is a loaded term in IVD regulation
In software, “open source” implies license terms and freedom to copy/modify. In IVDs, analogous freedoms collide with:
- **Quality System Regulation / manufacturing controls** (for commercial IVDs)
- **CLIA validation responsibilities** (for LDTs)
- **FDA’s product-specific authorization posture** (for EUA, 510(k), De Novo, PMA)
- **Liability and post‑market surveillance expectations**
Thus, an “open source diagnostic” in the *regulatory* sense usually needs a **governance model** (a steward, a network, contracts, verification, versioning).
---
## Case study: SalivaDirect as the canonical open‑protocol/open‑access EUA
### 1) What FDA publicly said in August 2020
In its August 15, 2020 press release announcing the EUA, FDA emphasized:
- saliva collected in a sterile container
- the ability to avoid a separate nucleic‑acid extraction step
- validation across different combinations of commonly used reagents/instruments
- and explicitly: Yale intended to provide the protocol as an **“open source” protocol** for **designated laboratories** to run under Yale’s instructions ([1], [21]).
That press release is one of the most explicit FDA uses of “open source” framing for an EUA’d diagnostic protocol.
### 2) What the nomination letter claims was novel
The attached nomination letter (June 3, 2022) frames SalivaDirect’s “open source protocol” EUA as unusual because:
- the academic team sought an IVD EUA **without intending to manufacture kits**,
- they **did not patent** the test, used **CDC primers**, fully disclosed ingredients, and validated multiple suppliers and instruments,
- FDA created a **designation** process allowing CLIA labs to use the EUA, and
- the lab network plus multi‑supplier validation produced supply‑chain redundancy and contributed to cost compression ([20]).
Some of these points are corroborated by FDA documents and later retrospectives ([1], [2], [7]); others (e.g., “most unusual submission FDA had ever received”) appear as narrative claims that would require independent confirmation beyond the nomination letter itself.
### 3) How the EUA wrapper operationalized “open access”
FDA authorization materials for SalivaDirect (held by SalivaDirect, Inc.) explicitly limit testing to **laboratories designated by the EUA holder** and impose obligations on both the steward and authorized laboratories (e.g., use only as authorized, reporting/recordkeeping, false result reporting pathways, etc.) ([2], [3]).
This is the “open access” scaffold: **one legal authorization → many performing labs**, with the steward acting as a compliance and quality gate.
### 4) The “steward model” in one picture (textual)
**Traditional kit EUA**
1. Manufacturer validates a fixed kit configuration.
2. FDA authorizes the kit.
3. Any qualifying lab buys and runs the kit (no “designation” step).
**SalivaDirect-style open protocol + open access**
1. Steward validates multiple acceptable configurations (reagents/instruments/workflows).
2. FDA authorizes the test system(s) as described in authorized labeling.
3. Steward **designates** labs that can run the protocol under the EUA.
4. Steward maintains the configuration list and manages amendments/bridging as supply chain or workflows change ([2], [7]).
### 5) Reported scale and evolution
A 2024 retrospective paper from the SalivaDirect team describes:
- the protocol as open-source and extraction-free using off-the-shelf reagents/equipment,
- a “novel regulatory framework” with EUA to Yale and designated CLIA high‑complexity labs under Yale’s oversight,
- growth to a U.S. network of **>200 labs**, and
- **>6.5 million tests as of May 2024**, plus multiple EUA expansions/amendments over time ([7]).
### 6) Why SalivaDirect is often described as “generic-like” diagnostics
The nomination letter’s “generics of diagnostics” analogy is directionally helpful but imperfect ([20]).
| Feature | Small-molecule drug generics (ANDA model) | SalivaDirect-style “generic-like” diagnostics |
|---|---|---|
| IP baseline | Active ingredient and reference product known; patents expire | Assay components may be public, but performance depends on workflow/instrument/reagent interactions |
| Regulatory mechanism | ANDA relies on reference listed drug, bioequivalence | No true “ANDA for diagnostics”; 510(k) is predicate-based but not a “copy this exact spec” pathway |
| Substitutability | High (chemically the same) | Variable (lab execution, instruments, reagents can shift performance) |
| Competition lever | Multiple manufacturers produce same product | Multiple suppliers can provide components; labs can implement; steward can validate combinations |
SalivaDirect’s key “generic-like” move was to pre‑validate multiple supply chain options (and keep adding more) while providing a compliance wrapper for widespread CLIA lab use ([1], [7]).
---
## Evidence of uptake in press, academia, and FDA-facing discussions
This section answers: **Was the open protocol + designation + stewardship concept discussed outside the nomination letter?**
### A) Press coverage: what was emphasized
Below is a non‑exhaustive sample of media coverage that explicitly references **open source** and/or the **designated lab** model.
| Outlet | Date | What it highlighted | Notes |
|---|---:|---|---|
| FDA press release | 2020‑08‑15 | “open source” protocol; designated labs; multi‑reagent/instrument validation | Primary source of FDA’s framing ([1]) |
| ContagionLive | 2020‑08‑15 | “open source system” where designated labs follow protocol | Trade/clinical media ([15]) |
| STAT | 2020‑08‑15 | Open protocol; access and cost angles | General audience ([16]) |
| TIME | 2020‑10‑13 | SalivaDirect as one path to broader testing access | More about access ([17]) |
| LabMedica | 2020‑08‑17 | Open‑source saliva PCR test and scaling | Trade press ([18]) |
| SelectScience | 2022 (interview) | “open-access protocol”; designated labs; amendments for redundancy | Quantitative adoption claims ([19]) |
**Observation:** Even when “open source” is mentioned, press stories often focus on *saliva* and *no extraction* as the innovation, with the open‑access regulatory design treated as secondary. This helps explain why the “open EUA” concept did not become a broadly discussed regulatory category during the pandemic.
### B) Academic and policy literature
A few categories of publications matter for understanding whether the concept “landed” in the literature:
1) **Method and validation papers** (how to implement and how well it performs)
2) **Implementation/network papers** (how it scaled, governance, real-world operations)
3) **Regulatory/policy retrospectives** (what it implies for future oversight and innovation)
A sample map:
| Publication type | Example(s) | Key relevance to “open EUA” idea |
|---|---|---|
| Method/validation | Vogels et al. SalivaDirect paper (2020) ([8]) | Simplified/flexible protocol; supports “off-the-shelf” concept |
| Implementation & scaling | SalivaDirect retrospective (2024) ([7]) | Explicitly frames “novel regulatory framework”; lab network, amendments, bridging studies |
| Policy analysis of open-source diagnostics | Monaco & Ware (2022) ([9]) | U.S. approval model poorly suited for open-source diagnostics; COVID as a stress test |
| Broader “open-source diagnostics” models | Emperador et al. (2020) ([10]) | Proposes open-source co-development model for outbreak preparedness (conceptual antecedent) |
### C) FDA-facing discussions and “signals” from regulators
Even if the concept didn’t lead to many additional “open protocol EUAs,” FDA documentation and public-facing materials show the agency had mechanisms and vocabulary for:
- “authorized” vs “designated” high-complexity labs ([2], [5])
- umbrella EUAs for certain test classes ([4], [5])
- templates to standardize submissions and accelerate review ([4])
FDA also published after-action and assessment materials describing how it prioritized tests that addressed shortages (e.g., pivot to saliva amid swab constraints) and how policy changes around LDT oversight affected EUA review load ([6]).
---
## Did FDA authorize other open‑protocol/open‑access EUAs?
### 1) “Designated laboratories” are not unique—but the *open protocol* framing is
FDA has long included in EUA scope/conditions the ability to restrict a test to:
- a single laboratory (classic LDT),
- a named set of laboratories, or
- “designated” laboratories (designated by an EUA holder) ([5]).
So the *designation tool* itself is not necessarily unique. What stands out about SalivaDirect is:
- FDA’s explicit “open source protocol” framing in a press announcement ([1]); and
- deliberate design around **multi‑supplier components** and **commodity equipment** to function as a generic-like, supply-chain-resilient assay ([7], [20]).
### 2) Umbrella EUAs: an alternate scaling pathway that looks “open” but isn’t
FDA issued “umbrella EUAs” for certain molecular test categories during COVID. These umbrellas can make it *easier* for many labs to be authorized, but they typically still result in **lab‑specific** authorizations or restrictions, and they do not automatically create a single stewarded open protocol ([4], [5]).
In other words:
- Umbrella EUA = standardized pathway to get many authorizations
- SalivaDirect model = one authorization + stewarded lab network running a shared protocol
### 3) Attempts to replicate the “open-source protocol EUA” idea
There is evidence that other groups pursued “open-source protocol EUA” submissions. For example, a 2022 meeting summary from the COVID‑19 Diagnostics Evidence Accelerator reports FloodLAMP stated it had submitted multiple open-source protocol EUAs and a pre‑EUA (and sought to resubmit with partners/federal support) ([22]). This suggests aspiration and activity—but not widespread authorization outcomes.
### 4) Bottom line
Based on public evidence reviewed for this report, SalivaDirect is:
- the most prominent FDA-described “open source protocol” EUA for a COVID PCR assay, and
- a rare example where the steward did not rely on proprietary equipment and instead validated multiple supply chain options and maintained a multi‑lab network under one authorization ([1], [2], [7]).
---
## Pre‑pandemic antecedents and “why this wasn’t obviously new”
### 1) Open protocols existed (but not as “open access FDA authorizations”)
Before COVID, diagnostic methods were routinely published and replicated as:
- research assays
- CLIA laboratory-developed tests (LDTs), often as “homebrew” assays implemented from literature
This is “open protocol” in the scientific sense, but it is not necessarily “open access under FDA authorization.”
### 2) Centralized oversight + distributed execution existed in public health
Public health labs and reference networks have long used shared protocols and central coordination. In emergencies, EUA authority existed pre‑COVID.
SalivaDirect’s twist was **pairing that networked operational model** with:
- *explicit* open-source positioning; and
- a design optimized for commodity supply chains rather than a proprietary kit ([1], [7], [20]).
### 3) “Open-source diagnostics” as preparedness strategy was discussed pre‑/early‑COVID
In 2020, Emperador et al. published a model for open-source co-development partnerships for molecular diagnostics, explicitly tied to outbreak and epidemic preparedness, emphasizing flexible, sustainable approaches (especially relevant to low- and middle-income country settings) ([10]).
This suggests the idea of open-source diagnostics was “in the air,” but the FDA EUA instantiation (as open access) was still unusual.
---
## Why the open‑protocol/open‑access model didn’t proliferate in COVID‑19
This section synthesizes the most plausible explanations supported by public evidence, plus reasonable inferences.
### 1) Mid‑pandemic policy whiplash around LDT EUAs
In August 2020 HHS announced a policy position affecting FDA’s ability to require premarket review/EUAs for LDTs, and FDA subsequently deprioritized or stopped reviewing many COVID LDT EUA requests in the fall of 2020 ([6], [11]).
FDA’s EUA assessment report later described that following the HHS statement, FDA “Declined to Review” a large number of LDT EUA requests, in part because LDTs could be marketed without an EUA during that period and FDA prioritized other categories (e.g., home collection and POC tests) ([6]).
**Implication for open EUAs:** If many labs could offer COVID testing as LDTs without an EUA, the incremental value of building a stewarded open-access EUA network may have dropped—especially for teams without resources to manage ongoing stewardship.
Later, in November 2021 HHS withdrew/reversed the 2020 policy, and FDA updated its COVID test policy accordingly ([12]). But by then, the market had evolved and many labs/tests were already entrenched.
### 2) The steward model is operationally heavy
An “open access” EUA steward must do what a kit manufacturer normally does, but without product revenue:
- maintain authorized labeling and version control
- onboard and train labs (contracts, verification, quality expectations)
- add new instruments/reagents via bridging studies and EUA amendments
- handle post‑market reporting, complaints, performance monitoring
- coordinate communications across a network
The SalivaDirect team’s retrospective emphasizes the amendment cadence and bridging work needed to keep expanding equipment/supply options ([7]).
### 3) Misaligned incentives and funding
Open protocols can reduce exclusivity. Without a durable funding source (public funding, philanthropy, fees, or a product business), a steward may be unable to sustain the governance load.
The nomination letter explicitly frames SalivaDirect’s cost compression as a public benefit—but that same dynamic can discourage commercial followers from replicating the model ([20]).
### 4) Technical scope mismatch with public demand shifts
PCR testing in high-complexity labs has different economics and logistics than:
- point-of-care molecular tests
- at-home antigen tests
- retail distribution models
As COVID response shifted, the “open PCR protocol executed by CLIA high-complexity labs” became less central to the consumer-facing narrative, even if it remained important for surveillance and institutional programs.
### 5) Regulatory structure: authorization attaches to an entity
The requestor’s key point is structural: even if every component is disclosed, FDA authorizes a product to a legal entity. Without a mechanism like “designated labs” or a modular authorization framework, open-source publication alone cannot create broad open access.
Monaco & Ware (2022) essentially make this argument from a policy angle: open-source diagnostics face structural hurdles under existing approval models ([9]).
---
## Where things stand now (2023–2026): open protocols vs open access
### SalivaDirect today (as reflected in public materials through 2024–2026)
Public sources indicate SalivaDirect evolved beyond the original Yale EUA to multiple EUAs held by SalivaDirect, Inc., including provisions for direct-to-consumer / at-home collection methods, and continues to rely on designated laboratories and maintained lists of qualified reagents/instruments ([2], [7]).
### LDT oversight turbulence matters for “open access diagnostics”
From 2024–2025, FDA finalized a rule attempting to increase oversight of LDTs, followed by legal challenges and later reporting that FDA would rescind/roll back the rule after a court decision ([13], [14]). This volatility affects the practical landscape:
- If **LDTs remain primarily CLIA-governed**, “open protocol” dissemination may be the dominant path (labs implement locally).
- If **FDA oversight expands**, there may be more demand for shared regulatory infrastructure—potentially increasing the attractiveness of stewarded open-access models (if legally supported).
### The “open access” gap remains
Even in 2026, the system still largely lacks a routine, non-emergency pathway equivalent to:
- **“one open dossier → many independent manufacturers/labs can legally operate under it”**
without those labs/entities filing their own marketing submissions.
That is the crux of why the SalivaDirect-style model remains important as a regulatory design pattern: it shows a way to approximate “generic diagnostics” during emergencies by combining open protocol + centralized stewardship + lab designation ([7], [20]).
---
## A practical framework for future open access diagnostics
Below are actionable design patterns, each with tradeoffs.
### Pattern 1: Stewarded Open Protocol EUA (SalivaDirect model)
**Best for:** rapid scale in high-complexity labs using commodity equipment, with supply-chain flexibility.
**Key requirements:** a capable steward + funding + governance ([7]).
**Enhancements to consider (policy or program design):**
- Public funding for stewardship activities (amendments, bridging, QA)
- Shared national infrastructure: proficiency testing, reference panels, shared QA dashboards
- Standardized contract templates and onboarding verification workflows
### Pattern 2: Government- or consortium-operated “reference protocol” with delegated execution
**Best for:** emergencies where equity, cost, and resilience matter more than exclusivity.
**What changes:** steward role is institutionalized (CDC, NIH, or multi-stakeholder consortium), not dependent on one academic lab.
### Pattern 3: Modular authorization / open master file + right-of-reference
**Goal:** allow many entities to “plug into” an openly available validated dossier (or module) rather than repeat work.
**Challenge:** today, right-of-reference systems often assume proprietary master files, not public-domain ones; FDA would need policy clarity.
### Pattern 4: Standards-based pathway (consensus methods + minimal bridging)
**Goal:** convert parts of “protocol validation” into standards (e.g., CLSI style), so following the standard reduces evidence burden.
**Challenge:** standards are slow to develop, and outbreak dynamics are fast.
---
## The CDC test as the canonical "open" government diagnostic
### Why the CDC test matters in the open EUA context
The CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel is, in an important sense, the original "open" COVID diagnostic test in the United States. As a government-developed and government-distributed assay, it embodied several key features that later open-protocol EUAs like SalivaDirect would build on — but it also illustrates the structural limitations that prevented even the most widely available public-sector test from functioning as a truly open-access platform.
The CDC test was authorized for use by any CLIA high-complexity laboratory. Its primer and probe sequences (N1, N2, and the RP internal control) were publicly published. Reagents were distributed through the International Reagent Resource (IRR) and, over time, commercially manufactured primer/probe alternatives were accepted. By the December 2020 revision of the IFU, multiple extraction platforms from QIAGEN, Roche, Promega, and bioMérieux were authorized. In these respects, the CDC test scored well on "openness" — full disclosure of chemicals and reagents, publicly available primer sequences, and multi-vendor sourcing of key components.
However, the CDC test also reveals the limits of openness without intentional design for access and resilience:
- **Single instrument dependency.** The test was authorized only on the Applied Biosystems 7500 Fast Dx Real-Time PCR Instrument. Unlike SalivaDirect, which validated across multiple RT-PCR platforms, the CDC test remained locked to one instrument family, limiting which labs could adopt it and creating a supply constraint.
- **Distribution model, not designation model.** The CDC did not use a "designated laboratory" framework like SalivaDirect. Instead, reagents were distributed through IRR and commercial channels to any qualifying lab. This is simpler than stewardship-with-designation but also means there was no systematic onboarding, quality oversight, or network coordination among implementing labs.
- **Supply chain fragility despite openness.** Despite disclosing reagents and accepting multi-vendor extraction methods, the CDC test suffered acute supply chain failures — most catastrophically, the contaminated initial test kit batch in February 2020, followed by extraction reagent shortages that hobbled testing capacity nationwide for weeks.
### The initial CDC test kit failure
The CDC's initial test kit failure was one of the most consequential early failures of the U.S. pandemic response. The first batch of RT-PCR test kits was distributed to state and local public health laboratories beginning February 5, 2020. Within days, multiple laboratories reported false positive reactivity in negative controls. A CDC internal investigation (published in PLOS ONE, 2021) identified two separate problems ([24]):
1. **N1 component contamination**: The N1 reagent in the distributed kits was contaminated with synthetic genetic material (positive control plasmid), causing approximately 2% false positive results. The contamination was not present in pre-validation material and was determined to have occurred during the post-production quality control process or packaging. The FDA confirmed that CDC manufactured its test in one of its research laboratories rather than in its manufacturing facilities, and did not follow its own manufacturing protocols ([25]).
2. **N3 probe design flaw**: The N3 probe exhibited false positive reactivity because two molecules in the probe frequently bound to each other in the absence of any virus, triggering a false fluorescent signal. This problem worsened with the age of the kits, which is why early evaluation runs using fresh materials did not catch it.
The combined effect was that the only authorized COVID test in the United States produced unreliable results at precisely the moment when early detection and containment were most critical. The N3 component was eventually dropped from the panel entirely, and replacement kits were not available until late February. A 2023 HHS Office of Inspector General audit concluded that the failure resulted from "internal control weaknesses" in CDC's development processes and laboratory quality procedures, including inadequate separation of duties, insufficient documentation, and lack of independent expert review prior to distribution ([26]). The OIG further warned that without corrective action, CDC risked "damaging public trust, which could undermine its ability to accomplish its mission."
The three- to four-week delay during February 2020 — a period when community transmission was establishing itself across the United States — is widely regarded as having materially worsened the trajectory of the U.S. outbreak. And the irony from the open-access perspective is acute: here was a government-developed, openly disclosed test, free of commercial interests, that failed not because of any inherent problem with the "open" model but because of basic manufacturing quality failures at the agency itself.
### Appendix A and the extraction-free protocol restriction
One of the most consequential — and least discussed — features of the CDC EUA IFU is **Appendix A: "Heat Treatment Alternative to Extraction."** In response to the global extraction reagent shortage, CDC validated a simple heat treatment protocol (95°C for 1 minute) using the Quantabio UltraPlex 1-Step ToughMix (4X) as a specimen processing alternative that bypassed nucleic acid extraction entirely. CDC's own data showed comparable detection performance between the extraction-based and heat-treatment methods.
This was a significant technical achievement: a direct, extraction-free protocol validated against the flagship government test, requiring only a thermal cycler and basic consumables — no complex extraction instruments or scarce extraction kits.
**But Appendix A carried a critical restriction: "This procedure is only for use by public health laboratories."**
An initial restriction to public health labs was arguably reasonable — CDC had validated the heat treatment method with a limited number of clinical specimens, acknowledged a potential reduction in sensitivity, and stated it should only be used "when a jurisdiction determines that the testing need is great enough to justify the risk of a potential loss of sensitivity." Starting with public health labs (which have closer institutional ties to CDC and more experience with method validation under emergency conditions) while further qualifying the protocol was defensible as a cautious first step.
But the restriction should have been temporary — a matter of weeks, not permanent. Once the method was further qualified (and CDC's own performance data showed comparable detection), the restriction should have been lifted to allow any authorized CLIA high-complexity lab to use the extraction-free protocol, especially given that the entire rationale for the method was a reagent shortage affecting *all* labs, not just public health labs.
Instead, the restriction appears never to have been lifted — the FDA-hosted March 7, 2023 revision of the CDC IFU still contains the identical "only for use by public health laboratories" language ([23]). The practical effect was that even as extraction reagent shortages crippled testing capacity at clinical laboratories across the country, the validated extraction-free alternative remained restricted to the narrower tier of public health laboratories. CLIA high-complexity labs — which constituted the bulk of the authorized testing network and clinical lab infrastructure in the United States — could not use it.
This represents a compounding narrowing of the testing funnel:
1. FDA EUAs generally restricted authorized COVID testing to CLIA high-complexity clinical laboratories, excluding the vast landscape of potential testing settings (schools, workplaces, community health organizations).
2. The CDC test was the most broadly available authorized assay within that clinical lab universe.
3. But the extraction-free simplification — the very innovation that could have helped labs most affected by supply shortages — was restricted to an even narrower subset: public health labs only.
Meanwhile, extraction-free protocols became one of the most important areas of innovation during the pandemic: SalivaDirect's extraction-free, multi-platform approach was a central reason for its scalability and supply-chain resilience, and many other EUA-authorized tests adopted extraction-free or direct-sample protocols. The contrast is stark — an academic lab (Yale) built an open, extraction-free platform that scaled to over 200 labs and 6.5 million tests, while the government's own flagship test validated the same general approach but locked it away from the labs that needed it most.
### The broader context: testing as a public health problem, not just a clinical one
The Appendix A restriction is symptomatic of a deeper structural problem that the pandemic exposed. COVID-19 testing was framed and regulated as a **clinical diagnostic activity** — individual patients, healthcare provider orders, CLIA-certified laboratories, FDA-authorized test systems. But the actual need was for **public health screening at population scale**: schools, workplaces, airports, community settings, congregate living facilities.
This mismatch between the regulatory architecture (designed for clinical medicine) and the operational need (public health surveillance and screening) meant that:
- Testing capacity was bottlenecked through the clinical laboratory system, which could not scale fast enough.
- Innovations that could have democratized testing — simpler protocols, extraction-free methods, LAMP-based assays, direct sample testing — faced regulatory barriers calibrated to clinical diagnostic standards rather than public health screening realities.
- Even when validated simplifications existed (as with the CDC's own heat treatment protocol), institutional caution and regulatory framing restricted their use rather than expanding it.
The pandemic demonstrated a need for a **distinct regulatory regime for non-medical testing and screening** — one that could authorize rapid deployment of validated, simplified protocols to a much broader range of settings and operators, without requiring each to operate as a CLIA high-complexity laboratory. The open EUA concept, as pioneered by SalivaDirect and aspired to by FloodLAMP, was an attempt to build something like this within the existing framework. But the CDC Appendix A example shows that even when the technical barrier was solved, the institutional and regulatory barriers remained.
### The regulatory asymmetry: why only the government can create a "universal" test
The CDC test reveals a striking structural asymmetry in the U.S. diagnostic regulatory system. The CDC — a government agency — was ultimately able to create a test that any CLIA high-complexity laboratory in the country could run, simply by obtaining the reagents. No stewardship model. No lab-by-lab designation. (Notably, the *earliest* version of the CDC EUA did limit testing to "qualified laboratories designated by CDC," but later reissued authorization letters broadened this to all CLIA high-complexity labs.) The EUA authorized the test for use by all qualifying labs, the reagents were distributed through the International Reagent Resource and commercial channels, and the protocol was fully public. CDC also provided a distinct form of openness through broad **Right of Reference** (RoR) to its performance data, which other EUA applicants could leverage when seeking their own authorizations — making the CDC assay function as a kind of regulatory "commons" ([4]). In effect, the CDC model was a **public reference protocol with a constrained authorized bill-of-materials**: fully disclosed, broadly available, but sourcing was gated to CDC-approved lots and channels. And even this model was available only to a government agency.
No other entity — academic, nonprofit, or commercial — has access to this pathway. When Yale developed SalivaDirect with comparable openness (fully disclosed protocol, publicly available primer sequences, commodity reagents, multiple validated instrument/reagent combinations), it could not simply publish and distribute. FDA required a stewardship and designation model: Yale (later SalivaDirect, Inc.) had to hold the EUA, designate each participating lab, maintain oversight, manage amendments and bridging studies, and bear the ongoing governance burden. This is the "open access" model described earlier in this report — a genuine innovation in regulatory design, but operationally heavy and dependent on a single steward's capacity and funding.
FloodLAMP pursued the same open-protocol EUA approach and unable not only to obtain an EUA authorization, but to get significant engagement from the FDA despite many efforts (see regulatory/correspondence), including presenting at the Reagan-Udall Foundation for the FDA (see archive file: `various/fl-presentations/FDA Reagan Udall Foundation - FloodLAMP Presentation (4-21-2022).md`). Beyond SalivaDirect, no other organization appears to have successfully replicated the open-protocol/open-access EUA pattern during COVID.
The asymmetry raises a fundamental question: **What justifies the assumption that only a government agency can produce a test reliable enough for unsupervised use by CLIA high-complexity laboratories?**
These are, by definition, laboratories that have demonstrated competence to perform the most complex diagnostic testing. Under CLIA, they are inspected, proficiency-tested, and staffed with qualified personnel. They have the technical capability to validate and run sophisticated molecular assays — and, critically, they have long done exactly this through laboratory-developed tests (LDTs). Granted, only a minority of CLIA labs have the capability to _develop_ a new LDT, but all can _run_ already developed tests, provided the test doesn't require special equipment or isn't unusually complex. Legally, a CLIA high-complexity lab can independently develop, validate, and clinically deploy its own molecular diagnostic test without any FDA premarket authorization, relying on its own scientific judgment and CLIA-regulated quality systems.
This makes the asymmetry even more paradoxical: FDA's regulatory framework simultaneously (a) trusts CLIA high-complexity labs to develop their own tests from scratch as LDTs, but (b) does not trust them to implement someone else's fully disclosed, validated, open protocol without a steward standing between them and the authorization. A lab that could design, validate, and deploy its own RT-PCR test targeting the same viral sequences apparently could not be trusted to follow a published protocol from an academic group — unless that group held an EUA and formally "designated" the lab.
The tension deepened in 2024 when FDA finalized a rule attempting to extend premarket review authority over LDTs — effectively seeking to bring the same CLIA high-complexity labs that had been independently developing and running their own tests under FDA's device-regulatory apparatus. This was a direct challenge to the autonomy that CLIA labs had exercised for decades. A federal court struck down the rule, and FDA subsequently moved to rescind it ([13], [14], see `regulatory/ldts/_AI_FDA 2024 LDT Rule - Status and Legal History.md`). The court's decision effectively affirmed that these labs possess the competence and regulatory standing to operate independently — which only sharpens the question of why non-governmental open protocols cannot be deployed to them without the overhead of a stewardship/designation wrapper.
The most plausible explanation is institutional, not technical: the FDA's product-centric regulatory architecture requires that *someone* be legally accountable for each authorized test system. For a commercial kit, the manufacturer is accountable. For the CDC test, the CDC is accountable. For an open protocol from an academic lab, there is no manufacturer — so FDA requires a steward to fill the accountability role. This is a reasonable structural concern, but the pandemic demonstrated that it can function as a bottleneck that prevents good, validated, open science from reaching the labs that need it. A regulatory framework that recognized the competence of CLIA high-complexity labs — the same competence that underlies the entire LDT system — could have enabled a lighter-weight pathway for deploying open protocols at scale, without requiring each one to build a bespoke stewardship infrastructure.
## Comparative table: openness characteristics of COVID-19 EUA diagnostic tests
### Original table (from FloodLAMP presentation)
slide 12 from `various/fl-presentations/BARDA Market Research - FloodLAMP Presentation (2022-03-07).md`
The following table compares openness characteristics across six categories of COVID-19 diagnostic tests, from a typical proprietary IVD EUA through several open or partially-open protocols, including both FloodLAMP submissions.
| | Typical IVD EUA | CDC EUA | SalivaDirect™ | SHIELD | FloodLAMP EasyPCR™ | FloodLAMP QuickColor™ |
|---|---|---|---|---|---|---|
| Disclosure of all chemicals and reagents? | No | Yes | Yes | Yes | Yes | Yes |
| Chemical and reagents available from multiple vendors? | No | Yes | Yes | No | Yes | Yes |
| Disclosure of primer sequences? | No | Yes (std for PCR) | Yes | No (ProptryThermo) | Yes | Yes |
| Primers commercially available from multiple vendors? | No | Yes | Yes (CDC Primers) | No (ProptryThermo) | Yes (CDC SD Primers) | Yes (Available but not launched) |
| Supply chain robust? | No | No/Maybe | Yes | No/Maybe | Yes | Yes |
| EUA Sponsor Organization Type | For Profit Company | Govt | Academic Not for Profit | Academic Not/For Profit ? | Public Benefit Corp | Public Benefit Corp |
| Designation of CLIA labs | Kit Sales | N/A (open RoR) | Impact & Expansion | Impact & Expansion | Impact & Expansion | Impact & Expansion |
### Final consolidated table
Below is the final revised version of the table, incorporating review from two independent AI analyses of the underlying EUA documents and public sources. Where both analyses agreed on a change, the change was adopted. Where they differed, a decision was made with rationale noted below.
| | Typical IVD EUA | CDC EUA | SalivaDirect™ | SHIELD | FloodLAMP EasyPCR™ | FloodLAMP QuickColor™ |
|---|---|---|---|---|---|---|
| Disclosure of all chemicals and reagents? | No | Yes | Yes | Partial (kit-level) | Yes | Yes |
| Chemical and reagents available from multiple vendors? | No | Yes* (by Dec 2020) | Yes | No | Yes | Yes |
| Disclosure of primer sequences? | No | Yes (published sequences) | Yes | No (proprietary ThermoFisher) | Yes | Yes |
| Primers commercially available from multiple vendors? | No | Yes, constrained (IRR + CDC-accepted lots) | Yes (CDC primers; multi-supplier validated) | No (proprietary ThermoFisher) | Yes (CDC/SD primers) | Yes |
| Supply chain robust? | No | No/Maybe | Yes | No/Maybe | Yes | Yes |
| EUA Sponsor Organization Type | For Profit Company | Govt | Academic Not for Profit | Academic / public university | Public Benefit Corp | Public Benefit Corp |
| Designation of CLIA labs | Kit Sales | No designation step; open to all CLIA HC labs | Impact & Expansion (stewarded designation) | Impact & Expansion (designated labs) | Impact & Expansion | Impact & Expansion |
\* CDC multi-vendor support is constrained: primer/probe and control materials must be from IRR or specific CDC-posted acceptable commercial lots — not "any vendor." Extraction methods have broader but still enumerated multi-vendor support.
### Annotations on changes from original table (with decision rationale)
**Changes where both reviews agreed (adopted):**
1. **SHIELD — "Disclosure of all chemicals and reagents"** changed from "Yes" to **"Partial (kit-level)"**: The covidSHIELD protocol specified which products to purchase (ThermoFisher TaqPath COVID-19 RT-PCR Kit), but the underlying primer/probe/reagent formulations within that kit were proprietary. This is a meaningful distinction from truly open protocols like CDC or SalivaDirect where the reagent compositions are fully disclosed. *(One review changed this; the other agreed in its narrative that SHIELD was "less open" due to proprietary Thermo components but didn't change the cell.)*
2. **CDC EUA — "Disclosure of primer sequences"** annotation changed from "std for PCR" to **"published sequences"**: The N1, N2, and RP sequences were newly designed for SARS-CoV-2 and publicly published; they were not pre-existing "standard" PCR primers. Both reviews agreed on this point.
3. **SHIELD — "Disclosure of primer sequences" and "Primers commercially available"** annotation expanded from "ProptryThermo" to **"proprietary ThermoFisher"** for clarity. Both reviews made this same change.
**Changes where reviews differed (decision with rationale):**
4. **CDC EUA — "Chemicals and reagents available from multiple vendors"**: One review used "Yes (by Dec 2020)"; the other used "Yes*" with a footnote about constrained sourcing. **Decision**: Merged both — **"Yes* (by Dec 2020)"** — because both qualifications are valid. The multi-vendor extraction support was not present at initial authorization (Feb 2020) and was added through subsequent IFU revisions. And even after expansion, primer/probe sourcing remained gated to IRR-distributed or CDC-posted acceptable lots, which is meaningfully more constrained than SalivaDirect's open sourcing from any vendor.
5. **CDC EUA — "Primers commercially available from multiple vendors"**: One review used "Yes (IRR + commercial)"; the other used "Limited (IRR + CDC-accepted lots only)." **Decision**: Adopted **"Yes, constrained (IRR + CDC-accepted lots)"** as a middle ground. The CDC IFU explicitly states that "only material distributed through the CDC International Reagent Resource and specific lots of material posted to the CDC website are acceptable for use with this assay under CDC's Emergency Use Authorization." Labs cannot synthesize the publicly known sequences and use them under the EUA. This is meaningfully more constrained than a simple "Yes" but "Limited" alone understates that multiple sources do exist — the constraint is on *which lots from which vendors*, not on the number of sources.
6. **SHIELD — "EUA Sponsor Organization Type"**: One review kept "Academic Not/For Profit ?" (original); the other changed to "Academic / public university." **Decision**: Adopted **"Academic / public university"** — the EUA sponsor was the University of Illinois, which is unambiguously a public university. The "?" about for-profit status related to Shield T3 LLC (an operational entity), but the authorization holder was the university itself.
7. **CDC EUA — "Designation of CLIA labs"**: One review used "N/A (open IRR distribution)"; the other used a verbose multi-clause description. **Decision**: Adopted **"No designation step; open to all CLIA HC labs"** as a concise synthesis. The CDC did not use a stewarded designation model like SalivaDirect; any qualifying CLIA high-complexity lab could obtain and run the test. (Note: the *earliest* CDC EUA letter did limit testing to "qualified laboratories designated by CDC" before later revisions broadened access.) The original table's "RoR" annotation referred to Right of Reference — CDC's provision of performance data to other EUA applicants — which is a distinct concept from lab designation and is better discussed in narrative context than in this cell.
8. **SalivaDirect / SHIELD — "Designation of CLIA labs"**: One review kept the original "Impact & Expansion" wording; the other used more technically descriptive labels ("Stewarded designation by EUA holder" / "Designated labs under EUA holder"). **Decision**: Kept the original **"Impact & Expansion"** framing (reflecting the user's characterization of purpose/intent) but added parenthetical mechanism descriptions for clarity.
9. **FloodLAMP QuickColor — "Primers commercially available"**: One review simplified from "Available but not launched" to "Yes"; the other kept "Yes (available but not launched)." **Decision**: Adopted **"Yes"** — primer sequences were disclosed and available for custom synthesis. Product launch status is a separate issue from primer availability and is better addressed in narrative context.
## Appendices
### Appendix A — Key terms (glossary)
| Term | Practical meaning in this context |
|---|---|
| **EUA** | Emergency Use Authorization under FD&C Act §564 for medical countermeasures during declared emergencies |
| **IVD** | In vitro diagnostic test (device) |
| **LDT** | Laboratory-developed test; historically under FDA enforcement discretion, primarily regulated via CLIA for lab operations |
| **Open protocol** | Protocol disclosed in enough detail for independent implementation |
| **Open access (regulatory)** | Multiple independent entities can legally operate under a shared authorization without each filing a full application |
| **Steward** | The entity that holds the authorization and manages changes, onboarding, and quality/labeling obligations |
### Appendix B — “Openness” checklists for future projects
**Open protocol checklist**
- [ ] Complete workflow: pre-analytical → analytical → reporting
- [ ] Bill of materials with part numbers and acceptable alternatives
- [ ] Instrument-specific parameters
- [ ] QC/controls guidance (positive/negative, internal controls)
- [ ] Versioning and change log
**Open access checklist**
- [ ] A legal mechanism for multi-entity execution (designation / licensing / umbrella)
- [ ] Onboarding, verification, and audit plan
- [ ] Governance for amendments (who tests, who approves, how to bridge)
- [ ] Funding model for ongoing stewardship
- [ ] Post-market reporting and complaint handling plan
---
## References
> URLs are provided for convenience. Many FDA sources are PDFs; some links may change over time if FDA reorganizes pages.
### Primary documents (FDA, authorization artifacts)
[1] FDA press release (Aug 15, 2020): “FDA Issues Emergency Use Authorization to Yale School of Public Health for SalivaDirect…”
https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-issues-emergency-use-authorization-yale-school-public-health
[2] FDA: SalivaDirect — Letter of Authorization (PDF; updated; held by SalivaDirect, Inc.)
https://www.fda.gov/media/141194/download
[3] FDA: SalivaDirect — EUA Summary (PDF)
https://www.fda.gov/media/141192/download
[4] FDA: In Vitro Diagnostics EUAs (index page; includes tables, templates, umbrella EUAs)
https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas
[5] FDA: Molecular Diagnostic Tests for SARS‑CoV‑2 (table; includes note on designated labs)
https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2
[6] FDA: Deliverable 15 — Emergency Use Authorization Assessment: Final Report (PDF)
https://www.fda.gov/media/152992/download
### SalivaDirect scientific & retrospective literature
[7] Wyllie et al. / SalivaDirect team (2024): “Scalable solutions for global health: the SalivaDirect model” (PMC)
https://pmc.ncbi.nlm.nih.gov/articles/PMC11554656/
[8] Vogels et al. (2020): SalivaDirect protocol paper (PMC)
https://pmc.ncbi.nlm.nih.gov/articles/PMC7418705/
### Open-source diagnostics policy / models
[9] Monaco & Ware (2022): “Structural Challenges in Deployment of an Open-Source Diagnostic Product”
https://theoryandpractice.citizenscienceassociation.org/articles/10.5334/cstp.530
[10] Emperador et al. (2020): “An open-source molecular diagnostic platform approach for outbreak and epidemic preparedness” (PMC)
https://pmc.ncbi.nlm.nih.gov/articles/PMC7564747/
### Policy context: LDT oversight and related developments
[11] American Hospital Association (Aug 21, 2020): HHS announcement on FDA premarket review of LDTs
https://www.aha.org/special-bulletin/2020-08-21-special-bulletin-trump-administration-blocks-fda-requiring-labs-submit-coronavirus-tests-review
[12] RAPS (Nov 15, 2021): FDA revises COVID test approach after HHS reverses LDT policy
https://www.raps.org/news-and-articles/news-articles/2021/11/fda-revises-covid-test-approach-after-hhs-reverses
[13] FDA: “Laboratory Developed Tests” (page reflecting 2024–2025 developments and updates)
https://www.fda.gov/medical-devices/vitro-diagnostics/laboratory-developed-tests
[14] Reuters (Sep 18, 2025): FDA to roll back LDT oversight rule following court decision
https://www.reuters.com/legal/litigation/us-fda-roll-back-lab-developed-test-oversight-rule-following-court-decision-2025-09-18/
### Representative press coverage focusing on “open source” aspect
[15] ContagionLive (Aug 15, 2020): “FDA Grants Emergency COVID-19 Authorization to Yale's Open Source Method…”
https://www.contagionlive.com/view/fda-grants-emergency-covid19-authorization-yale-open-source-method-saliva-testing
[16] STAT (Aug 15, 2020): Yale’s saliva test / open approach coverage
https://www.statnews.com/2020/08/15/yales-saliva-test-gets-emergency-authorization-a-step-toward-cheaper-more-rapid-covid-19-testing/
[17] TIME (Oct 13, 2020): “This 3‑Dollar COVID‑19 Test Could Do More…”
https://time.com/5899765/saliva-covid-19-testing/
[18] LabMedica (Aug 17, 2020): Open‑source saliva PCR test coverage
https://www.labmedica.com/covid-19/articles/294784114/new-open-source-saliva-based-covid-19-test-can-be-deployed-in-clinical-laboratories-across-us.html
[19] SelectScience (interview, ~2022): “Saliva-based open-source tests for COVID-19…”
https://www.selectscience.net/article/saliva-based-open-source-tests-for-covid-19-how-saliva-sampling-improves-compliance-saves-costs-and-relieves-the-strained-supply-chain
### Additional related sources used for specific points
[22] COVID‑19 Diagnostics Evidence Accelerator (May 19, 2022): Meeting 46 Summary (PDF) — includes FloodLAMP statement re: open-source protocol EUA submissions
https://evidenceaccelerator.org/sites/default/files/2022-05/COVID%2019%20Diagnostics%20Evidence%20Accelerator%20Meeting%2046%20Summary_Final.pdf
### CDC test (EUA IFU and related)
[23] CDC: "CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel — Instructions for Use"
Catalog # 2019-nCoVEUA-01. Revision 06 dated Dec 1, 2020; later revisions through at least March 7, 2023 retain the Appendix A public-health-lab-only restriction. Includes Appendix A (Heat Treatment Alternative to Extraction, restricted to public health laboratories), Appendix B (Pooled Specimen Preparation), Appendix C (Implementation and Monitoring of Pooled Specimen Testing).
IFU PDF (FDA-hosted): https://www.fda.gov/media/134922/download
EUA Letter of Authorization: https://www.fda.gov/media/134919/download
EUA index page: https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas
### CDC initial test kit failure
[24] Kondor et al. (2021): "CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel: Root Cause Analysis" (PLOS ONE)
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0260487
[25] CNN (June 20, 2020): "Early CDC test kits were delayed because of contamination issues, HHS report affirms"
https://www.cnn.com/2020/06/20/politics/cdc-test-kits-contamination/index.html
[26] HHS Office of Inspector General (Oct 24, 2023): "CDC's Internal Control Weaknesses Led to Its Initial COVID-19 Test Kit Failure, but CDC Ultimately Created a Working Test Kit" (Report A-04-20-02027)
https://oig.hhs.gov/reports/all/2023/cdcs-internal-control-weaknesses-led-to-its-initial-covid-19-test-kit-failure-but-cdc-ultimately-created-a-working-test-kit/
### Attached documents provided by the requestor (local)
[20] “Anne Wyllie Nomination for FDA Foundation 2022 Innovations in Regulatory Science Awards” (June 3, 2022) — provided as attached markdown
[21] “FDA Issues EUA for SalivaDirect” (FDA press release copy, Aug 15, 2020) — provided as attached markdown
# 1,190 _context-commentary_regulatory-open-euas.md
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## Context
This subcategory documents the concept of "open EUAs," the combination of open-source diagnostic protocols with open-access FDA authorization, which was central to FloodLAMP's regulatory strategy. For a comprehensive analysis of the concept, its history, regulatory mechanics, and implications, see the companion research report in this subcategory: `_AI_open-euas-open-access-diagnostics-report.md`.
The files here include:
- **FDA press release (Aug 15, 2020)** announcing the SalivaDirect EUA, which contains FDA's explicit use of "open source protocol" framing and describes the designated-laboratory model.
- **Anne Wyllie nomination letter (June 2022)** for the Reagan-Udall Foundation Innovation in Regulatory Science Award, written by FloodLAMP's founder, articulating the regulatory novelty of SalivaDirect's approach: an academic team seeking an IVD EUA without intending to manufacture kits, using CDC primers, fully disclosing ingredients, validating multiple suppliers and instruments, and working with FDA to create a designation process for CLIA labs.
- **Open EUA Consortium main document (late 2020)** recording FloodLAMP's attempt to convene multiple test developers around the open EUA model. The consortium aimed to build a suite of 5-8 open EUAs covering different sample types and technologies, with shared validation materials and supply chain coordination. It stalled quickly by end of 2020.
The "open EUA" concept, as analyzed in the AI report, is not merely about publishing protocols. It involves an institutional and legal pattern combining open-source protocols (fully disclosed, implementable with commodity components), open supply chains (multiple validated suppliers), and open-access authorization (multiple labs operating under one EUA through a steward/designation model). SalivaDirect remains the most prominent example in FDA's COVID-19 authorization corpus. FloodLAMP pursued the same approach for its LAMP-based tests and was unable to obtain authorization.
These files connect to the FDA correspondence subcategory (`regulatory/correspondence`), which documents FloodLAMP's direct engagement with the agency on its own open-source protocol EUA submissions, and to the FDA EUA submissions subcategory (`regulatory/fda-euas`), which contains FloodLAMP's submitted tests.
## Commentary
The open EUA concept was at the center of FloodLAMP's regulatory strategy, and we consider it one of the most important points of regulatory progress to emerge from the COVID-19 diagnostic response. The AI research report in this subcategory provides a thorough analysis; here we offer FloodLAMP's perspective.
SalivaDirect demonstrated that it was possible to build a scalable, supply-chain-resilient testing network under a single FDA authorization using commodity components and a steward/designation model. We modeled our own EUA submissions on this approach and nominated Anne Wyllie for the Reagan-Udall Foundation Innovation Award based on direct experience with the model and our assessment of its significance. The nomination letter in this subcategory lays out the case for why the open-source protocol EUA represented a genuine regulatory innovation, not just a scientific one.
The Open EUA Consortium was our attempt to scale the idea beyond a single test. We convened a small group of developers in late 2020, but the consortium stalled quickly. At one level,the reasons are well captured by the AI report's analysis: the HHS policy change in August 2020 reduced the regulatory incentive for open EUAs (labs could offer LDTs without an EUA), the stewardship burden was significant, and funding was not available to sustain the coordination effort. At another level, trying to coordinate this group was like herding cats. FloodLAMP founder, Randy True, decided it was just going to be easier to pursue the EUAs independently, so we validated and submitted three related tests, Colorimetric LAMP, Fluorimetric LAMP, and the Direct PCR from the same inactivated sample. The plan was to then either help other groups in the gLAMP community get their EUAs or collaborate with them to do under the FloodLAMP organization. In hindsight, this was quite overconfident.
FloodLAMP submitted multiple open-source protocol EUAs and was unable to obtain authorization, or to get meaningful engagement from FDA on these submissions (see `regulatory/correspondence`). The structural barriers identified in the AI report were real and material. The most striking is the asymmetry between government and non-government entities: the CDC was able to produce a test that any CLIA high-complexity lab in the country could run, simply by distributing reagents. No stewardship model, no lab-by-lab designation. When an academic lab (Yale/SalivaDirect) created something comparably open, the regulatory system required a full stewardship and designation infrastructure. When a small public benefit company (FloodLAMP) attempted the same, the barrier was even higher.
The AI report's analysis of the CDC test's Appendix A, the extraction-free protocol restricted to public health labs only despite being developed in response to a nationwide reagent shortage affecting all labs, captures a pattern we observed repeatedly: technical solutions existed but were constrained by institutional caution and regulatory framing rather than by scientific or safety considerations.
The "generics of diagnostics" framing from the nomination letter remains, in our assessment, directionally correct. The U.S. diagnostic regulatory system lacks a routine mechanism for deploying validated open protocols to competent laboratories without each lab filing its own submission or depending on a single steward's capacity. SalivaDirect showed one way to approximate this during an emergency. Whether the model can be institutionalized for future outbreaks is an open question, but the design patterns in the AI report, particularly the four-layer taxonomy of openness and the practical framework for future open-access diagnostics, may be a useful starting point.
# 884 2020-08-15_FDA Website - Press Release FDA Issues EUA for SalivaDirect.md
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summary_short: The FDA press release announces the August 15, 2020 emergency use authorization for Yale School of Public Health’s SalivaDirect SARS-CoV-2 diagnostic test, highlighting saliva-based collection and a workflow that can skip nucleic acid extraction. It explains how the “open source” protocol and validation across multiple common reagents/instruments could expand testing capacity while reducing reliance on scarce swabs and extraction kits.
CONTENT
FDA News Release
***INTERNAL TITLE:*** Coronavirus (COVID-19) Update: FDA Issues Emergency Use Authorization to Yale School of Public Health for SalivaDirect, Which Uses a New Method of Saliva Sample Processing
For Immediate Release:
August 15, 2020
Today, the U.S. Food and Drug Administration issued an emergency use authorization (EUA) to Yale School of Public Health for its SalivaDirect COVID-19 diagnostic test, which uses a new method of processing saliva samples when testing for COVID-19 infection.
“The SalivaDirect test for rapid detection of SARS-CoV-2 is yet another testing innovation game changer that will reduce the demand for scarce testing resources,” said Assistant Secretary for Health and COVID-19 Testing Coordinator Admiral Brett P. Giroir, M.D. “Our current national expansion of COVID-19 testing is only possible because of FDA’s technical expertise and reduction of regulatory barriers, coupled with the private sector’s ability to innovate and their high motivation to answer complex challenges posed by this pandemic.”
“Providing this type of flexibility for processing saliva samples to test for COVID-19 infection is groundbreaking in terms of efficiency and avoiding shortages of crucial test components like reagents,” said FDA Commissioner Stephen M. Hahn, M.D. “Today’s authorization is another example of the FDA working with test developers to bring the most innovative technology to market in an effort to ensure access to testing for all people in America. The FDA encourages test developers to work with the agency to create innovative, effective products to help address the COVID-19 pandemic and to increase capacity and efficiency in testing.”
SalivaDirect does not require any special type of swab or collection device; a saliva sample can be collected in any sterile container. This test is also unique because it does not require a separate nucleic acid extraction step. This is significant because the extraction kits used for this step in other tests have been prone to shortages in the past. Being able to perform a test without these kits enhances the capacity for increased testing, while reducing the strain on available resources. Additionally, the SalivaDirect methodology has been validated and authorized for use with different combinations of commonly used reagents and instruments, meaning the test could be used broadly in most high-complexity labs.
Yale intends to provide the SalivaDirect protocol to interested laboratories as an “open source” protocol, meaning that designated laboratories could follow the protocol to obtain the required components and perform the test in their lab according to Yale’s instructions for use. Because this test does not rely on any proprietary equipment from Yale and can use a variety of commercially available testing components, it can be assembled and used in high-complexity labs throughout the country, provided they comply with the conditions of authorization in the EUA.
This is the fifth test that the FDA has authorized that uses saliva as a sample for testing. Testing saliva eliminates the need for nasopharyngeal swabs, which have also been prone to shortages, and alleviates the patient discomfort associated with these swabs. Since the saliva sample is self-collected under the observation of a healthcare professional, it could also potentially lower the risk posed to healthcare workers responsible for sample collection. While FDA has seen variable performance in tests using saliva, Yale School of Public Health submitted data with its EUA request from which the FDA determined that Yale’s test meets the criteria for emergency authorization when used to test saliva samples for SARS-CoV-2, the virus that causes COVID-19 infection.
The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.
Related Information
Coronavirus Disease 2019 (COVID-19)
Emergency Use Authorization: Coronavirus
Types of Tests FDA has authorized (video)External Link Disclaimer
Content current as of:
08/15/2020
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# 5,102 2020-10-15_SalivaDirect EUA IFU - Yale School of Public Health SalivaDirect assay EUA Summary.md
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summary_short: The SalivaDirect EUA Summary (updated Oct. 15, 2020) outlines Yale’s extraction-free saliva RT-qPCR test authorized for use only in CLIA high-complexity laboratories designated by Yale, including the intended use, workflow, validated instruments, and detailed reagent/vendor options to support supply-chain flexibility. It provides control requirements, result interpretation criteria, and performance data including LoD studies across multiple reagent and instrument combinations and a paired clinical comparison showing high positive agreement with an authorized comparator.
CONTENT
***INTERNAL TITLE:*** Yale School of Public Health, Department of Epidemiology of Microbial Diseases SalivaDirect assay EUA Summary – Updated October 15, 2020
EMERGENCY USE AUTHORIZATION (EUA) SUMMARY SARS-CoV-2 RT-PCR Assay (Yale School of Public Health, Department of Epidemiology of Microbial Diseases)
For In vitro Diagnostic Use Rx Only For use under Emergency Use Authorization (EUA) only
(The SalivaDirect assay will be performed at laboratories designated by the Yale School of Public Health, Department of Epidemiology of Microbial Diseases, that includes the Clinical Molecular Diagnostics Laboratory, Department of Pathology, Yale School of Medicine, located at 310 Cedar St., New Haven, CT 06510, that are also certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a and meet the requirements to perform high complexity tests, as described in the Laboratory Instructions for Use that was reviewed by the FDA under this EUA.)
## INTENDED USE
SalivaDirect is a real-time reverse transcription polymerase chain reaction (rRT-PCR) test intended for the qualitative detection of nucleic acid from SARS CoV-2 in saliva collected without preservatives in a sterile container from individuals suspected of COVID-19 by their healthcare provider. Testing is limited to laboratories designated by the Yale School of Public Health, Department of Epidemiology of Microbial Diseases, that includes the Clinical Molecular Diagnostics Laboratory, Department of Pathology, Yale School of Medicine, located at 310 Cedar St., New Haven, CT 06510, that are also certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a and meet the requirements to perform high complexity tests.
Results are for the detection and identification of SARS-CoV-2 RNA. The SARS-CoV-2 RNA is generally detectable in saliva specimens during the acute phase of infection. Positive results are indicative of the presence of SARS-CoV-2 RNA. Clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities.
Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information. Negative results for SARS-CoV-2 RNA from saliva should be confirmed by testing of an alternative specimen type if clinically indicated.
SalivaDirect is intended for use by qualified and trained clinical laboratory personnel specifically instructed and trained in the techniques of RT-qPCR and in vitro diagnostic procedures. The assay is only for use under the Food and Drug Administration's Emergency Use Authorization.
## DEVICE DESCRIPTION AND TEST PRINCIPLE
SalivaDirect is an RNA-extraction free, dualplex RT-qPCR method for SARS-CoV-2 detection (Fig. 1). It can be broadly implemented as it (1) does not require saliva collection tubes containing preservatives, (2) does not require specialized equipment for nucleic acid extraction, and (3) is validated for use with products from multiple vendors. Thus, the simplicity and flexibility of SalivaDirect means that it is not as affected by supply chain bottlenecks as some other assays. The method is nucleic acid extraction-free, which enables testing of low volume and minimally processed saliva in dualplex RT-qPCR for SARS-CoV-2 detection. Saliva is first treated with proteinase K followed by a heat inactivation step, and is then directly used as input in the dualplex RT-qPCR test using validated primer and probe sets (2019-nCoV_N1 and RP) developed by the US CDC. The human Ribonuclease P (RP) probe was modified with a different fluorophore so that the primer/probe set could be combined in a dualplex assay, reducing the number of tests to 1 assay with 2 sets.
## INSTRUMENTS USED WITH TEST
SalivaDirect should be used with the following RT-qPCR instruments:
| | ||
| --- | --- | --- |
| RT-qPCR instrument | Bio-Rad | CFX96 Touch Real-Time PCR Detection System |
| | ThermoFisher Scientific | Applied Biosystems 7500 Fast Real-Time PCR System |
| | ThermoFisher Scientific | Applied Biosystems 7500 Fast Dx Real-Time PCR System |
| | ThermoFisher Scientific | Applied Biosystems QuantStudio 5 Real-Time PCR System ||
||
## REAGENTS AND MATERIALS
| Vendor | Item | Catalog number | Quantity | # Reactions |
|---|---|---|---|---|
| | Order one of the following Proteinases K | | | |
| ThermoFisher Scientific | MagMAX Viral/Pathogen Proteinase K | A42363 | 10 mL | 4.000 reactions |
| New England Biolabs | Proteinase K, Molecular Biology Grade | P8107S | 2 mL | 320 reactions |
| AmericanBio | Proteinase K | AB00925 | 100 mg | 800 reactions |
| | Order one of the following RT-qPCR kits | | | |
| New England Biolabs | Luna Universal Probe One-Step RT-qPCR Kit | E3006S | 2 mL | 200 reactions |
| | | E3006L | 5 mL | 500 reactions |
| | | E3006X | 10 mL | 1.000 reactions |
| | | E3006E | 25 mL | 2.500 reactions |
| Bio-Rad | Reliance One-Step Multiplex RT-qPCR Supermix | 12010176 | 1 mL | 200 reactions |
| | | 12010220 | 5 mL | 1.000 reactions |
| | | 12010221 | 10 mL | 2.000 reactions |
| ThermoFisher Scientific | TaqPath 1-Step RT-qPCR Master Mix, GC | A15299 | 5 mL | 1.000 reactions |
| | | A15300 | 10 mL | 2.000 reactions |
| | Order one of the following primer and probe sets | | | |
| Eurofins Genomics | SalivaDirect™ primer and probe set (complete set of the 6 primers and probes) | 12YS-010YST | 50-100 nmol | 12.500 reactions |
| Integrated DNA Technologies | nCOV_N1 Forward Primer Aliquot | 10006821 | 50 nmol | 6.250 reactions |
| | | 10006830 | 100 nmol | 12.500 reactions |
| | nCOV_N1 Reverse Primer Aliquot | 10006822 | 50 nmol | 6.250 reactions |
| | | 10006831 | 100 nmol | 12.500 reactions |
| | nCOV_N1 Probe Aliquot | 10006823 | 25 nmol | 6.250 reactions |
| | | 10006832 | 50 nmol | 12.500 reactions |
| | RNase P Forward Primer Aliquot | 10006827 | 50 nmol | 16.600 reactions |
| | | 10006836 | 100 nmol | 33.300 reactions |
| | RNase P Reverse Primer Aliquot | 10006828 | 50 nmol | 16.600 reactions |
| | | 10006837 | 100 nmol | 33.300 reactions |
| | RNase P Probe | Custom order (Cy5) | 25 nmol | 6.250 reactions |
| | | Custom order (Cy5) | 50 nmol | 12.500 reactions |
| | | 10007061 (ATTO647) | 25 nmol | 6.250 reactions |
| | | 10007062 (ATTO647) | 50 nmol | 12.500 reactions |
| LGC Biosearch Technologies | nCOV_N1 Forward Primer | nCoV-N1-F-100 | 100 nmol | 12.500 reactions |
| | | nCoV-N1-F-1000 | 1000 nmol | 125.000 reactions |
| | nCOV_N1 Reverse Primer | nCoV-N1-R-100 | 100 nmol | 12.500 reactions |
| | | nCoV-N1-R-1000 | 1000 nmol | 125.000 reactions |
| | nCOV_N1 Probe | nCoV-N1-P-25 | 25 nmol | 6.250 reactions |
| | | nCoV-N1-P-250 | 250 nmol | 62.500 reactions |
| | RNase P Forward Primer | RNP-F-20 | 20 nmol | 6.660 reactions |
| | | RNP-F-100 | 100 nmol | 33.300 reactions |
| | | RNP-F-1000 | 1000 nmol | 333.300 reactions |
| | RNase P Reverse Primer | RNP-R-20 | 20 nmol | 6.660 reactions |
| | | RNP-R-100 | 100 nmol | 33.300 reactions |
| | | RNP-R-1000 | 1000 nmol | 333.300 reactions |
| | RNase P Probe | RNP-PQ670-25 | 25 nmol | 6.250 reactions |
| | | RNP-PQ670-250 | 250 nmol | 62.500 reactions |
| | Order one of the following nuclease-free waters | | | |
| Integrated DNA Technologies | Nuclease-free water | 11-04-02-01 | 20 mL | |
| | | 11-05-01-14 | 300 mL | |
| | | 11-05-01-04 | 1 L | |
| New England Biolabs | Nuclease-free water | B1500S | 25 mL | |
| | | B1500L | 100 mL | |
| | Order the following positive control | | | |
| Twist Bioscience | Synthetic SARS-CoV-2 RNA Control 2 | 102024 | 100 µL | |
||
## CONTROLS RUN WITH THE COVID-19 RT-PCR
The following controls are run with the SalivaDirect assay:
| Control | Description | Purpose | Frequency |
|---|---|---|---|
| Negative Extraction Control (NEC) | Nuclease-free water | To monitor for contamination during saliva processing | Every batch of up to 93 saliva samples |
| Negative Template Control (NTC) | Nuclease-free water | To monitor for contamination of PCR reagents | Every PCR plate with up to 93 saliva samples |
| Positive | Twist Synthetic SARS-CoV-2 RNA control. (Dilute to 100 copies/µL) | To monitor functioning of RT-qPCR reagents | Every PCR plate with up to 93 saliva samples |
| Internal Process Control | Primer/Probe set detecting RNaseP | To ensure that saliva of a sufficient quantity and quality was tested | Every sample |
||
## INTERPRETATION OF RESULTS
1) ***SARS-CoV-2 RT-PCR test Controls – Positive, Negative, and Internal:***
**Positive control**: The positive control should yield a “detected” result for the N1 target and “not detected” for the RNaseP control.
**Negative Extraction Control (NEC)**: The NEC should yield a “not detected” result for the N1 target and “detected” for RNaseP.
**Negative Template Control**: The NTC should yield a “not detected” result for both the N1 and RNaseP targets.
**Internal Control**: Detection of RNaseP at PCR cycle threshold (CT) <35 indicates that saliva of sufficient quantity and quality were tested. Detection of RNaseP is required to report a negative SARS-CoV-2 result.
2) ***Examination and Interpretation of Patient Specimen Results:***
All test controls should be examined prior to interpretation of patient results. If the controls are not valid, the patient results cannot be interpreted. Results will be interpreted according to the table below:
**Bio-Rad CFX96 / ABI 7500 Fast / ABI QuantStudio 5**
| Result | Ct value N1 | Ct value RP |
|---|---|---|
| Positive | <40 | Any value |
| Negative | ≥40 | <35 |
| *Invalid | ≥40 | ≥35 |
||
**ABI 7500 Fast Dx**
| Result | Ct value N1 | Ct value RP |
|---|---|---|
| Positive | <37 | Any value |
| Negative | ≥37 | <35 |
| *Invalid | ≥37 | ≥35 |
||
## PERFORMANCE EVALUATION
1) ***Analytical Sensitivity:***
Limit of Detection (LoD):
A positive saliva specimen from a confirmed COVID-19 healthcare worker with a known virus concentration (3.7 × 104 copies/µL) was spiked into saliva collected from healthcare workers who tested negative for SARS-CoV-2 using the CDC assay. The following 2-fold dilution series was tested in triplicate to determine the preliminary limit of detections: 400, 200, 100, 50, 25, 12, and 6 copies/µL. Spiked saliva specimens were tested according to the SalivaDirect protocol. In total, three different proteinase K reagents, three different RT-qPCR kits, and three different RT-qPCR thermocyclers were validated with the assay. Input volumes, matrices and RT-qPCR programs were the same for each combination of proteinase K, RT-qPCR kit, and RT-qPCR instrument. The preliminary limit of detection was then confirmed with 20 additional replicates. The table below shows the final limit of detection for the different reagents/instruments used with SalivaDirect.
### Proteinase K
| Proteinase K | RT-qPCR kit | RT-qPCR instrument | LOD | Positive replicates | Mean Ct value (SD) |
|---|---|---|---|---|---|
| Thermo | NEB Luna | Bio-Rad CFX96 | 6 copies/µL | 100% (20/20) | 36.7 (1.0) |
| NEB | NEB Luna | Bio-Rad CFX96 | 6 copies/µL | 100% (20/20) | 35.6 (0.4) |
| AmericanBio | NEB Luna | Bio-Rad CFX96 | 6 copies/µL | 100% (20/20) | 35.5 (0.4) |
||
### RT-qPCR kit
| Proteinase K | RT-qPCR kit | RT-qPCR instrument | LOD | Positive replicates | Mean Ct value (SD) |
|---|---|---|---|---|---|
| Thermo | Bio-Rad Reliance | Bio-Rad CFX96 | 6 copies/µL | 100% (20/20) | 36.4 (0.6) |
| Thermo | Thermo TaqPath | Bio-Rad CFX96 | 12 copies/µL | 100% (20/20) | 35.9 (1.2) |
||
### RT-qPCR instrument
| Proteinase K | RT-qPCR kit | RT-qPCR instrument | LOD | Positive replicates | Mean Ct value (SD) |
|---|---|---|---|---|---|
| Thermo | Thermo TaqPath | ABI 7500 Fast | 12 copies/µL | 95% (19/20) | 36.8 (1.2) |
| Thermo | Thermo TaqPath | ABI 7500 Fast Dx | 6 copies/µL | 95% (19/20) | 32.4 (0.9) |
||
*Bridging Studies for Additional Instruments*
A bridging study was performed to validate an additional thermocycler, the ABI QuantStudio 5. A 2-fold dilution series was tested in triplicate with the ABI QuantStudio 5 in parallel with the ABI 7500 Dx Fast to establish equivalent performance. Samples were prepared by spiking positive saliva from a confirmed COVID-19 healthcare worker with a known concentration (3.7 x 104 copies/µL) into saliva collected from healthcare workers who tested negative for SARS-CoV-2. The following concentrations were tested: 100, 50, 25, 12, 6, 3, and 1 copies/µL. All samples were tested using the Thermo Proteinase K with the NEB Luna RT-qPCR kit. The table below lists the positivity rates for each concentration when tested using either thermocycler:
| | 100 copies/µL | 50 copies/µL | 25 copies/µL | 12 copies/µL | 6 copies/µL | 3 copies/µL | 1 copy/µL | 0 copies/µL |
|---|---:|---:|---:|---:|---:|---:|---:|---:|
| ABI 7500 Dx Fast | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 2/3 | 0/3 |
| ABI QuantStudio 5 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 3/3 | 1/3 | 0/3 |
||
2) ***Analytical Inclusivity/Cross Reactivity***
The sequences for the N1 primers and probe used in this assay are identical to the primer/probe sequences used in the FDA authorized CDC SARS-CoV-2 assay. Please refer to EUA200001/A004 for an updated in silico analysis of the primers/probes used with the CDC assay.
In addition, SalivaDirect was tested on 52 saliva specimens collected from adults during the 2018/2019 and 2019/2020 (pre-COVID19) autumn/winter influenza seasons. Out of the 52 specimens tested, 51 resulted as negative, and one resulted as invalid (both N1 and RP were not detected).
3) ***Clinical Evaluation:***
Performance of SalivaDirect was compared to the authorized ThermoFisher Scientific TaqPath RT-PCR COVID-19 combo kit by testing paired nasopharyngeal and saliva samples. Nasopharyngeal swabs and saliva were collected from inpatients and healthcare workers in the Yale-New Haven Hospital. Saliva was collected in sterile urine cups or 5 mL tubes without addition of any preservatives.
For the preliminary selection of specimens, specimens were tested with a modified version of the US CDC assay. Based on these results, a total of 67 NP/saliva pairs were tested for the current study, with 37 being NP positive and 30 being NP negative by the modified CDC assay. These NP and saliva specimens were subsequently tested in parallel with the EUA-authorized TaqPath COVID-19 combo kit (on NP specimens) and SalivaDirect (on saliva specimens). The ThermoFisher Scientific TaqPath COVID- 19 combo kit combines RNA extraction using the MagMax Viral/Pathogen Nucleic Acid Isolation Kit with a multiplex RT-PCR diagnostic assay targeting 3 regions of the SARS-CoV-2 genome. For SalivaDirect testing, the ThermoFisher Scientific proteinase
K, ThermoFisher Scientific TaqPath RT-PCR kit, and Bio-Rad CFX96 instrument were utilized.
Out of the 37 NP specimens that originally tested positive by the modified CDC assay, 34 tested positive with the TaqPath COVID-19 Combo Kit and three tested negative. The TaqPath results from these 34 specimens were used as the comparator for the SalivaDirect when evaluating positive percent agreement (PPA). All 30 NP specimens that were negative by the original modified CDC assay also tested negative by the TaqPath assay. The results from these 30 specimens plus the three TaqPath negative NP specimens described above were used as the comparator for the SalivaDirect when evaluating negative percent agreement (NPA).
The results from this paired study are described below:
**Qualitative outcome of parallel testing of paired nasopharyngeal swabs and saliva with SalivaDirect and the ThermoFisher Scientific TaqPath COVID-19 combo kit.**
**TaqPath RT-PCR COVID-19 (Nasopharyngeal swab)**
| SalivaDirect Saliva | Positive | Negative |
|---|---:|---:|
| Positive | 32 | 3 |
| Negative | 2 | 30 |
| **Total** | **34** | **33** |
| Positive agreement = 94.1% (32/34) |
| Negative agreement = 90.9% (30/33) |
||
Out of the 34 individuals with nasopharyngeal swab specimens that tested positive by the TaqPath COVID-19 kit, 32 had saliva specimens that were positive by the SalivaDirect, yielding a PPA of 94.1%. Out of the 33 individuals with negative NP swab specimens by the TaqPath assay, 30 had saliva specimens that were negative by SalivaDirect, generating an NPA of 90.9%. There were three individuals who tested positive by SalivaDirect on saliva specimens but negative by TaqPath on NP specimens. It should be noted that these 3 individuals previously tested weakly positive with the modified CDC assay.
As an additional analysis, the results from the SalivaDirect on saliva specimens were compared to the results from the modified CDC assay on the paired NP specimens. This modified CDC assay used the 2019-nCoV_N1, 2019-nCoV_N2, and RP primer-probe sets with the NEB Luna Universal Probe One-Step RT-qPCR kit on the Bio-Rad CFX96. The SalivaDirect results were concordant with 94.6% (35/37) of the NP positive results and 100% of the NP negative results, as shown below:
**Modified CDC RT-PCR (Nasopharyngeal swab)**
| SalivaDirect Saliva | Positive | Negative |
|---|---:|---:|
| Positive | 35 | 0 |
| Negative | 2 | 30 |
| **Total** | **37** | **30** |
| Positive agreement = 94.6% (35/37) |
| Negative agreement = 100% (30/30) |
||
## WARNINGS:
- This test has not been FDA cleared or approved;
- This test has been authorized by FDA under an EUA for use by laboratories designated by the Yale School of Public Health, Department of Epidemiology of Microbial Diseases, that includes the Clinical Molecular Diagnostics Laboratory, Department of Pathology, Yale School of Medicine, located at 310 Cedar St., New Haven, CT 06510, that are also certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a and meet the requirements to perform high complexity tests.
- This test has been authorized only for the detection of nucleic acid from SARS- CoV-2, not for any other viruses or pathogens; and
- This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
# 1,428 Anne Wyllie Nomination for FDA Foundation 2022 Innovations in Regulatory Science Awards.md
METADATA
last updated: 2026-03-05 by BA
file_name: Anne Wyllie Nomination for FDA Foundation 2022 Innovations in Regulatory Science Awards.md
file_date: 2022-06-03
title: Anne Wyllie Nomination for FDA Foundation 2022 Innovations in Regulatory Science Awards
category: regulatory
subcategory: open-euas
tags:
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summary_short: The Reagan-Udall Foundation nomination argues that Anne Wyllie’s SalivaDirect EUA pioneered an “open source protocol” model by validating saliva and extraction-free processing while disclosing components and qualifying multiple reagent/instrument options for broad CLIA lab adoption. It highlights the FDA “designation” approach, legal and operational infrastructure for scaling a lab network, and downstream effects such as supply-chain resilience and industry-wide cost compression in molecular testing. The nomination frames SalivaDirect as a template for “generic” diagnostics authorization with relevance to future pandemic preparedness, while disclosing FloodLAMP’s advisory relationship to Wyllie.
CONTENT
***INTERNAL TITLE:*** Nomination for the Reagan-Udall Foundation Innovation in Regulatory Science Award
June 3, 2022
The FDA called it the most unusual submission they had ever received. They were referring to the EUA for the SalivaDirect SARS-CoV-2 RT-PCR Test EUA, developed by Anne Wyllie and a small, dedicated team at the Yale School of Public Health. Dr. Wyllie, working with Professor Nathan Grubaugh, pioneered innovations on several different fronts of diagnostic testing, by 1) validating saliva as an excellent specimen type for a respiratory virus, 2) omitting the gold standard RNA extraction step, and with it a significant cost and supply chain vulnerability, and 3) creating the first "open source protocol" EUA. For the latter "ground breaking" "game changing"^1^ contribution to the field of regulatory science, we nominate Dr. Anne Wyllie for the Reagan-Udall Foundation's 2022 Innovation Award.
What made the SalivaDirect EUA so unusual is that Dr. Wyllie and her team submitted for an IVD EUA even though they never intended to manufacture and sell test kits. Normally university labs submit for LDT EUAs which are inherently limited to a single clinical lab, or affiliated lab network. Dr. Wyllie understood that to have a large impact, their test would need to be available to all CLIA labs, as is the case for commercial molecular diagnostic test kits. Working with 2 former FDA reviewers, they came up with a multifaceted creative solution.
First, they bucked the almost universal proprietary approach in the diagnostics industry by not patenting their test. Next they chose the open access CDC primers, configuring them into a convenient duplex format. Further they fully disclosed the ingredients of their test and crucially validated multiple suppliers of all 3 components: the primers, proteinase K, and PCR master mix, along with multiple qPCR instruments.
To appreciate the significance of the SalivaDirect EUA, it is important to understand that the FDA does not authorize or approve protocols, only "test systems". The specimen type, exact reagents and the particular step-by-step procedures must be fully specified, along with all validated instruments. It was a lot of work for the team to validate the different combinations, but this created supply chain redundancy at a time in the pandemic when it was sorely needed. It also created plug-and-play capability that is unique in the field outside the CDC EUA. When our lab ordered the reagents for SalivaDirect, all came within 24 hours due to the commercial relationships setup by Wyllie and team.
The thoughtful development of commercial support was coupled with a focus on simplicity. The "Direct" in the test name refers to the elimination of the RNA extraction/purification step. "Think about SalivaDirect. To do an RNA assay without RNA extraction - pretty creative. Cuts off an hour and a ton of time and money. Nobody would have even said that was possible. Don't even think about it." (9-12-2021 Mara Aspinall, advisor to Rockefeller Foundation and National Testing Action Plan). Our novice lab technician had never done PCR and was able to independently run SalivaDirect with success on her first try. That is a testament to this well designed, well vetted test protocol.
On August 15, 2020 the FDA embraced the new and innovative "open source protocol," issuing a press release along with the authorization. The FDA created a new "designation" process for the SalivaDirect team to authorize CLIA labs to use the EUA. The designation process was greatly streamlined over labs doing their own LDTs. Wyllie led the establishment of standard legal contracts for different types of labs, including state-wide contracts, to further facilitate expansion of access to the test. This is just one example of the hard work done outside the lab under the leadership of Wyllie that has led to the tremendous success of SalivaDirect. Other notable efforts include a weekly meeting for designated labs, an email newsletter, conference appearances, website buildout, and coordination with other testing groups such as the gLAMP consortium.
The impact of Dr. Wyllie's work and SalivaDirect has been far reaching. Perhaps the most significant practically has been the opening up of far greater access to low cost testing. The cost of goods for the SalivaDirect test is $2-3/test, when in 2020 and through much of 2021, typical kits cost in excess of $20 even in large volumes. Mark Roth, CEO of Lighthouse Lab Services, stated that SalivaDirect singlehandedly cause cost compression in the entire industry. Because the test wasn't patented and the protocol was openly disclosed, many CLIA labs created their own "extraction-less" saliva tests during the year long window when HHS removed the FDA's oversight of LDTs. We estimate that the number of such copycat tests done outside of the SalivaDirect EUA is an order of magnitude or more greater than those done by designated labs.
The SalivaDirect lab network has grown to 170 labs in 41 states, performing millions of tests and saving many lives during the pandemic. They have shown what's possible with innovation, coordination, and perseverance. Dr. Wyllie has led the successful addition of 24 amendments to the SalivaDirect EUA over almost 2 years, including commercial partnerships for OTC at home collection, sample pooling, and a large assortment of instruments. SalivaDirect has gone international, advocating for effective COVID testing and helping to get similar tests authorized in low and middle income countries around the world.
Dr. Wyllie has spearheaded a new paradigm of regulatory authorization, pioneering what can be thought of as the generics of diagnostics. She created a pathway for labs to easily and directly access large volume reagent suppliers, while building the framework to manage those suppliers and the labs under current FDA regulations. FDA leadership has expressed that open source protocol EUAs have strong potential for future pandemics. Anne Wyllie has been a true innovator in creating the template for open source protocol tests and blazing the trail in low cost, accessible diagnostics when they were needed most.
DISCLOSURE: Dr. Wyllie is a scientific advisor to FloodLAMP Biotechnologies, a public benefit corporation. FloodLAMP has submitted tests to the FDA as open source protocol EUAs.
1. [FDA Press Release - Aug 15, 2020](https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-issues-emergency-use-authorization-yale-school-public-health)
FLOODLAMP ARCHIVE FILE PATH: regulatory/open-euas/2020-08-15_FDA Website - Press Release FDA Issues EUA for SalivaDirect.md
Sincerely,
Randy True
CEO, FloodLAMP Biotechnologies, PBC
# 3,766 Open EUA Consortium (stalled quickly end of 2020) - Main Doc.md
METADATA
last updated: 2026-03-05 by BA
file_name: Open EUA Consortium (stalled quickly end of 2020) - Main Doc.md
file_date: 2020-12-01
title: Open EUA Consortium (stalled quickly end of 2020) - Main Doc
category: regulatory
subcategory: open-euas
tags:
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pdf_gdrive_url: https://drive.google.com/file/d/1h7fYRtMEm54Mmq_nvdVkLAMhHJtbFRhk
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notes:
summary_short: The Open EUA Consortium overview describes a collaborative effort among COVID-19 test developers to build a small suite of low-cost, interoperable “open source protocol” EUAs modeled on SalivaDirect, enabling designated labs (or CLIA labs via LDT revalidation) to run validated methods using off-the-shelf components. It lays out goals, membership growth, and the operational needs—shared validation materials, blanket Rights of Reference (especially for standardized LAMP primers), supply-chain coordination, and implementation playbooks—to rapidly scale screening and diagnostic testing across diverse settings.
CONTENT
## Overview
The Open EUA Consortium (OEC) is a recently formed group of COVID test developers who are cooperating to create low-cost, widely available, FDA validated tests.
Following in the footsteps of SalivaDirect (Wyllie, Grubaugh), the primary mode of the OEC is to provide labs with "open source" protocols. To run an Open EUA test, labs can either be officially "designated" to operate under the EUA and according to the IFU, or CLIA labs can re-validate the test as their own LDT. Further, non-CLIA labs can also run the tests (using sample pooling) under the "surveillance" regime, with the confidence that the baseline protocol is validated and well characterized.
The plan is to obtain 5-8 core Open EUAs that include various sample types and technologies, This suite of Open EUAs will cover the majority of lab testing needs, from small to medium sized labs, and the most common equipment sets. Importantly, the suite will also cover individual clinical diagnostic testing of people with symptoms or persons suspected of COVID as well as large scale pooled screening of schools and workplaces.
An key aspect of the OEC is that ultimately the EUAs belong to and are controlled by entities. Normally the interactions between these entities, which are usually companies, and the FDA are totally siloed and considered trade secret. We're breaking down those barriers and cooperating by sharing knowledge of the FDA process and expectations, and perhaps sharing key validation materials such as characterized controls and clinical samples. We are seeking priority with the FDA for expedited review and open channels of communication.
In addition to identifying the suite of assays, validation/bridging studies, and other regulatory work, parallel efforts need to quickly be spun up to 1) secure the supply chain of chemicals and consumables, 2) organize the logistics at the national, state, and local levels, and 3) build out the implementation playbooks for the major stakeholders, such as governors, mayor, DPHs, labs, screening programs, schools, businesses, and individuals.
This plan is ambitious, but all the pieces are in place to execute today.
## Mission
Our mission is to usher in a new era of open source molecular testing to improve human health.
## Goals
Overarching goal is to expand COVID testing as quickly as possible in the U.S. to have positive impact on the crisis and help save lives.
More specifically, goals include:
1. Obtain FDA authorizations for a suite of Open EUAs covering a variety of testing needs \[by end of Dec\]
2. Establish prioritization at the FDA for Open EUAs and a structure for expedited communication \[by mid Dec\]
3. Gather support and funding, both for the individual entities pursuing Open EUAs and for the consortium collectively (with dedicated or dotted line staff).
4. Establish a framework for Open EUAs, addressing legal, business, and practical issues.
5. Cooperate with a greater effort and the National Testing Plan to put the supply chain, logistics, and playbooks in place to quickly maximize the potential of the suite of Open EUAs \[throughout Dec on, plan in place by end of Dec\]
## Who
The OEC is currently composed of 5 groups and will soon be recruiting more.
See groups and summary of their tests and status below.
Can expand to add more groups but should avoid redundancy, suggest merging similar EUAs, no publication of submitted EUAs, academic groups especially may be interested in merging
Want to avoid organization problems from adding too many groups to OEC before ready.
Guiding view is that we don't need 20 open source tests or even 10, but say 4-6.
Can add on to approved EUAs w bridging studies.
Is it possible to give a ROR to all or a big chunk of an authorized EUA for a new EUA instead of bridging onto the 1st one? If so, provides a streamlined way to expand without draining resources of authorized EUA holder and also not jeopardizing shutdown if performance problems from labs running the 2nd EUA. Authorized EUA holder looses some control over their EUA because the new EUA holder technically has autonomy (I think unless I'm misunderstand, or some other legal arrangements are made).
## OEC Chart (redacted)
## Status of Consortium
Convened 1st meeting end of Nov
Next group meeting Dec 11 or 14
Soliciting funding and support
Focus this week (12/7) on LAMP primers and swabs
## Current Resources
Minimal budgets and staff of each group
## Needed Resources
Significant
Funding for each group individually
Joint staff either dedicated to consortium as whole to staff at one or more groups can have % allocation to consortium wide activities
Priorities for shared, consortium wide technical resources include:
- bank of positive clinical samples (pref w Ct values)
- verification panel materials (quantified spike stocks for LOD studies)
- selection of primary swabs for validation
- primers
Supply chain and logistical expertise
Contract manufacturing support
Primer production (Eurofins and LGC)
Infrastructure and local support for running pilots, particularly for pooled screening pilot projects
## Designation Process
Labs, once "designated" by the EUA holder, can obtain the required chemicals and reagents and perform the protocol as described in the EUA Instructions for Use (IFU).
## Rights of Reference
CDC PCR assay, primer set, extraction kits, CDC recently added pooling
Need a blanket ROR to a LAMP primer set - which one?
Gates Foundation funded the Quantigen study which has blanket ROR
What other chunks can OEC validate and offer ROR's for?
## Sources of Validation Materials
Interfering substances [price list with Vendor and Catalog Numbers](https://docs.google.com/spreadsheets/d/1v7VZYTwgw1ZzjY87q_h14Zo8qiR0VTXg6KwKyFXV6S0/edit?usp=sharing) from [Pro-Lab Dx EUA](https://drive.google.com/file/d/1G24k4ns8syox-CYDxIrQcnm0nqgxPFX2/view?usp=sharing)
## LAMP Primers
[Primers Compilation LAMP](https://docs.google.com/spreadsheets/d/1cdVJ0oi6qHysaYQLEQiPhjqIjwjeXhaF9u8WSCbL70Q/edit?usp=sharing)
12-15 RT requesting validation run of AS1e, E1, N2 from Eurofins - 10X in water, std desalt
## FDA Links
[CLIA Classification](https://www.fda.gov/medical-devices/ivd-regulatory-assistance/clia-categorizations#:~:text=A%20score%20of%201%20indicates,are%20categorized%20as%20high%20complexity)
[FDA Town Halls](https://www.fda.gov/medical-devices/workshops-conferences-medical-devices/virtual-town-hall-series-coronavirus-covid-19-test-development-and-validation-12092020-12092020?utm_medium=email&utm_source=govdelivery) - FDA link and FloodLAMP youtube page link, our notes link
[FDA Town Hall Survey](https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDIsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMDEyMDguMzE3Mjk5NzEiLCJ1cmwiOiJodHRwczovL3d3dy5zdXJ2ZXltb25rZXkuY29tL3IvY2RyaHZpcnR1YWx0b3duaGFsbHM_dXRtX21lZGl1bT1lbWFpbCZ1dG1fc291cmNlPWdvdmRlbGl2ZXJ5In0.1nAGtlX2lXpNcGQQYKhnXNy6xQI0ZRlgFchTyWumv18/s/1299946100/br/91257259322-l)
[FDA Pre-EUA](https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/how-submit-pre-eua-vitro-diagnostics-fda)
[CDRH-EUA-Templates@fda.hhs.gov](mailto:CDRH-EUA-Templates@fda.hhs.gov)
[https://www.cms.gov/files/document/clia-university-lab-testing.pdf](https://www.cms.gov/files/document/clia-university-lab-testing.pdf)
[https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19)
[11-17 COVID-19 Update: FDA’s Ongoing Commitment to Transparency for COVID-19 EUAs](https://www.fda.gov/news-events/press-announcements/covid-19-update-fdas-ongoing-commitment-transparency-covid-19-euas)
## Helpful Links
[Gates Nasal Swab Presentation 9-17-20](https://aslm.org/wp-content/uploads/2020/09/1600973669-Nasal-swab-methods-and-results-BMGF-17Sept2020_1_.pdf?x16776)
KAREN A HEICHMAN, PhD Senior Program Officer, Innovative Technology Solutions Program Global Health at Bill and Melinda Gates Foundation
Has dry swab elution protocol (10min, vortex)
[FDA SARS-CoV-2 Reference Panel Comparative Data - Google Sheet by Matt McFarlane](https://docs.google.com/spreadsheets/d/1Y1H4bPgi-xeD08LaMvvtvQhyj6vchuf1tObI9KTyKcw/edit?usp=sharing)
[https://www.resiliencehealth.com/tests.html](https://www.resiliencehealth.com/tests.html)
[https://opencovidpledge.org/](https://opencovidpledge.org/)
[Pledging intellectual property for COVID-19](https://www.nature.com/articles/s41587-020-0682-1) - Nature Biotechniques 10-5-2020
[https://www.invetechgroup.com/insights/2020/05/emergency-use-authorization-how-diagnostic-developers-can-address-covid-19/](https://www.invetechgroup.com/insights/2020/05/emergency-use-authorization-how-diagnostic-developers-can-address-covid-19/)
## Article Links
[Open-source toolkit helps developing countries meet demand for COVID-19 R&D](https://www.cam.ac.uk/research/news/open-source-toolkit-helps-developing-countries-meet-demand-for-covid-19-research-and-diagnostics)
## Suggestions for New Open Source EUA FDA Meetings
1. 2-3 times per week meetings (is that necessary?)
2. prefer on demand answers to questions - we can vet the questions through our group first
3. define clear criteria for Open EUA
1. could ask FDA to solicit all current pre-EUAs and EUAs if they would join
4. SD model
1. multiple reagent suppliers
2. don't sell kits
3. non commercial/non profit designation process
4. seems like primary mode for universities
5. FloodLAMP model, Public Benefit Corp
1. EUA includes base chemicals and protocol for solution prep
2. no/low cost designation process
3. sell kits
4. partner w NEB for MM
5.
6. commonality is commitment to royalty/profit free designation to non-profit (university) labs, what about DPH and commercial? standardize on low% royalty rate - there are terms and structure to figure out here, goal is to keep it simple
7. maybe the important things are open protocol and transparent, standardized terms and agreements (like SD)
## LAMP EUAs
from Matt McFarlane (twitter @mattmcfar)
| EUA Date | Test | Diagnostic | Target | IC | Detection | Extraction | Amplification | LOD spike | LOD GE/3ml swab |
|---|---|---|---|---|---|---|---|---|---:|
| Nov-17 | Lucira (At Home POC) | Lucira COVID-19 All-In-One Test Kit | N, N | External + IC | Colorimetric | ~Direct | Lucira device | Inactivated virus | 2,700 |
| Oct-05 | Seasun (2 duplex) | AQ-TOP COVID-19 Rapid Detection Kit PLUS | orf1ab, N | Human RNaseP | PNA Probe | Manual (Qiagen_60704 or Seasun_SS-1300) or Automated (Panagene_PNAK-1001 on PanaMax48) | BioRad_CFX96 or ABI7500 | NCCP_43326 genomic RNA | 3000 |
| Sep-01 | Detectachem | MobileDetect Bio BCC19 (MD-Bio BCC19) Test Kit | N, E | only external controls | Colorimetric | Direct (1µl of transport media into LAMP) | heat block or qPCR (MD-Bio heater or BioRad_T100 or AB_Veriti or …) | Twist_MT007544.1 synthetic gRNA | 225,000 |
| Aug-31 | Mammoth | SARS-CoV-2 DETECTR Reagent Kit | N | Human RNaseP | CRISPR Probe | Automated (Qiagen_955134 on Qiagen_EZ1AdvancedBenchtop) | ABI7500 | SeraCare_AccuPlex_0505-0168 IVT encapsulated RNA | 60,000 |
| Aug-13 | Pro-Lab | Pro-AmpRT SARS-CoV-2 Test | RdRP | only external controls | Probe | Direct (swab into 0.1ml) or kit (swab into 1ml then Pro-Lab_PLM-2000) | Optigene_GenieHT | BEI_NR-52287 inactivated virus | 125* |
| Jul-09 | UCSF/Mammoth | SARS-CoV-2 RNA DETECTR Assay | N | Human RNaseP | CRISPR Probe | automated (Qiagen_955134 on Qiagen_EZ1) | ABI7500 | SeraCare_AccuPlex_0505-0126 (lot 10480311) IVT RNA | 60,000 |
| May-21 | Seasun (1 duplex) | AQ-TOP COVID-19 Rapid Detection Kit | orf1ab | Human RNaseP | PNA Probe | manual (Qiagen_60704) | BioRad_CFX96 or ABI7500 | NCCP_43326 gRNA | 21,000 |
| May-18/Aug31 | Color | Color Genomics SARS-CoV-2 RT-LAMP Diagnostic Assay | N, E, nsp3 | Human RNaseP | Colorimetric | automated (PerkinElmer_CMG-1033 on PerkinElmer_Chemagic360) | plate reader (Biotek_NEO2), Hamilton_Star | ATCC_VR-1986D (gRNA) | 2,250 |
| May-06 | Sherlock BioSci | Sherlock CRISPR SARS-CoV-2 Kit | orf1ab, N | Human RNaseP | CRISPR Probe | Manual (ThermoFisher_12280050) | heat block or qPCR, Plate reader (BioTek_NEO2) | gRNA | 20,250 |
| Apr-10 | Atila BioSystems | iAMP COVID-19 Detection Kit | orf1ab, N | human GAPDH | Probe | Direct (swab into 350µl, 15min RT then 3µl to LAMP) | BioRad_CFX96 or ABI7500 or Roche_LightCycler480II or Atila_PG9600 | SeraCare_AccuPlex_0505-0129 pseudovirus (recombinant alphavirus) | 3,500* |
||
## FDA Statements and Quotes
9-23 FDA Town Hall, Time Stenzel:
"the third thing was visually-read tests. So we haven’t authorized, I mean, we’ve probably authorized just one visually-read test \[think this is DetectaChem\]. There is a lot I know in development and hopefully they will come to the market in the relatively near future and there’s nothing wrong with the visually-read tests
"we’re very eager to authorize home diagnostic tests either over-the-counter or by prescription. I have to say though we haven’t received a single EUA application for a home test, not one and we’ve had our template out there for a long time and we’ve clearly expressed flexibility so we want to reiterate. We want to see home test submissions and we’re willing to be very flexible here."
"So what we have attempted to do is provide as much flexibility to add an asymptomatic claim to anybody who wants one."
METADATA
last updated: 2026-03-10_105731
file_name: _archive-combined-files_reg-articles-misc_45k.md
category: regulatory
subcategory: reg-articles-misc
gfile_url: **FLAGGED - TBD user-facing Google-hosted public file URL**
words:
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CONTENT
# _archive-combined-files_reg-articles-misc_45k (5 files, 44,561 tokens)
# 6,354 _AI_fda-eua-covid-retrospectives_post2022_report.md
METADATA
last updated: 2026-02-26 RT initial creation
file_name: _AI_fda-eua-covid-retrospectives_post2022_report.md
file_date: 2026-02-26
title: FloodLAMP FDA EUA COVID-19 Retrospectives and Criticisms -- Post-2022 Research Report
category: regulatory
subcategory: reg-articles-misc
tags: EUA, diagnostics, FDA, COVID-19, retrospective, oversight, policy-critique, pandemic-preparedness
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license: CC BY 4.0 - https://creativecommons.org/licenses/by/4.0/
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notes: Created by ChatGPT 5.2 Pro Extended during archive preparation. **NOT HUMAN VERIFIED - MAY CONTAIN ERRORS** Research report on retrospectives and criticisms of the FDA's EUA process during COVID-19, focusing on post-2022 publications from government oversight agencies, legislative bodies, NGOs, professional associations, and academics. Key source documents: FloodLAMP project description and reg-articles-misc archive bundle.
summary_short: Research report identifying post-2022 retrospectives, evaluations, and criticisms of the FDA's Emergency Use Authorization (EUA) process during COVID-19, covering government oversight reports (HHS OIG, GAO, FDA), legislative responses, NGO and professional association critiques, and academic analyses, with archive-ready metadata for each source.
CONTENT
## Prompt (Verbatim)
I do a thorough research report on retrospectives and especially criticisms of the FDA's EUA process during the COVID-19 pandemic. This is for an archive project that's provided in the project description. I'm providing a few example files that I'm including in the archive and I'm looking for more reports like these and particularly ones that have come out since the end of the pandemic, since the end of 2022. The Booz Allen report was prior to the Omicron surge so there's a severe test shortage of testing then. These could be from any official government sources such as the FDA but also look for them from independent nonprofits or NGOs related to pandemic preparedness and response and then also from academics. Okay, do this and then, you know, organize the report well and provide the output as a markdown file that I can download where the content in the markdown file starts with heading number two. Okay, do it.
**Files included in context window:**
- project-description.md
- _archive-combined-files_reg-articles-misc.md
## Prompt (Cleaned)
Do a thorough research report on retrospectives and especially criticisms of the FDA's EUA process during the COVID-19 pandemic. This is for an archive project described in the project description. I'm providing a few example files included in the archive and am looking for more reports like these, particularly ones that have come out since the end of the pandemic (since the end of 2022). The Booze Allen report was prior to the Omicron surge, so there was a severe shortage of testing then. These could be from any official government sources such as the FDA, but also look for them from independent nonprofits or NGOs related to pandemic preparedness and response, and from academics. Organize the report well and provide the output as a markdown file where the content starts with heading level two.
**Files included in context window:**
- project-description.md
- _archive-combined-files_reg-articles-misc.md
## Retrospectives and Criticisms of the FDA Emergency Use Authorization Process During COVID-19
*(Archive-oriented research report; emphasis on post-2022 publications)*
### How to use this document
This report is designed for an **archive / curation workflow**:
- It identifies **post-2022 retrospectives, evaluations, and critiques** of FDA's Emergency Use Authorization (EUA) process during COVID-19--especially for **diagnostic tests**, but also vaccines and therapeutics.
- For each candidate source, it provides (a) a short annotation, (b) the main "EUA process" critique or lesson, and (c) suggested archive metadata (tags + a filename pattern) so the item can be added to a folder like `reg-articles-misc`.
### Baseline context (already in your example archive bundle)
Your examples (e.g., the FDA-commissioned Booz Allen independent assessment, plus an FDA overview report) are valuable "baseline" sources because they cover:
- **Early-to-mid pandemic test EUA operations** (triage, templates, staffing, postmarket monitoring, outreach)
- **Policy volatility / guidance churn** and its effects on developers and access
- Recommendations that later reappear in official guidance (e.g., validation frameworks; clearer enforcement-discretion triggers)
This report focuses on **what came after ~late 2022**, when more formal retrospectives, oversight reports, and "future emergency" guidance began to crystallize.
---
## 1) What "EUA criticism" typically means in COVID-19 retrospectives
Across the literature, "criticisms of the EUA process" cluster into recurring themes. These are useful tags and an organizing lens for archiving.
### A. Diagnostics: speed vs. validity under extreme uncertainty
Common critique: policies that expanded testing access sometimes **traded off analytic/clinical validity**, increased false results risk, or produced uneven test quality (particularly early serology, and later some rapid antigen test performance debates).
### B. Diagnostics: policy volatility and interagency conflict
Common critique: frequent shifts in FDA testing policy (e.g., pre-EUA pathways, laboratory-developed test policies, enforcement discretion) created **confusion and wasted effort** for developers and laboratories.
### C. Transparency, documentation, and public trust
Common critique: the public and outside experts sometimes lacked **timely access to the evidence** or internal decision records supporting EUA decisions (especially salient for vaccines).
### D. Postmarket monitoring, revocation, and "variant churn"
Common critique: EUA products can become obsolete as the emergency evolves (e.g., variant escape for monoclonal antibodies). Retrospectives examine whether FDA's **revocation / communication mechanisms** kept pace.
### E. Transition planning (EUA --> traditional authorization; end of PHE vs end of EUA declaration)
Common critique: stakeholders struggled with what happens when the **Public Health Emergency (PHE)** ends, while **Section 564 EUA declarations** and individual EUAs may continue.
---
## 2) Key post-2022 sources (annotated, archive-ready)
### 2.1 Official oversight and accountability (government)
#### A) HHS OIG: FDA's early testing EUA policy adaptation (retrospective with developer survey)
**Source:** *FDA Repeatedly Adapted Emergency Use Authorization Policies To Address the Need for COVID-19 Testing* (HHS Office of Inspector General, 2022)
**Link:** https://oig.hhs.gov/reports/all/2022/fda-repeatedly-adapted-emergency-use-authorization-policies-to-address-the-need-for-covid-19-testing/
**Why it belongs in this archive:** One of the most direct **post-hoc evaluations** of FDA's test EUA policies--focused on the critical early months (Jan--May 2020) and grounded in FDA documents + interviews + a survey of test developers.
**EUA-process takeaways (from the OIG framing):**
- FDA used EUA authority to rapidly expand test availability when no test existed; oversight bodies later evaluated how FDA balanced access with quality.
- The report explicitly treats **developer experience** (survey results) as evidence about clarity, timeliness, and friction in the EUA pathway.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, COVID-19 testing, oversight, OIG, policy volatility, developer experience]`
- `suggested_filename: 2022-00-00_HHS-OIG_FDA-Repeatedly-Adapted-EUA-Policies_COVID-Testing.md/pdf`
#### B) GAO: testing availability, enforcement discretion, and "policy triggers" (recommendation with later follow-through)
**Source:** *COVID-19: FDA Took Steps to Help Make Tests Available; Policy for Future Public Health Emergencies Needed* (U.S. Government Accountability Office, GAO-22-104266, May 12, 2022)
**Link:** https://www.gao.gov/products/gao-22-104266
**Why it belongs in this archive:** Although dated 2022, GAO's recommendation directly shaped later FDA guidance: **FDA should define when it begins/ends enforcement discretion for unauthorized tests** in a future emergency.
**Core critiques / lessons (EUA-process relevant):**
- In COVID-19, enforcement discretion was broadened early, then narrowed; GAO argues future emergencies need **pre-defined criteria** for start/stop.
- Frames a governance problem: "emergency flexibility" without a policy framework creates uncertainty and risk.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, enforcement discretion, GAO, policy triggers]`
- `suggested_filename: 2022-05-12_GAO-22-104266_FDA-Testing-EUA-Enforcement-Discretion.md/pdf`
#### C) FDA: final guidance establishing a framework for enforcement discretion during Section 564 emergencies (direct response to GAO-style critique)
**Source:** *Consideration of Enforcement Policies for In Vitro Diagnostic Tests During a Section 564 Declared Emergency* (FDA/CDRH, **Final Guidance**, Sep 23, 2025)
**PDF:** https://www.fda.gov/media/178123/download
**Why it belongs in this archive:** A post-COVID policy artifact that encodes "lessons learned" into a framework: **factors FDA intends to consider** when deciding whether to exercise enforcement discretion for unapproved IVDs during a declared emergency, and when to end such policies.
**Core critiques / lessons (EUA-process relevant):**
- Treats COVID-19 as an explicit case study for when FDA widened and later narrowed enforcement policies.
- Moves the debate from ad hoc decisions --> **criteria** (need, benefits/risks, alternatives, mitigations, re-evaluation cadence).
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, enforcement discretion, CDRH, guidance, Section 564]`
- `suggested_filename: 2025-09-23_FDA_Guidance_Enforcement-Policies-IVD_Tests_Section-564-Emergency.md/pdf`
#### D) FDA: draft guidance on validation for emerging-pathogen IVDs during a Section 564 emergency (institutionalizing "validation framework" lessons)
**Source:** *Validation of Certain In Vitro Diagnostic Devices for Emerging Pathogens During a Section 564 Declared Emergency* (FDA/CDRH, **Draft Guidance**, Jan 2025)
**Landing page:** https://www.fda.gov/regulatory-information/search-fda-guidance-documents/validation-certain-in-vitro-diagnostic-devices-emerging-pathogens-during-section-564-declared-emergency
**Why it belongs in this archive:** Post-COVID attempt to standardize validation expectations for future outbreak tests, addressing a central critique from COVID diagnostics: **how to validate quickly without sacrificing reliability**.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, validation, emerging pathogens, CDRH, guidance]`
- `suggested_filename: 2025-01-00_FDA_Draft-Guidance_Validation-IVDs_Emerging-Pathogens_Section-564.md/pdf`
#### E) FDA: "EUA authorities" umbrella guidance (useful legal/regulatory reference for archiving)
**Source:** *Emergency Use Authorization of Medical Products and Related Authorities* (FDA, Guidance; updated Sep 12, 2022)
**Link:** https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities
**Why it belongs in this archive:** Not a critique, but a **canonical post-COVID reference** consolidating EUA authorities, definitions, and related pathways. Helpful "reference spine" for the retrospective literature.
**Suggested archive metadata:**
- `tags: [EUA, legal framework, FDA guidance, Section 564]`
- `suggested_filename: 2022-09-12_FDA_Guidance_EUA-of-Medical-Products-and-Related-Authorities.md/html/pdf`
#### F) FDA: statements on "PHE ending" vs "EUA continuing" (transition clarity)
**Source:** FDA FAQ, *What happens to EUAs when a public health emergency ends?*
**Link:** https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/faqs-what-happens-euas-when-public-health-emergency-ends
**Why it belongs in this archive:** Retrospectives often confuse (or critique) the U.S. legal architecture: the **PHE under the Public Health Service Act** can end while **Section 564 EUA declarations** remain in effect and EUAs continue unless revoked/terminated. This FAQ is a canonical clarification.
**Suggested archive metadata:**
- `tags: [EUA, transition planning, Section 564, PHE, legal framework]`
- `suggested_filename: 2023-00-00_FDA_FAQ_EUA-After-PHE-Ends.md/html`
#### G) FDA Voices (agency retrospective framing, May 11 2023)
**Source:** *Lessons Learned from COVID-19 Are Informing Preparation for Future Public Health Emergencies* (FDA Voices blog, May 11, 2023)
**Link:** https://www.fda.gov/news-events/fda-voices/lessons-learned-covid-19-are-informing-preparation-future-public-health-emergencies
**Why it belongs in this archive:** While not a critique, it is an official retrospective narrative explaining FDA's view of lessons learned, including how EUAs persist and how FDA expects transition to traditional marketing pathways.
**Suggested archive metadata:**
- `tags: [EUA, FDA retrospective, transition, communications]`
- `suggested_filename: 2023-05-11_FDA-Voices_Lessons-Learned_COVID-19_Preparing-Future-Emergencies.md/html`
#### H) FDA testimony: "Preparing for the Next Pandemic" (late retrospective, with diagnostics + EUA process detail)
**Source:** Testimony of Dr. Hilary Marston, *Preparing for the Next Pandemic: Lessons Learned and the Path Forward* (FDA, Nov 14, 2024)
**PDF:** https://www.fda.gov/media/183533/download
**Why it belongs in this archive:** Succinct congressional-facing synthesis of lessons learned across vaccines, therapeutics, diagnostics--useful as an "official capstone" perspective.
**Suggested archive metadata:**
- `tags: [EUA, testimony, pandemic preparedness, diagnostics, vaccines, therapeutics]`
- `suggested_filename: 2024-11-14_FDA-Testimony_Preparing-for-the-Next-Pandemic_Lessons-Learned.md/pdf`
#### I) GAO: "public health preparedness" (broader after-action oversight; useful context for EUA reforms)
**Source:** *Public Health Preparedness* (GAO-25-106980, June 4, 2025)
**Link:** https://www.gao.gov/products/gao-25-106980
**Why it belongs in this archive:** Not exclusively about FDA EUAs, but useful for "higher-level" retrospectives on federal preparedness, where EUA-related testing policy appears as a component of readiness.
**Suggested archive metadata:**
- `tags: [pandemic preparedness, oversight, GAO, diagnostics ecosystem]`
- `suggested_filename: 2025-06-04_GAO-25-106980_Public-Health-Preparedness_Context.md/html/pdf`
---
### 2.2 Legislative / policy responses (useful for "what changed because of EUA criticism")
#### J) House Select Subcommittee recommendations (policy critique and reform agenda; note partisan context)
**Source:** *Final Report Recommendations* (Select Subcommittee on the Coronavirus Pandemic, U.S. House; Dec 4, 2024)
**PDF:** https://oversight.house.gov/wp-content/uploads/2024/12/2024.12.04-SSCP-FINAL-REPORT-RECOMMENDATIONS.pdf
**Why it belongs in this archive:** Captures a congressional critique agenda, including positions on how EUA should be used and how guidance / surveillance should work.
**Important caveat:** This content is politically situated; archive it as a viewpoint document.
**Suggested archive metadata:**
- `tags: [EUA, Congress, oversight, policy critique, diagnostics, vaccines]`
- `suggested_filename: 2024-12-04_US-House-SSCP_Final-Report-Recommendations_EUA-and-COVID-Response.md/pdf`
#### K) PREVENT Pandemics Act (Dec 2022) and test-evaluation provisions (CRS-style explainer)
**Source:** CRS-derived explainer, *PREVENT Pandemics Act (P.L. 117-328, Division FF, Title II)* (EveryCRSReport mirror; Aug 15, 2023)
**Link:** https://www.everycrsreport.com/reports/R47649.html
**Why it belongs in this archive:** Tracks how Congress encoded "EUA lessons" into statutory tools--e.g., provisions around **third-party test evaluation during emergencies**.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, legislation, PREVENT Pandemics Act, third-party evaluation]`
- `suggested_filename: 2023-08-15_CRS_PREVENT-Pandemics-Act_EUA-Testing-Provisions.md/html`
#### L) Third-party EUA review process (implementation-level response to EUA surge / capacity issues)
**Source:** Commentary on FDA guidance: *FDA releases final guidance on 510(k) Third Party Review Program and Third Party Emergency Use Authorization (EUA) Review* (Jan 31, 2025)
**Link:** https://www.cmhealthlaw.com/2025/01/fda-releases-final-guidance-on-510k-third-party-review-program-and-third-party-emergency-use-authorization-eua-review/
**Why it belongs in this archive:** The COVID EUA surge stressed review capacity; third-party mechanisms are one "capacity valve" that became more salient post-COVID.
**Suggested archive metadata:**
- `tags: [EUA, review capacity, third-party review, CDRH, process reform]`
- `suggested_filename: 2025-01-31_Commentary_Third-Party-EUA-Review_510k-Program.md/html`
---
### 2.3 Professional associations, NGOs, and policy stakeholders (diagnostics focus)
#### M) American Clinical Laboratory Association (ACLA): PAHPA feedback referencing EUA experience
**Source:** *ACLA Responds to Senate RFI on PAHPA* (Mar 29, 2023)
**PDF:** https://www.acla.com/wp-content/uploads/2023/04/ACLA-Responds-to-Seante-RFI-on-PAHPA.pdf
**Why it belongs in this archive:** Represents laboratory-sector critique and reform priorities informed by COVID EUA testing experience, especially around LDTs, regulatory clarity, and emergency readiness.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, laboratories, ACLA, policy feedback, PAHPA]`
- `suggested_filename: 2023-03-29_ACLA_Response_Senate-RFI_PAHPA_EUA-Testing.md/pdf`
#### N) Stanford Law policy commentary (LDT/EUA governance debate remains unresolved)
**Source:** *FDA policy reform for in vitro diagnostics and laboratory develop tests remains in limbo* (Stanford Law, Aug 3, 2023)
**Link:** https://law.stanford.edu/2023/08/03/fda-policy-reform-for-in-vitro-diagnostics-and-laboratory-develop-tests-remains-in-limbo/
**Why it belongs in this archive:** Concise synthesis of the post-COVID LDT governance limbo--useful for connecting EUA-era controversies to broader regulatory reform debates.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, LDT, policy analysis, Stanford]`
- `suggested_filename: 2023-08-03_Stanford-Law_LDT-Policy-Reform-Limbo_Post-COVID.md/html`
---
### 2.4 Academic and independent analyses (diagnostics and broader EUA governance)
#### O) Legal/academic deep dive on COVID test regulation and EUA policy shifts
**Source:** Gibbs & Javitt, *Test of Emergency* (PDF posted Jan 2023; law/policy analysis of COVID testing regulation and FDA EUA policy shifts)
**PDF:** https://hpm.com/wp-content/uploads/2023/01/Test-of-Emergency-Gibbs-Javitt.pdf
**Why it belongs in this archive:** Detailed narrative of the "zig-zagging" testing policy environment and its impacts--useful for historians and regulatory analysts.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, LDT, legal analysis, policy volatility, COVID testing]`
- `suggested_filename: 2023-01-00_Gibbs-Javitt_Test-of-Emergency_COVID-Testing-EUA-Policy.md/pdf`
#### P) Laboratory-developed tests (LDT) reform literature (post-COVID diagnostic governance debate)
**Source:** Miller (2024), *FDA's proposed rule for the regulation of laboratory-developed tests* (Journal of Clinical Microbiology)
**Link:** https://journals.asm.org/doi/10.1128/jcm.01488-23
**Why it belongs in this archive:** Connects COVID-era diagnostic shortcomings and policy debates to the post-COVID push to formalize oversight of LDTs--an adjacent but important "EUA aftermath" topic.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, LDT, regulation reform, peer-reviewed]`
- `suggested_filename: 2024-00-00_Miller_FDA-Proposed-Rule_LDTs_Post-COVID-Diagnostics-Governance.md/html/pdf`
#### Q) CRS explainer on FDA's LDT proposed rule (policy overview; good for non-lawyers)
**Source:** CRS-derived explainer, *Regulation of Laboratory-Developed Tests: FDA's Proposed Rule* (Apr 8, 2024)
**Link:** https://www.everycrsreport.com/reports/IF12628.html
**Why it belongs in this archive:** Compact background and timelines; useful as a "bridge document" between COVID testing failures/EUA debates and LDT rulemaking.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, LDT, CRS, oversight]`
- `suggested_filename: 2024-04-08_CRS_IF12628_LDT-Proposed-Rule_Context-from-COVID.md/html`
#### R) Federal Register (public inspection PDF): LDT rulemaking text referencing COVID emergency enforcement guidance
**Source:** *Medical Devices; Laboratory Developed Tests* (Public Inspection PDF, Apr 29, 2024; Doc. 2024-08935)
**PDF:** https://public-inspection.federalregister.gov/2024-08935.pdf
**Why it belongs in this archive:** Primary-source regulatory text that situates emergency enforcement guidance (e.g., for COVID/mpox IVDs) within FDA's broader IVD oversight posture.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, LDT, Federal Register, enforcement discretion]`
- `suggested_filename: 2024-04-29_Federal-Register_2024-08935_LDT-Rule_Public-Inspection.pdf`
#### S) Academic/legal discussion of vaccine EUA controversy (example post-2022 scholarly record)
**Source:** Sax (2024), *COVID-19 pediatric vaccine authorization, FDA ...* (PubMed Central article)
**Link:** https://pmc.ncbi.nlm.nih.gov/articles/PMC11034974/
**Why it belongs in this archive:** Captures a scholarly framing of why vaccine EUA decisions generated controversy; useful for the "EUA and trust" thread.
**Suggested archive metadata:**
- `tags: [EUA, vaccines, pediatrics, controversy, scholarly analysis]`
- `suggested_filename: 2024-00-00_Sax_COVID-19-Pediatric-Vaccine-Authorization_EUA-Controversy.md/html`
#### T) HHS/ASPE: clinical trial enterprise lessons learned (where EUA acceleration intersects with trial design norms)
**Source:** *COVID-19 Pandemic Lessons Learned for the Clinical Trial Enterprise* (HHS ASPE, 2024)
**PDF:** https://aspe.hhs.gov/sites/default/files/documents/3a0c88cdfc78c03d50043088da18ec4e/Clinical-Trial-Lessons-Learned.pdf
**Why it belongs in this archive:** While broader than EUA, it's useful for documenting how "emergency" timelines (including EUA endpoints) pressured trial infrastructure and standards.
**Suggested archive metadata:**
- `tags: [EUA, clinical trials, pandemic preparedness, HHS, lessons learned]`
- `suggested_filename: 2024-00-00_HHS-ASPE_Clinical-Trial-Enterprise_Lessons-Learned_COVID.md/pdf`
---
### 2.5 Postmarket corrections, revocations, and transparency disputes (for historical completeness)
#### U) Diagnostic EUAs revoked (example of postmarket quality control)
**Source:** CDC Laboratory Alert, *FDA Revokes EUAs for Six SARS-CoV-2 In Vitro Diagnostic Devices* (Mar 26, 2024)
**Link:** https://www.cdc.gov/locs/php/messages/2024/2024-03-26-fda-revokes-euas-for-six-sars-cov-2-in-vitro-diagnostic-devices.html
**Why it belongs in this archive:** Useful exemplar of how EUA oversight continues after authorization--revocation as a corrective mechanism.
**Suggested archive metadata:**
- `tags: [EUA, diagnostics, revocation, postmarket monitoring, CDC LOCS]`
- `suggested_filename: 2024-03-26_CDC-LOCS_FDA-Revokes-EUAs_SARS-CoV-2-IVDs.md/html`
#### V) Therapeutic EUAs revoked as variants made products ineffective (news record)
**Source:** Reuters, *US FDA revokes authorization for four COVID antibody drugs* (Dec 23, 2024)
**Link:** https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-revokes-authorization-five-covid-treatments-2024-12-23/
**Why it belongs in this archive:** Documents the practical lifecycle of therapeutic EUAs amid variant churn; relevant to critiques about how quickly EUA status must adapt to changing evidence.
**Suggested archive metadata:**
- `tags: [EUA, therapeutics, revocation, variants, postmarket]`
- `suggested_filename: 2024-12-23_Reuters_FDA-Revokes-EUAs_COVID-Antibody-Treatments.md/html`
#### W) Transparency / FOIA litigation about vaccine EUA decision records (news record)
**Source:** Reuters, *FDA must disclose more COVID-19 vaccine records, US judge rules* (Dec 6, 2024)
**Link:** https://www.reuters.com/legal/government/fda-must-disclose-more-covid-19-vaccine-records-us-judge-rules-2024-12-06/
**Why it belongs in this archive:** Captures a central "EUA criticism" theme: the perceived gap between emergency decision-making and later transparency expectations.
**Suggested archive metadata:**
- `tags: [EUA, vaccines, transparency, FOIA, trust, litigation]`
- `suggested_filename: 2024-12-06_Reuters_FDA-Vaccine-EUA-Records_Disclosure-Order.md/html`
---
## 3) Crosswalk: Which sources speak to which critique themes?
| Theme / critique area | Especially relevant sources to archive |
| --- | --- |
| Diagnostics: evidence standards and validation under time pressure | OIG (2022); FDA Draft Validation Guidance (2025); Gibbs & Javitt (2023) |
| Diagnostics: enforcement discretion start/stop triggers | GAO (2022); FDA Final Enforcement Policies Guidance (2025) |
| Policy volatility / clarity for developers | OIG (2022); Gibbs & Javitt (2023); ACLA (2023); House SSCP Recommendations (2024) |
| Postmarket monitoring, revocation, and communication | CDC LOCS (2024); Reuters revocation coverage (2024); FDA enforcement policy framework (2025) |
| Transparency and trust (especially vaccines) | Reuters FOIA litigation coverage (2024); scholarly discussions like Sax (2024) |
| Transition planning (PHE ends; EUAs may persist) | FDA FAQ on EUAs after PHE; FDA Voices (May 11 2023); FDA testimony (2024) |
| "EUA surge" capacity and process design | Booz Allen baseline (2021); third-party EUA review mechanisms (2025); FDA guidance modernization (2022--2025) |
| | |
---
## 4) Practical archiving guidance (FloodLAMP-style)
### Suggested filename convention
Use a consistent format for easy sorting:
`YYYY-MM-DD__.`
Examples:
- `2025-09-23_FDA_CDRH_Guidance_Enforcement-Policies-IVD_Section-564.pdf`
- `2022-11-00_HHS-OIG_FDA-EUA-Policies_COVID-Testing.pdf`
### Suggested tags (consistent across documents)
Recommended tag vocabulary for this topic:
- `EUA`
- `diagnostics`, `IVD`, `LDT`, `vaccines`, `therapeutics`
- `enforcement discretion`
- `validation`, `evidence standards`
- `policy volatility`, `guidance churn`
- `postmarket monitoring`, `revocation`
- `transparency`, `FOIA`, `trust`
- `pandemic preparedness`, `after-action`, `lessons learned`
- `review capacity`, `third-party review`
---
## 5) Notes on completeness and next steps
This report emphasizes **high-signal, archive-worthy** documents that either:
1) directly evaluate FDA's EUA decision-making during COVID-19, or
2) codify lessons learned into post-COVID policy and guidance (2023--2025).
If you want to deepen the **academic** slice further, a next pass could focus on:
- peer-reviewed analyses of vaccine EUA evidence standards and advisory committee process;
- comparative analyses (FDA vs EMA/UK MHRA emergency pathways);
- empirical studies of EUA revocations, postmarket signals, and communications.
# 649 _context-commentary_regulatory-reg-articles-misc.md
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last updated: 2026-03-01 RT
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CONTENT
## Context
This subcategory collects a small number of higher-level reports and assessments related to FDA oversight of COVID-19 diagnostics. Unlike other regulatory subcategories in the archive that focus on specific FloodLAMP interactions with the FDA (submissions, correspondence, townhalls), these files are third-party or government-produced documents that provide broader perspective on the EUA process and diagnostic test validation during the pandemic.
The three documents are:
- **Booz Allen Hamilton Independent EUA Assessment** (`2021-10-08_FDA Report - EUA Assessment by Booze Allen.md`): An FDA-commissioned review of CDRH's COVID-19 test EUA response, covering how the FDA used templates, guidance updates, triage, and deprioritization to manage thousands of submissions. It includes priority recommendations around IT systems, staffing models, and a validation framework for future emergencies. This report predates the Omicron surge and the severe testing shortages that followed.
- **FDA's Work to Combat the COVID-19 Pandemic** (`2022-07-01_FDA Report - FDAs Work to Combat the COVID-19 Pandemic.md`): A broad FDA overview summarizing cross-center actions on vaccines, therapeutics, diagnostics, supply chain, inspections, and regulatory science, with data current as of April 2022.
- **Phillips and Dinakar Proposal** (`2021-01-18_Phillips and Dinakar - A Proposal for Increasing the Speed of Validating SARS-CoV-2 Diagnostic Tests.md`): A paper proposing three extensions to the EUA process for accelerating diagnostic test validation: structured (machine-readable) EUA data submissions, distributed FDA-directed CLIA-led validation, and building an open synthetic patient clinical specimen panel.
In addition, an AI-generated research report (`_AI_fda-eua-covid-retrospectives_post2022_report.md`) was created during archive preparation to identify post-2022 retrospectives, evaluations, and criticisms of the FDA's EUA process. That report catalogs sources from government oversight agencies (HHS OIG, GAO, FDA), legislative bodies, NGOs, professional associations, and academics, and may serve as a starting point for readers interested in pursuing the broader literature on EUA reform and pandemic preparedness policy.
## Commentary
TThe Phillips and Dinakar proposal for structured, machine-readable EUA data submissions resonated with FloodLAMP's own experience navigating the EUA process. The idea that submissions could be standardized in a way that accelerates FDA review, reduces ambiguity for developers, and enables computational analysis of submission data is the kind of practical, systems-level reform that would likely have compounding benefits across future emergencies.
More broadly, the potential for AI to improve FDA processes around diagnostic test evaluation, guidance development, and emergency response has been a recurring theme throughout this archive (see commentary on the FDA townhalls subcategory and the open-EUAs subcategory). The scale and complexity of the COVID-19 testing response — thousands of EUA submissions, rapidly evolving guidance, variant-driven obsolescence — represent exactly the kind of problem where AI-assisted workflows could meaningfully reduce friction and improve outcomes.
# 8,418 2021-01-18_Phillips and Dinakar - A Proposal for Increasing the Speed of Validating SARS-CoV-2 Diagnostic Tests.md
METADATA
last updated: 2026-03-05 by BA
file_name: 2021-01-18_Phillips and Dinakar - A Proposal for Increasing the Speed of Validating SARS-CoV-2 Diagnostic Tests.md
file_date: 2021-01-18
title: Phillips and Dinakar - A Proposal for Increasing the Speed of Validating SARS-CoV-2 Diagnostic Tests
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summary_short: Phillips and Dinakar's proposal paper (v0.1.9, January 2021) recommends three extensions to the FDA's EUA process for accelerating validation of SARS-CoV-2 diagnostic tests: structured (machine-readable) EUA data submissions, distributed FDA-directed CLIA-led validation leveraging existing laboratory expertise, and building an open synthetic patient clinical specimen panel to reduce dependence on limited clinical samples for test validation.
CONTENT
***INTERNAL TITLE:*** A Proposal for Increasing Speed of Validating SARS-CoV-2 Diagnostic Tests
Alexander James Phillips †, Karthik Dinakar ‡
† Center of Complex Interventions, ‡ Massachusetts Institute of Technology
Correspondence to ajp@centerofci.org
v0.1.9 - 2021 Jan 18th
## SUMMARY
Rapid access to diagnostics for emerging high priority pathogens is of great importance from a clinical, public health and economic point of view. Currently in the United States there are several technological, regulatory and organisational improvements that might be adopted for the COVID-19 and future pandemics. In this article, we suggest a proposal for increasing the speed of validating SARS-CoV-2 diagnostic tests, suggestions include: a structured (machine readable) EUA data submission process, distributed FDA directed CLIA led validation, and building an open synthetic patient clinical sample panel. This document is a work in progress, containing some ideas which may be of value to consider and implement. We welcome you to add your name to this proposal or make a contribution of any size and scope. This concept and paradigm will be of utmost importance for pandemics of diseases more prone to the emergence of new mutant strains that evade current diagnostics and vaccines.
## CONTENTS
1 The Opportunity and Goals
- 1.1 Diagnostic tests are powerful tools, we need rapid access to them
- 1.2 We need trustworthy knowledge of diagnostics performance
- 1.3 Emergency Use Authorisation, United States Code
2 The Current Situation
- 2.1 Initial response time
- 2.2 EUA backlog delays tests coming to market
- 2.3 Heterogeneous quality of test performance data
- 2.4 No guarantee of accurate test performance data
- 2.5 Quality control and reference materials
3 Possible Extensions to Current Validation Process
- 3.1 EUA minimum structured data
- 3.2 FDA directed CLIA led validation
- 3.3 Synthetic clinical specimen panel challenge
- 3.3.1 Current strategy: waiting for infections to get specimens to validate against
- 3.3.2 New strains are harder to counter
- 3.3.3 Underpowered validation: Clinical specimen edge cases
- 3.3.4 Routes to characterised viral material for reproducible validation of diagnostics
- 3.3.5 Synthetic patient specimen panel
- 3.3.6 Potential advantages of a synthetic patient specimen panel
4 Request for Comment
5 Revision History
## 1 THE OPPORTUNITY AND GOALS
### 1.1 Diagnostic tests are powerful tools, we need rapid access to them
Well characterised diagnostic tests for diseases are powerful tools to help clinicians, public health and policy makers treat patients, and lessen the burden of communicable diseases on communities. In situations of newly emerging serious infectious diseases, rapid access to diagnostics tests is of utmost importance. Diagnostic tests allow clinicians to better treat their patients. Population screening allows public health officials to help trace and break chains of infection and find asymptomatic individuals. In conjunction with policy makers providing support, this allows for test, trace and isolate public health programs to reduce or eliminate community transmission [4].
### 1.2 We need trustworthy knowledge of diagnostics performance
As important as the test itself is clear and trustworthy knowledge of the tests performance characteristics. Although we do need tests "that work", it's important that we know how well tests work, which includes the uncertainty of those metrics describing the test's performance.
One of the objectives of the VITAL Act (Verified Innovative Testing in American Laboratories) of 2020 is to "ensure that laboratory-developed testing procedures are accurate, precise, clinically-relevant" [23, 22d]. In other words, it is necessary for an initial validation to be performed for each new diagnostic test and for that initial validation to be well characterised and consistent to allow comparison between different tests.
### 1.3 Emergency Use Authorisation, United States Code
The United States Food and Drug Administration (FDA) oversees the Emergency Use Authorisation (EUA) process, including that for COVID-19 related medical devices [6]. The criteria for the issuance of EUAs are stated in Act 21 U.S.C. §§ 360bbb-3(c)(1-5) [30]. Included is the legal and binding duty to ensure:
the known and potential benefits of the product, when used to diagnose, prevent, or treat such disease or condition, outweigh the known and potential risks of the product, taking into consideration the material threat posed
and that
there is no adequate, approved, and available alternative to the product for diagnosing, preventing, or treating such disease or condition
This thought piece does not disagree with these objectives and criteria; it raises the question of whether and how we might fulfil these requirements but do so more quickly.
## 2 THE CURRENT SITUATION
### 2.1 Initial response time
Crucial to the early access to diagnostics was the timely and accurate publication of the SARS-CoV-2 genome [34]. This enabled high complexity CLIA labs and commercial manufacturers to respond quickly; both in the production of the tests ready for EUA submission and in the quality control material necessary to begin reproducible measurement and validation of test performance.
Many elements of our molecular pathology diagnostic response to this pandemic have been exceptional. The rapid speed at which diagnostics were made ready by molecular pathology laboratories was on par with the 2009 H1N1 pandemic [18, 22b]. However the FDA's EUA process initially significantly slowed efforts to deploy these tests. Without these tests, samples were sent to central public health labs which limited the scale of testing and slowed down the test to result time. Both testing capacity and responsiveness are crucial factors in getting ahead of outbreaks and containing them through public health counter measures. This lack of testing and responsiveness also limited clinicians and policy makers in treating and providing scientific, data driven leadership [17].
The FDA responded to these challenges and updated their guidance to accommodate more risk [5c]. This was a crucial leadership decision that will surely be reflected upon and copied for future infectious disease outbreaks.
### 2.2 EUA backlog delays tests coming to market
Over the following months, almost 1 new diagnostic test was given EUA status per day [15]. The FDA simultaneously grew their diagnostics review team from 25 to 100 (as of mid October [10]) with many more support staff. Despite these admirable efforts there remains a backlog of new diagnostic tests awaiting FDA review for EUA [11b, 10]. This backlog delays companies from bringing their test to market. This delay has a negative effect on our collective ability to leverage all supply chains and technologies as quickly as possible and bring them to bear against this new infectious disease. In hindsight this backlog and associate delay, along with many other shortcomings outside of the FDA's EUA process [8, 21] may be shown to have had a significant negative effect on the ability of the United States to effectively respond to the pandemic.
### 2.3 Heterogeneous quality of test performance data
As previously stated, rapid access to tests with trustworthy evaluation of test performance is a fundamental requirement. Although many tests have now attained EUA, the quality of the documentation and validation of these tests is heterogeneous [28]. This characteristic has persisted since the beginning of the outbreak, is a large source of uncertainty for laboratory staff and managers making decisions about which test to purchase, and increases the burden needed to validate a new diagnostics test. The information heterogeneity shows itself in many forms, the first of which being information in EUAs. Some EUAs are thorough and concise with all the necessary information present. On the other extreme are EUAs that lack crucial information, have errors, or reference data that does not exist. The clearest example of this are primer sequences which although requested by the FDA are only present in 34% of submissions dropping to 5.8% of the most frequently used tests [28]. This is important information given the range of mutations which have been found to negatively impact test performance [13, 32, 2]. Performance degradation might have occurred in other tests and is unlikely to have been detected in all cases. Inclusion of primer / probe sequence information might increase the ability of laboratory, public health and others to be more proactive in the face of new mutant viral strains [29b].
### 2.4 No guarantee of accurate test performance data
Finally the current EUA process does not ensure the validation results reported are reproducible. In several instances [14, 3b] widely used diagnostic test were assessed and a significant difference was found between the limit of detection (LOD) reported in the EUA and that which the investigators measured using their own reagents and protocol. These are not isolated incidences and the sensitivity of diagnostics given by its LOD is important for effective public health Test Trace Isolate (TTI) programs [1].
As mentioned previously, in several cases the EUA process has not guaranteed disclosure of some essential attributes of diagnostic test characteristics. Similar to the previously cited example where LOD reported in EUAs was not reproducible, several EUAs also report LOD with non SI units of TCID50 ml⁻¹ [28]. This prohibits investigations to reproduce the claimed performance characteristics.
The lack of information or guarantees about the performance of diagnostics tests has transferred the cost of validation to the labs adopting the tests [22c, 20d]. Various open and closed networks of laboratory staff have taken up the role of sharing important test performance information. It would be powerful if there was an open, structured data repository of diagnostic test performance data. Similar to Wikipedia, lab staff could contribute verification / validation data of diagnostic test performance; benefiting other labs, in return benefiting from data submitted by other labs and collectively benefitting the patients they serve. Whilst such a community of lab staff and shared data store would be of great aid to a public health emergency, most labs are primarily driven by commercial pressures and would not be expected to contribute towards such a collective effort despite benefitting from it.
### 2.5 Quality control and reference materials
Viral positive control materials were produced early on and are now widely available. Providers include a range of commercial and government sources [7]. Viral material includes positive clinical specimens, naked RNA, virus like particles, live virus and inactivated virus.
## 3 POSSIBLE EXTENSIONS TO CURRENT VALIDATION PROCESS
These proposals revolve around 3 main themes. Firstly, the merits of defining a minimum set of required data for a diagnostics EUA and doing so in a structured form. Secondly, utilising the validation work already done by some of the high complexity CLIA laboratories around the United States. Thirdly, combining existing quality control materials to provide a representative and extensible panel of synthetic clinical specimen challenges for tests to pass. We hope these suggestions aid further discussion around new models of validating tests, potentially helping bring tests to market sooner, both during this pandemic and any future pandemics.
### 3.1 EUA minimum structured data
The normal submission process for a new diagnostic tests accumulates thousands of pages and takes years [26b]. The EUA process instead requires only tens of pages and should take days to complete. This might enable labs and manufacturers to legally distribute their test within days and meet the urgent need for diagnostics to contain and aid treatment of SARS-CoV-2.
Some tests awaiting review and approval by the FDA have taken over a hundred days and counting. This has largely been due to the volume of testing required which has stimulated a large market response. The correspondingly large volume of submissions has saturated the FDA's capacity to review new submissions in a timely fashion.
As mentioned previously the FDA has been exemplary in their continual adaptation and responsiveness. Expanding their team by many factors [10], reducing and refining the minimum set of information required for EUAs and providing multiple template EUA documents [12]. These templates have aided manufacturers, laboratories and others in their EUA submission process by helping to ensure the minimum information is included. And secondly may have aided the FDA reviewers by providing a more standardised form of EUA submission which makes comprehending and reviewing the EUAs a faster process.
For the same EUA submission type, for example "Molecular Diagnostic Template for Commercial Manufacturers", each EUA submission should contain the same types of data. However despite the templates provided there is still significant heterogeneity in the data [28].
Adopting a tool to enforce structured data upon submission for an EUA might aid both the companies in ensuring all the necessary fields are completed, and the reviewers in checking the data. There are many providers of such tools such as TypeForm, Microsoft Forms, etc. These off the shelf solutions are cheap, secure, fast to configure and reliable. The structured data they take in could then be provided as is or additionally used to automatically populate the templates mentioned earlier. The applications for structured data are many but at a minimum might allow laboratories looking for a new test to more easily compare and search across the available EUA data. The structured data might also aid the FDA's internal processes, allowing for better prioritisation, communication with and tracking of applicants.
_Flowchart diagram showing the EUA process from test manufacturers through FDA review to approval and publication of EUAs/IFUs. Solid red boxes indicate where structured data could be employed at the submission, initial review, and laboratory use stages. Dashed boxes indicate downstream processes and workflows—such as prioritisation, clarification requests, and cross-EUA comparison—that may be aided by the presence of structured data._
**Figure 1:** Locations in the current EUA process where structured data may be employed (solid red boxes) to expedite and enable related processes and workflows (dashed boxes) by ensuring data is present, formatted consistently and easier to parse, prioritise and compare against other EUAs. IFU: Instructions For Use documentation may form part of the package inserts. Adapted from FDA's SHIELDx presentation [25]. SHIELDx (Systemic Harmonization and Interoperability Enhancement for Lab Data) program's stated goal is to "Describe the same test data the same way".
### 3.2 FDA directed CLIA led validation
The requirement of an EUA for a Laboratory Developed Test (LDT) has recently been lifted by the FDA [16b]. Whilst there may have been a component of political pressure, this in part is due to the depth of expertise of the directors and staff in the nation's ~2,500 high complexity CLIA laboratories subspecialising in virology (~127,000 high complexity CLIA laboratories as of 2011 [33b] of which 2% subspecialise in virology [33c]). The LDT EUA rescission has allowed many hundreds of laboratories to legally begin immediate use of their LDTs for diagnosis. In conjunction with the LDTs they have developed and validated, many laboratories have and will continue to increase their testing capacity by evaluating and purchasing commercial test manufacturers equipment and reagents.
It has already been highlighted that expert validation work of newly purchased diagnostic tests is being conducted by the purchasing labs [22c], as is required by CLIA regulations [27b]. Taken together this validation work may collectively be being conducted with a much broader range of acceptable sample types. This is important as it has the potential to contain a sufficient number of specimens to be representative of the population of specimens and avoid being a statistically underpowered validation of a diagnostic test. Secondly this work is inherently aligned to the interests of patients, society, laboratories, regulators and test manufacturers by avoiding the potential unconscious bias of diagnostic manufacturers as they validate their own test. As previously suggested [20b], there is an obvious opportunity to leverage this expert validation work being conducted by CLIA labs. What follows is a potential model the FDA could design, implement and coordinate in this and future pandemics:
1. A prospective supplier seeking an EUA sends a number of copies of the machine (a minimum of 3, preferably more) and sufficient reagents (e.g. for 1000+ tests each) to the FDA along with their submission of structured data describing the test, its performance characteristics as assessed by the manufacturer, claimed capabilities, etc.
2. Separately, for free or a fee, laboratories make themselves available to the FDA to review the EUA and validate machines. This is a task all have already had to do during this pandemic and seems prudent to harness this significant capacity of distributed talented work
3. The FDA can conduct their own evaluation of the machine whilst also sending the draft EUA, a machine, and reagents to a random subset of available laboratories. Optionally a reference panel (see "Synthetic clinical specimen panel challenge" below) can be sent as well. Amongst other potential benefits a reference panel would enable harmonising results between laboratories
4. The initial standard sets of validation data, including positive viral materials used, comparator test, etc. are uploaded to a centralised database
5. Any significant discrepancy between laboratory validation results are resolved
6. The company is authorised for a particular set of EUA performance characteristics
7. Only then can the submitting company know which labs are in possession of their test machine and may offer them to buy it
This is one potential model for the distributed initial validation of diagnostics for emerging, high priority pathogens. It is coordinated by the FDA and uses the existing legislation but leverages the latent, capable and eager talent of our molecular pathology laboratories.
_Flowchart diagram showing test manufacturers submitting EUAs along with machines and reagents to the FDA, which then distributes them to randomly selected available CLIA laboratories for independent validation. The laboratories conduct CLIA-led validation and report results back to the FDA for review, leading to approval and publication of EUAs/IFUs._
**Figure 2:** Potential model leveraging validation work being performed in CLIA laboratories to maximise speed, volume and accuracy of authorising emergency diagnostics. IFU: Instructions For Use.
### 3.3 Synthetic clinical specimen panel challenge
#### 3.3.1 Current strategy: waiting for infections to get specimens to validate against
When a new pathogen emerges the availability of clinical samples to test with is very limited. This limitation slowed down the effective development and validation of much needed new diagnostics for COVID-19 pandemic. (todo: find and cite paper reiterating benefits of international sharing of specimens) Our current strategy is to wait for sufficient new infections to get sufficient samples needed for multiple labs, commercial manufacturers and government agencies to all develop and validate their diagnostics tests. If not addressed, this strategy will slow down the response to the next pathogen or strain that emerges.
Secondly the threshold for which diagnostics tests must overcome to show clinical efficacy was 20 and is now set at 30 positive patient samples. During the early stages of a pandemic, when testing is most important to control spread, there are insufficient samples which makes this barrier insurmountable.
#### 3.3.2 New strains are harder to counter
In later stages of a pandemic that is under control there will also be insufficient samples. If there are many new infections, such as the United States and other countries like the United Kingdom are experiencing coming into the winter of 2020, there is a different problem, namely the increased infections, increases the chance of mutations rendering existing diagnostics less effective [13, 32, 2]. This is an identical, if not harder, scenario to contend with than at the outset of a pandemic. It is harder because there will be many infections from existing strains which makes identifying appropriate samples for testing against more challenging. Simultaneously, in the early phase of a new strain spreading, there will be a very low absolute and relative number of specimens for which to validate tests against.
#### 3.3.3 Underpowered validation: Clinical specimen edge cases
Finally, the validation of new diagnostic tests is conducted using a random but small set of samples from clinical specimens. This is likely to be statistically underpowered whilst also likely not including many or any of the significant edge cases a diagnostic test would preferably be able to correctly deal with. Edge cases such as a concurrent infection with pus, elevated mucin levels, blood, or for saliva samples, the presence of food, or acidity from orange juice etc. Some EUAs, often submitted during periods of relatively low disease prevalence, used contrived samples based on repeating tests on the same clinical sample, further limiting the range of samples the test is validated for. Other EUAs have been given based on samples of RNA in solutions of stabilizing buffer RNA Diluent P which although likely justifiable given the circumstances, would seem to have significant room for improvement to meet US Federal Regulations calling for samples used (in proficiency testing) to "mimic actual patient specimens when possible" [31].
#### 3.3.4 Routes to characterised viral material for reproducible validation of diagnostics
In the absence of a national or international standard of SARS-CoV-2 material the FDA has made available a reference panel of samples [9]. This material is an important step and one called for previously to enable the standardisation of diagnostic test sensitivity [20c]. In the context of the current pandemic, wider and early access to such a control material would enable a more robust characterisation of diagnostic tests between different laboratories, machines, and batches of reagents and consumables.
As this material is still restricted to the diagnostics tests which have received EUA an alternative approach is the use of commercially available control materials [7]. As these are not yet benchmarked a harmonisation study being prototyped by JIMB is underway [19]. The results from this important work should allow the use of commercial control materials to yield commutable results of diagnostics test sensitivity. This study is predicated on the quality control material being homogenous and consistent with one batch.
#### 3.3.5 Synthetic patient specimen panel
With the FDA reference panel, or an open source panel constructed from harmonised commercial viral material it would then be possible for multiple testing labs, and or by the FDA or another organisation like FINDDX [24]. to conduct independent and comparable validation of diagnostic sensitivity.
If an open source list of ingredients for each of the reference panel specimens were made available, then over time it could be improved to more closely represent clinical specimens and extended to cover more edge cases. For example the inclusion of blood, mucin, a simulated concurrent bacterial infection and other interfering components and pharmaceuticals could be included in an extended reference panel.
_Timeline comparison diagram showing two parallel processes. The current process proceeds from pathogen isolation through sequencing, test development, waiting for community prevalence to rise, collecting sufficient clinical specimens, conducting test validations, and finally granting EUAs for widespread deployment. The proposed process using a synthetic specimen panel bypasses the need to wait for clinical specimens by spiking a pre-made panel with inactivated viral material, enabling earlier test validation and EUA granting. The diagram indicates that the time saved would result in avoided community infections._
**Figure 3:** How the use of a pre made clinically relevant synthetic patient specimen panel spiked with inactivated viral material may allow more rapid validation of diagnostics. Based on the assumptions that rapid access to diagnostics aids public health test, trace and isolate interventions to curtail community transmission and secondly that limited clinical samples delayed validation of new diagnostics.
#### 3.3.6 Potential advantages of a synthetic patient specimen panel
Confronted with a new pathogen, or a mutant of an existing pandemic pathogen, it might be much faster to spike new synthetic or inactivated viral material into such a reference panel than wait for sufficient patient specimens to validate a diagnostic test. Such a panel would also offer the opportunity to include all the edge cases such a test should be able to handle. And finally with these consistent and characterised synthetic specimens a more consistent and reproducible validation of diagnostic tests may be conducted allowing the performance characteristics to be compared to each other. This would help lab staff make informed decisions about which diagnostic system to purchase or implement, this aids patient care, supports public health initiatives and provides a crucial piece of information to make the diagnostics market more competitive and efficient.
## 4 REQUEST FOR COMMENT
This is a work in progress and any contributors who would like to join the draft with any size and scope of change are welcome. We look forward to receiving your thoughts and integrating them in this or a subsequent document. Please contact ajp@centerofci.org.
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[18] D. B. Jernigan et al. "Detecting 2009 Pandemic Influenza A (H1N1) Virus Infection: Availability of Diagnostic Testing Led to Rapid Pandemic Response". In: *Clinical Infectious Diseases* 52.suppl 1 (Jan. 2011), S36–S43. doi: 10.1093/cid/ciq020. [link](https://doi.org/10.1093/cid/ciq020).
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[21] Amy Maxmen. "Scientists baffled by decision to stop a pioneering coronavirus testing project". In: *Nature* (May 2020). doi: 10.1038/d41586-020-01543-x. [link](https://doi.org/10.1038/d41586-020-01543-x).
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## 5 REVISION HISTORY
- v0.1.9 - 2021 Jan 18th - Integrate feedback, gratefully received from Dr Alex Greninger, University of Washington School of Medicine.
- v0.1.8 - 2020 Nov 25th - Add 3 figures
- v0.1.7 - 2020 Nov 23rd - Typesetting polishing and readability
- v0.1.6 - 2020 Nov 19th - Typesetting polishing
- v0.1.5 - 2020 Nov 19th - Author affiliations
- v0.1.4 - 2020 Nov 19th - Add summary
- v0.1.0 - 2020 Nov 17th - First public version
# 20,803 2021-10-08_FDA Report - EUA Assessment by Booze Allen.md
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summary_short: The FDA/Booz Allen Hamilton “Emergency Use Authorization Assessment — Final Report” summarizes an independent review of CDRH’s COVID-19 test EUA response, including how FDA used templates, guidance updates, triage/content screens, and deprioritization to manage thousands of EUA and pre-EUA submissions while prioritizing tests that increased capacity and access. It describes FDA’s validation approach (including the SARS-CoV-2 molecular reference panel and postmarket monitoring via adverse event reporting, removal lists, warning letters, and safety communications) and highlights extensive outreach tools such as town halls, FAQs, and email inboxes. It also presents Booz Allen’s priority recommendations — improving IT systems for EUA workflows, creating a systematic staffing/surge model, and developing a framework for validating diagnostics for emerging pathogens during future public health emergencies, along with FDA’s stated agreement with these priorities.
CONTENT
FDA PERSPECTIVE
***INTERNAL TITLE:*** Emergency Use Authorization Assessment — Final Report
## Introduction
During the prior six declared public health emergencies under section 564 of the Federal Food, Drug, and Cosmetic Act, the FDA has used its emergency use authorization (EUA) authority to authorize diagnostic tests developed by commercial manufacturers and laboratories. The EUA process provides critical flexibility and expedites access to tests during emergencies. The EUA process enabled COVID-19 tests to be developed, validated, authorized, and deployed in weeks rather than months to years, as may be the case of the more rigorous evidentiary standard required outside of a public health emergency. To date, the FDA has authorized approximately 400 tests and home collection kits and granted emergency use authorization or full marketing authorization for over 1,700 medical devices, including tests, PPE, ventilators, and other devices for diagnosing, preventing, or treating COVID-19.
## Background
In March 2021, Booz Allen Hamilton was selected by the FDA to conduct an independent assessment of the FDA’s Coronavirus Disease 2019 (COVID-19) Emergency Use Authorization (EUA) response. Booz Allen Hamilton reviewed primary documents and conducted internal and external stakeholder interviews to evaluate the FDA’s response and develop recommendations for improvement.
To further address current and future public health needs, the FDA’s Center for Devices and Radiological Health (CDRH) is sharing Booz Allen Hamilton’s independent assessment. For an overview of the recommendations from the independent assessment, along with CDRH’s perspectives and steps we have taken or plan to take to address the feedback, see Emergency Use Authorization of COVID-19 Tests: Independent Assessment of the FDA’s Response.
The FDA agrees with the three priority recommendations identified by Booz Allen Hamilton that are presented in the independent assessment. Booz Allen Hamilton recommends that the FDA:
• Optimize the IT system to account for EUA processes
• Develop a systematic approach (a strategy and plan) for allocation and tracking of staff during public health emergencies (PHE)
• Develop a framework for how to conduct validation of diagnostic tests for emerging pathogens in the setting of a declared PHE
**Priority Recommendations to Support the EUA Process**
**Recommendation: Consider ways to optimize the IT system to account for EUA processes**
• From March 2020 to present, CDRH took several steps to identify IT system needs to improve tracking of EUA requests. In parallel CDRH has been working to streamline EUA processes.
• Further, CDRH initiated a Digital Transformation Initiative, launched in Fiscal Year (FY) 2016, which is ongoing. This initiative is focused on providing better IT infrastructures, technology solutions, and data to help both internal and external stakeholders across all regulatory programs**.** The Digital Transformation Initiative:
o Will improve tracking and data for several program areas, including EUAs, over the next two to three years.
o Will help CDRH be more agile and address pressing IT challenges and stakeholder needs during a public health emergency.
o Is made possible by funding first received from Congress in FY 2019 to support CDRH’s Digital Transformation Initiative.
**Recommendation: Consider developing a systematic approach (a strategy and plan) for allocation and tracking of staff during public health emergencies (PHEs).**
CDRH is undertaking efforts to proactively prepare for future situations by focusing on how to identify staffing needs and deploy staff to the “right place at the right time” by:
• Outlining a blueprint for an Emergency Response Process that will provide guidelines for information sharing, staff mobilization, and operational flexibility with the goal of engaging the right people at the right time in future emergencies.
• Starting a process improvement effort to address how ‘Surge Capacity’ is defined and managed in a standardized way across the Center.
• Using a resource pool of qualified contractors to support various activities, including EUA review activities on an ‘as-needed’ basis to address the demands of the PHE.
In addition to identifying ways to manage resource needs, CDRH is exploring ways to simplify and streamline the EUA process. For example, the use of review templates reduced the number of manufacturer submission pages and focused on what was the most important data to submit to the FDA. This helped FDA review staff work more efficiently given the staffing challenges. The Center will continue to develop strategies to improve its ability to increase capacity for future PHEs.
**Recommendation: Consider developing a framework for how to conduct validation of diagnostic tests for emerging pathogens in the setting of a declared PHE.**
CDRH’s experience with COVID-19 tests highlights the need for a common legislative framework to help ensure that all tests are accurate and reliable, regardless of whether they are developed in a laboratory or by a commercial manufacturer and regardless of whether there is an emergency. CDRH plans to:
• Engage with test developers to speed the availability of future *in vitro* diagnostic (IVD) devices, including
establishing:
o Generic templates for commonly anticipated pathogens that may be adapted for potential future outbreaks.
o A framework for conducting appropriate validation under different circumstances.
• Continue strengthening communication strategies and tools that have proved effective during the COVID-19 PHE.
Further, CDRH suggests that the U.S. government consider:
• Working with international partners to establish a plan for sharing clinical specimens as soon as a public
health threat emerges.
• Establishing the capacity to independently evaluate test performance before outbreaks occur so that independent evaluation can be performed quickly during an outbreak.
**For more information:**
• Emergency Use Authorization of COVID-19 Tests: Independent Assessment of the FDA’s Response
**Deliverable 15:**
**Emergency Use Authorization**
**Assessment – Final Report**
CONTRACT NO. HHSF223201510027B
ORDER NO. 75F40121F19043
## CONTENTS
EXECUTIVE SUMMARY ........................................................................................................ 3
1. ASSESSMENT BACKGROUND AND OBJECTIVES .................................................................. 4
2. METHODOLOGY .............................................................................................................. 5
3. ASSESSMENT FINDINGS .................................................................................................. 6
3.1 Approach to development, review, and authorization of COVID-19 tests .......................... 6
Policy developed to address COVID-specific challenges .................................................... 6
Stakeholder perspectives and lessons learned .................................................................. 9
3.2 Approach to process improvements and review times ...................................................... 9
Implemented process changes to keep pace with evolving needs and increasing submission volume .......... 9
Various factors impacted review times over the course of the public health emergency ...................... 12
Stakeholder perspectives and lessons learned .................................................................. 18
3.3 Approach to test validation, postmarket actions, and evaluation of real-world test performance .......... 18
Validation and use of reference panel to demonstrate performance ........................................ 18
Using real-world evidence to confirm test performance ..................................................... 20
Stakeholder perspectives and lessons learned .................................................................. 22
3.4 Approach to communication with requestors, clinical community, and the public .............................. 22
Established multiple communication channels .................................................................. 22
Stakeholder perspectives and lessons learned .................................................................. 25
4. BEST PRACTICES AND PRIORITY RECOMMENDATIONS .................................................... 26
5. APPENDIX .................................................................................................................... 28
5.1 Glossary .................................................................................................................. 28
---
List of Figures
Figure 1-1. Key Actions in FDA’s Response to Development and Authorization of COVID-19 Tests ................. 5
Figure 3-1. Submission Templates Published ....................................................................................... 9
Figure 3-2. Percentage of OHT7 Working on COVID-19 ....................................................................... 12
Figure 3-3. Authorized IVDs During Previous PHEs ............................................................................ 13
Figure 3-4. EUA Authorizations and Acknowledgements by Month .......................................................... 13
Figure 3-5. Number of IVD EUA Requests Received by Month ................................................................ 14
Figure 3-6. Review Times of Original EUA Requests (Authorized and Declined to Issue or Denied) .............. 15
Figure 3-7. Review Times of Authorized and Acknowledged EUA Requests (Originals and Supplements) ....... 16
Figure 3-8. Review Times of Original Molecular EUA Requests from Laboratories (Authorized and Declined to Issue or Denied) .... 16
Figure 3-9. Review Times of Original Molecular EUA Requests from Commercial Manufacturers (Authorized and Declined to Issue or Denied) .. 17
Figure 3-10. Review Times of Original, Authorized, Molecular EUA Requests (Commercial Manufacturers and Laboratories) with Overlay of Number of IVD EUA Requests by Month ............................................. 17
Figure 3-11. Distribution of Original Molecular EUA Requests by Decision (Commercial Manufacturers and Laboratories) .............. 18
---
List of Tables
Table 2-1. Assessment Objectives ........................................................................................................ 5
Table 3-1. Overview of Policies Outlined in Guidance to Expand Access to for COVID-19 Tests .................... 7
Table 3-2. Overview of Umbrella EUAs for COVID-19 Tests .................................................................... 7
Table 3-3. Use of Individual and Umbrella EUAs .................................................................................. 8
Table 3-4. Stakeholder Perspective on the Approach to Development, Review, and Authorization of COVID-19 Tests ................. 9
Table 3-5. COVID-19 Test Prioritization Factors .................................................................................. 10
Table 3-6. COVID-19 Test EUA Breakdown by Decision ......................................................................... 14
Table 3-7. Stakeholder Perspective on the Approach to Process Improvements and Review Times ................................. 18
Table 3-8. Molecular Diagnostic Reference Panel Results ...................................................................... 19
Table 3-9. EUA Postmarket Actions .................................................................................................... 21
Table 3-10. Collaborations to Evaluate the Potential Application of RWE During a PHE ............................................ 21
Table 3-11. Stakeholder Perspective on the Approach to Test Validation, Postmarket Actions, and Evaluation of Real-world Test Performance ..................................................................................................................... 22
Table 3-12. Stakeholder Perspective on the Approach to Communication with Requestors, Clinical Community, and the Public .......... 26
Table 4-1. Best Practices Identified by Booz Allen to Support the EUA Process ...................................................... 26
Table 4-2. Priority Recommendations Identified by Booz Allen to Support the EUA Process .......................................... 26
Table 5-1. Glossary of Abbreviations and Acronyms .............................................................................. 28
## EXECUTIVE SUMMARY
In March 2021, Booz Allen was selected by the U.S. Food and Drug Administration (FDA) to conduct an independent assessment of the Agency’s Coronavirus Disease 2019 (COVID-19) Emergency Use Authorization (EUA) response. Booz Allen reviewed primary documents and interviewed internal and external stakeholder to evaluate FDA’s response and develop recommendations for improvement. FDA has played a critical role in our nation’s response to the COVID-19 public health emergency (PHE). As medical devices, particularly diagnostic tests, are the first line of defense against an emerging outbreak, the Center for Devices and Radiological Health (CDRH) was the first FDA Center to review EUA requests that were authorized under the Agency’s authority to issue EUAs in this PHE. The number of device EUA requests granted by FDA were well above the total number of EUAs granted for all previous PHEs combined. The current pandemic has driven a need for medical devices, including tests and more, that has far exceeded what was experienced in prior PHEs.
This assessment focuses on the EUA process for COVID-19 tests, how the Agency prioritized processing of EUA requests, review times, accuracy/reliability of the COVID-19 tests, a comparison of FDA’s response to prior PHEs, and requestors’ perspectives. Throughout the course of the PHE, FDA modified the EUA process to respond to the increased volume of submissions. The findings outlined in the report identify key actions FDA took in their response to COVID-19, including the following:
• **Requestor Support:** Published three guidance documents and developed ten submission templates, and continuously updated these to maximize development of and facilitate access to COVID-19 tests with flexible policies.
• **Review Prioritization:** Established factors to prioritize review of EUA requests, including test capacity, accessibility, and supply chain considerations, to focus review time on the most impactful requests based on the state of the pandemic.
• **Process Improvements:** Developed and implemented process improvements to operationalize prioritization factors and improve review efficiency, including a front-end triage, content screen, and deprioritization process.
• **Review Volume:** Reviewed and closed out over 2,000 EUA-related submissions, including Original EUAs and Supplements as well as over 1,000 Pre-EUAs as of April 2021\.
• **Authorization:** Authorized a total of 360 Original EUA requests and 452 EUA Supplements for *in vitro* diagnostics (IVD) as of April 12, 2021\.
• **Real-World Evidence (RWE) Generation:** Established collaborations focused on gathering and analyzing Real World Data (RWD)/RWE to enable data sharing, harmonized data standards, reporting, and data collection.
• **Communications and Outreach:** Hosted over 50 Town Hall sessions and webinars; posted over 300 Frequently Asked Questions (FAQ); stood-up a 24/7 hotline; created a central mailbox to help requestors accelerate submissions by providing frequent feedback; and developed educational testing resources for health care providers.
• **Test Performance Transparency:** Created three informational websites addressing test performance (molecular reference panel website, serology test performance website, and viral mutations impacts website); sent out Warning Letters and Safety Communications; and collaborated with the National Cancer Institute (NCI) for independent evaluation of certain performance characteristics of serology tests.
The recommendations presented in this report incorporate lessons learned and stakeholder perspectives and serve as a summary of actions for the Agency to consider as they continue to serve on the frontline in response to current and future public health needs.
## 1\. ASSESSMENT BACKGROUND AND OBJECTIVES
Booz Allen evaluated the Center for Devices and Radiological Health’s (CDRH) Emergency Use Authorization (EUA) process for Coronavirus Disease 2019 (COVID-19) tests. Specifically, we performed a comprehensive analysis of how the Agency prioritized the processing of the EUA requests, review times, accuracy/reliability of the COVID-19 tests, a comparison of the U.S. Food and Drug Administration’s (FDA) response to prior public health emergencies (PHE), and requestors’ perspectives.
FDA is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation. On January 31, 2020, the Secretary of the Department of Health and Human Services (HHS) declared a PHE related to COVID 19\. On February 4, 2020, pursuant to Section 564 of the Federal Food, Drug, and Cosmetic Act (FD\&C Act), the Secretary of HHS provided FDA with the authority to grant EUAs for *in vitro* diagnostics (IVD) to detect and/or diagnose COVID-19. EUA authority helps strengthen the nation’s public health protections by facilitating the availability and use of unauthorized medical products, or unapproved uses of approved medical products, during PHEs. An EUA request for a test can be issued when, among other things, FDA determines based on the totality of scientific evidence, that there is a reasonable belief that the test may be effective in diagnosing patients, and the known and potential benefits outweigh the known and potential risks, rather than waiting to grant full marketing authorization when it has reasonable assurance that the product is safe and effective.
FDA recognized the need to quickly detect the spread of COVID-19, and the first EUAs issued were for COVID-19 tests in February 2020,1,2 allowing them to be deployed much quicker than under traditional premarket pathways. FDA faced criticism over public perceptions that surrounded COVID-19 testing ranging from the amount of time to development and availability, to the validity of tests. However, there were underlying reasons for these challenges including supply chain shortages of materials needed to develop and perform tests, unprecedented EUA volume, and inexperienced test developers.
Prior to the declaration of the PHE, FDA took actions to advance development of diagnostic tests to control the emergence and spread of COVID-19. To support early engagement with EUA requestors, FDA began proactively coordinating EUA related activities including the development of voluntary EUA review templates, interactive review with requestors, policy development, initiating the development of reference materials, and external communications. Such initial efforts required internal coordination across the Center and were made possible by policies and procedures put in place during prior PHEs. In January 2020, FDA reached out to requestors with previous EUA experience to solicit interest in development of a COVID-19 test. In addition, FDA reached out to requestors with existing authorized tests for similar viruses to ask that they conduct analyses to determine whether their tests could be used to detect COVID-19. Figure 1-1 outlines the key actions FDA took to provide guidance and flexibility to test developers, communicate regularly with EUA requestors, implement prioritization and efficiency efforts, and develop tools and templates.
**Figure 1-1. Key Actions in FDA’s Response to Development and Authorization of COVID-19 Tests**
_Horizontal timeline spanning January 2020 through April 2021, with milestone markers organized across four action categories — Created Multiple Pathways & Notification Process, Established Communication Channels, Implemented Prioritization & Process Efforts, and Developed Tools & Templates — plus HHS Actions, showing key dates such as the PHE declaration (1/31), mailbox establishment (2/20), Town Hall launch (3/2), and content screen implementation (11/30)._
\* FDA first posted notice of template availability on its website on 1/27/2020. See Figure 3-1 for additional EUA template milestones.
\*\* Policies A through D are outlined in FDA’s “Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency.” See Table 3-1 for descriptions of each policy.
## 2\. METHODOLOGY
In this assessment, Booz Allen used quantitative and qualitative data analysis, as well as stakeholder interviews, to evaluate CDRH’s response to COVID-19.
This independent assessment focused on the EUA process for COVID-19 diagnostic tests and how the Agency prioritized the processing of the EUA requests, review times, accuracy and reliability of the COVID-19 tests, a comparison to prior PHEs, and requestors’ perspectives as outlined in Table 2-1. There are a variety of different types of tests (i.e., molecular, antigen, and serology) and each are used for different purposes. Molecular tests are preferred for diagnosis and are the primary focus of this report.
The goal of the assessment is to evaluate FDA’s response, better understand challenges, and propose potential recommendations for consideration. Booz Allen gathered quantitative and qualitative data from CDRH points of contact, internal and public-facing documentation, and stakeholder interviews. These data were used to develop the findings and recommendations in this report.
**Table 2-1. Assessment Objectives**
| Assessment Objective | Description |
|---|---|
| Prioritization | Evaluate how the Agency prioritized the processing of EUA requests and actions taken to facilitate the development, validation, and authorization of COVID–19 diagnostic tests, including:
• Modified processes and policies including postmarket monitoring
• Communications and interactions with EUA requestors
• Triage process
• Process improvements |
| Review Times | Evaluate Agency review times for EUAs over the course of the pandemic and assess causes and challenges |
| Accuracy and Reliability | Report on the accuracy and reliability of diagnostic tests, particularly real-world, postmarket performance |
| Comparative Response | Evaluate how the Agency’s response to EUAs for COVID-19 tests compares to prior PHEs |
| Requestor Perspectives | Evaluate EUA requestor perspectives of what has worked well compared to previous PHEs and what can be improved |
||
## 3\. ASSESSMENT FINDINGS
Booz Allen evaluated CDRH’s COVID-19 response, including actions to facilitate the development, validation, and authorization of COVID-19 diagnostics. For each report section, we describe the approach taken by CDRH, how these actions compare to those during previous PHEs, and challenges and successes noted by stakeholders.
### 3.1 Approach to development, review, and authorization of COVID-19 tests
**POLICY DEVELOPED TO ADDRESS COVID-SPECIFIC CHALLENGES**
**Created Notification Process to Provide Flexibility**
To help accelerate the development and availability of COVID-19 tests, CDRH issued guidance3 on February 29, 2020\. This guidance described a policy for diagnostic tests developed by Laboratories certified to perform high complexity testing under the Clinical Laboratory Improvement Amendments (CLIA), Policy A, shown in Table 3-1. The guidance described a unique notification policy to address the urgent need for diagnostic tests by allowing developers to offer certain tests prior to submitting their EUA request and while their EUA request was under review. The notification process established in February called for laboratory developers to: validate their test, notify FDA of their intent to offer tests, include a statement in the test report that the test was not reviewed by FDA, submit an EUA request containing test performance data within a reasonable period of time (e.g., 15 days), and confirm results for the first five positive and first five negative clinical specimens with an authorized test. Where this notification process is used, FDA explained it did not intend to object to the use of these tests.
Through an update on March 16, 2020, CDRH developed more policies to provide flexibility for additional circumstances, types of developers, and types of tests, shown in Table 3-1. Policy B allowed state authorities to take responsibility for authorizing tests developed by Laboratories certified under CLIA that meet the CLIA regulatory requirements to perform high complexity testing in their state; Policy C extended the notification process to Commercial Manufacturers of diagnostic tests, including antigen tests, and recommended that manufacturers publish performance characteristics of their test on their website; and Policy D outlined FDA’s intent not to object to marketing of serology tests from Commercial Manufacturers or Laboratories who validate their test, notify FDA of the intent to offer the test, and include statements in the test report indicating the test has not been reviewed by FDA and should not be used to diagnose or exclude severe acute respiratory syndrome coronavirus 2 (SARS-CoV-24) infection. The March 16, 2020 update also broadened flexibility to modifications of authorized tests. Under this update, FDA stated that it did not intend to object to High Complexity Laboratories using a modified version of an already authorized test without a new or amended EUA request, provided that the modification was validated with a bridging study.5 In addition, FDA did not object to immediate implementation of modifications to EUA-authorized tests from any manufacturer where validation data supporting the modification had been submitted to FDA while FDA conducted its review.
Policy D was intended to accelerate the availability of serology tests to advance the scientific community’s study and understanding of COVID-19, but a concerning number of notified serology tests demonstrated poor performance and some tests were marketed with misleading claims. In response, CDRH updated their policy on May 4, 2020 to reflect that EUA requests were expected for serology tests from Commercial Manufacturers within 10 days of notification to ensure that claims and performance were independently assessed. CDRH established a notification list following the initial publication of the guidance6 and published a public removal list7 to provide transparency and address questions on the status of tests following the May 4th update. If the requestor does not submit an EUA request within a reasonable period of time, or CDRH identifies significant problems with a test, CDRH would intend to remove the test from the notification list and take additional actions, as necessary.
**Table 3-1. Overview of Policies Outlined in Guidance to Expand Access to for COVID-19 Tests**
| Policy | Date Introduced | Date Updated | Developer | Test Type* | Key Point |
|---|---|---|---|---|---|
| Policy A | February 29, 2020 | N/A | High Complexity Laboratories | Molecular | Notification process created
EUA request expected within 15 days |
| Policy B | March 16, 2020 | N/A | High Complexity Laboratories | Tests for COVID-19 | States could take responsibility for authorizing tests from High Complexity Laboratories
EUA not expected |
| Policy C | March 16, 2020 | N/A | Commercial Manufacturers | Molecular and Antigen | EUA request expected within 15 days
Notification process was extended to Commercial Manufacturers |
| Policy D | March 16, 2020 | May 4, 2020 | Commercial Manufacturers and High Complexity Laboratories | Serology | Following May 2020 revision, EUA request became expected within 10 days for Commercial Manufacturers but not for High Complexity Laboratories |
||
\*Excluding at-home testing and specimen collection
On March 31, 2020, CDRH used another novel mechanism created earlier in the pandemic, the Umbrella EUA, to further streamline the authorization process for certain tests, shown in Table 3-2. This mechanism creates efficiency by allowing FDA to quickly authorize multiple similar devices under pre-specified conditions of use. By using the same Letter of Authorization and fact sheets, CDRH can eliminate layers of review while maintaining the same standards for authorization as the individual device. The first Umbrella EUA for tests allows FDA to authorize multiple molecular-based tests developed and performed by Laboratories certified under CLIA to perform high complexity tests under a single EUA.
**Table 3-2. Overview of Umbrella EUAs for COVID-19 Tests**
| Date Introduced | Date Updated | Developer | Test Type | Key Point |
|---|---|---|---|---|
| March 31, 2020 | N/A | High Complexity Laboratories | Molecular | Eligible tests may be added to the Appendix of the Umbrella EUA |
| April 28, 2020 | Revoked July 21, 2020 | Commercial Manufacturers | Serology | Eligible tests that have been independently validated may be added to the Appendix of the Umbrella EUA^8 |
| April 20, 2021 | N/A | Developers of Certain Authorized Molecular Diagnostic Tests | Molecular | Amends the authorization of certain previously authorized tests to include pooling and serial screening (i.e., pooled specimens for screening asymptomatic individuals when used as part of a serial testing program) |
||
Table 3-3 illustrates the number of requestors with tests authorized in an Umbrella EUA as of May 21, 2021\. FDA authorized 38 molecular Laboratory Developed Tests (LDT) under this mechanism, representing approximately 14% (38/281) of all authorized molecular tests. On April 28, 2020, less than a month after creating the Umbrella EUA for molecular LDTs, CDRH subsequently issued an Umbrella EUA for serology tests. The Umbrella EUA for serology tests was revoked on July 21, 2020 given concerns that the scope of the Umbrella EUA was too restrictive of the test performance and claims. Instead, FDA authorized Individual EUAs for these tests since this allowed for broader indications and scopes of authorization, individualized conditions of authorization to address any issue unique to a specific test, and more streamlined EUA amendments such as additional uses that would not fall under the Umbrella EUA.
**Table 3-3. Use of Individual and Umbrella EUAs**
| Test Type | EUA Type | Number of EUAs Issued* |
|---|---|---|
| Molecular test | Individual | 243 |
| Molecular test | Umbrella | 38^9 |
| Antigen test | Individual | 25 |
| Serology test | Individual | 79 |
||
*\*As of May 21, 2021*
**Continued to Update Policy to Address Evolving Needs**
CDRH continues to adjust authorization policies and make updates when appropriate. For example, on March 16, 2021, CDRH published a new supplemental template that outlined a streamlined path to authorization for COVID-19 tests for screening with serial testing. Approximately two weeks later, FDA issued the first five authorizations for serial screening tests, including non-prescription tests for fully at-home use. In April 2021, FDA issued a pooling and serial testing umbrella amendment10 that streamlined the approach to adding pooling and serial screening claims to certain authorized tests.
An emerging need identified by requestors was guidance on transitioning an EUA-authorized test to a full marketing authorization under traditional pathways (e.g., De Novo, 510(k)). FDA discussed this topic and lessons learned from past PHEs at a February 2020 workshop hosted by the Medical Device Innovation Consortium (MDIC) and announced plans in November 2020 to develop a draft guidance on transitioning COVID-19 tests authorized under EUA. On March 17, 2021, one test received a full marketing authorization via the De Novo pathway, which established special controls and opened the 510(k) pathway for other COVID-19 molecular tests.
**Developed Templates to Streamline Submission Process**
CDRH developed voluntary templates to support developers with EUA requests, as was done in prior PHEs (e.g., Zika virus). Ten EUA templates were developed to support various test types and developers,shown in Figure 3-1. The templates help organize the EUA request and outline recommendations for the submission package. In addition, the templates provide specific recommendations on analytical and clinical validation (e.g., number of clinical specimens recommended for evaluation). These templates also form the basis for CDRH’s internal review memos, streamlining the review process as well as the submission process.
The templates were initially available upon request, which allowed CDRH to track who was developing tests and provide this information to government partners such as the Biomedical Advanced Research and Development Authority (BARDA). On February 29, 2020, the same day that FDA issued guidance, FDA made the template available on its website to support its new notification policy. As CDRH gained experience with reviewing EUA requests for specific test types and noticed certain information was commonly missing in submissions, they revised the templates to include more specific details about test validation. Templates were revised a total of 11 times as of April 12, 2021\. These templates also expanded over time to address different testing scenarios that increased access and availability of testing.
**Figure 3-1. Submission Templates Published**
_Horizontal timeline spanning January 2020 through April 2021, showing publication and update dates for ten EUA submission templates covering molecular diagnostics, serology, antigen, home specimen collection, and non-laboratory-use test types for both Commercial Manufacturers and Laboratories._
**STAKEHOLDER PERSPECTIVES AND LESSONS LEARNED**
To help inform current and future public health needs, Table 3-4 outlines stakeholder perspectives and lessons learned on the approach to development, review, and authorization of COVID-19 tests. Stakeholders included a mix of experienced/inexperienced firms, small and large companies, multiple technologies and Laboratories as well as Commercial Manufacturers, and developers with varied previous EUA experience.
**Table 3-4. Stakeholder Perspective on the Approach to Development, Review, and Authorization of COVID-19 Tests**
| Focus Areas | Key Takeaway and Lessons Learned |
|---|---|
| Policy | • All stakeholders noted that the templates were helpful resources and often requested additional ones for different test types and developers.
• Stakeholders appreciated FDA’s efforts to gather feedback on the templates.
• Some stakeholders noted changes in the guidances were hard to follow. For example, there was confusion regarding some of the nuanced CLIA laboratory certifications and the state-based authorization processes listed in Policy B.
• Stakeholders identified the need for guidance on transitioning an EUA-authorized test to full marketing applications (e.g., De Novo, 510(k)).
• Stakeholders provided input on ways to communicate and incorporate continuous improvements to the templates. For example, stakeholders indicated that definitions (e.g., low positive sample, high sensitivity) were not the same across the templates, causing some stakeholders to refer to multiple templates to determine all information needed. |
||
### 3.2 Approach to process improvements and review times
**IMPLEMENTED PROCESS CHANGES TO KEEP PACE WITH EVOLVING NEEDS AND INCREASING SUBMISSION VOLUME**
**Developed CDRH-specific Standard Operating Procedure to Define Roles and Enhance Review Efficiency**
Prior to the COVID-19 pandemic, the FDA had in place an Agency-wide Standard Operating Procedure (SOP) for EUAs used during previous PHEs. CDRH has followed this SOP from the beginning of the outbreak. As part of CDRH’s 2018-2020 strategic priorities, CDRH had engaged in a process improvement effort for all major business processes, including for CDRH’s portion of the EUA process. These efforts were still ongoing when the pandemic began and did not take into consideration a scenario in which the volume of EUA requests approached that seen during the COVID-19 pandemic. In the Spring of 2020, CDRH determined that a more detailed Center-level SOP was needed to manage COVID-19 EUA requests due to the higher volume of EUA requests compared to prior PHEs and to reflect CDRH-specific processes put in place during the COVID-19 PHE (e.g., electronic submissions through the public inbox). Taking into consideration the lessons learned from the 2019 business process improvement effort and experience with EUA requests in the COVID-19 pandemic, CDRH implemented a CDRH EUA Pilot Process SOP on July 10, 2020 to more clearly outline CDRH staff roles and responsibilities and consistent processes to follow for EUA review in CDRH.
**Developed Prioritization Factors and Implemented Processes to Address Growing Backlog**
At the beginning of the pandemic when there were relatively few diagnostic tests authorized, the Center’s priority was to rapidly increase the availability of tests, which meant that every test was a priority. CDRH staff were able to interact closely with most developers, including requestors who submitted incomplete requests and those who had little to no prior experience with EUAs or FDA. As the number of tests available and in development increased and the state of the pandemic changed, the early levels of interaction were unsustainable and necessitated the development of prioritization factors shown in Table 3-5 to best utilize the available CDRH resources for the public health need. Prioritization factors were implemented internally and discussed at weekly Town Halls in Spring 2020\. In the context of tests offered through the notification policies described above, FDA focused on tests for which an initial review identified performance or safety concerns. In such cases, FDA made it a priority to work with the developer to address the concerns or stop testing. In early October 2020, factors FDA considers in prioritizing review of EUA requests were posted on FDA’s website12 through Frequently Asked Questions (FAQ) and further discussed during the weekly Town Hall sessions. CDRH identified a series of process improvements to support prioritization and efficiency, which are described below in the next sections.
**Table 3-5. COVID-19 Test Prioritization Factors**
| Factors | Description |
|---|---|
| Increases Testing Capacity | Tests for which there is a capacity for large-scale manufacturing, distribution, or processing (e.g., high-throughput tests, high product volume tests), or that reduce reliance on limited testing supplies (e.g., saliva-based tests) |
| Expands Test Accessibility | Tests with increased availability or convenience because of where they can be performed (e.g., Point-of-care (POC) tests, home collection devices, at-home tests) |
| Reduces Real-World Performance Concerns | Tests that were being offered under a notification policy and for which FDA identified performance concerns |
||
**Implemented Process Changes**
In Fall 2020, CDRH introduced a number of process changes to try to address the growing backlog of EUA requests and help focus Center resources. These changes included alignment with the structure of CDRH’s standard review processes for other regulatory submissions. In addition, updates to the pilot SOP enabled reviewers to more efficiently deal with incomplete submissions (i.e., close files with requests for information), allowing them to focus on submissions with complete information that could move quickly through the authorization process. If files were closed with requests for information, requestors could provide the requested information in response for FDA to review.
*Front-End Triage*
Beginning in Fall 2020, CDRH instituted a front-end triage and prioritization process for all EUA requests to help focus Center resources on tests that were deemed to have a significant impact on the PHE, such as those that would increase testing accessibility or capacity. Staff use this process for all Pre-EUA and EUA requests soon after they are logged into CDRH’s IT systems and assigned a Lead Reviewer. Given the substantially higher submission volume received during this pandemic compared to prior PHEs, having a formal set of prioritization factors was necessary to evaluate the potential scope and urgency of each request.
*Deprioritization Processes*
To complement the front-end triage process, CDRH introduced streamlined mechanisms to quickly Decline to Issue tests that had significant validation problems and Decline to Review low-priority files such as those that were highly manual, low-volume tests. Prior to implementation, CDRH processed all negative decisions for tests as Denials, which were issued by the FDA Chief Scientist. These deprioritization processes (i.e., Decline to Issue and Decline to Review), introduced in Spring 2020 and streamlined for IVDs beginning in October 2020,13 was designed to allow CDRH to more easily process these files when requests were not a priority (or were deemed to not have an impact on the PHE), did not have sufficient information to evaluate whether they met the EUA criteria, or had validation or performance issues (and were not being offered under a notification policy). In the case of low-priority tests (e.g., because they were low throughput or low manufacturing capacity), CDRH would Decline to Review the file and close it, communicating the decision and reason why to the requestor. Alternatively, for priority tests with critical deficiencies (e.g., inadequate or missing performance data) that the requestor was unable to resolve in a reasonable period of time, CDRH would Decline to Issue the EUA, notifying the requestor and providing them with a list of deficiencies that had been identified. Requestors could choose to address the outstanding concerns in a follow up to the submission. Both options provided a mechanism for reviewers to focus on relatively high-priority (i.e., high-impact) and comparatively complete EUA requests that were going to make an impact on the PHE.
Following HHS’s August 2020 statement14 announcing its updated policy that FDA would no longer require premarket review of any LDTs (including those for COVID-19) absent rulemaking, CDRH Declined to Review over 200 LDT EUA requests in October. Given that LDTs could be marketed without an EUA and also the high volume of other EUA requests, this action allowed CDRH to focus valuable resources on priority tests that could not be offered without FDA review and authorization (e.g., home collection tests, POC tests, multi-analyte panels).
*Supply Chain Monitoring*
Beginning early in the pandemic, global manufacturing and distribution supply chains experienced strain, especially in response to demand increases, which had a substantial impact on certain medical devices. Recognizing this, FDA proactively reached out to medical device companies in February 2020 to monitor the supply chain for signs of shortages. Provisions in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (enacted March 2020\) further strengthened the Agency’s early response by providing FDA with new statutory authority to require manufacturers to notify FDA about changes in the production of certain devices to mitigate public health impacts of shortages. In addition, CDRH established a Medical Devices Shortages Mailbox for manufacturers to report interruptions, shortages, and discontinuances of devices critical to the pandemic, and additionally conducted outreach to other U.S. government agencies, trade groups, hospital systems, and non-profit organizations to determine supply and demand issues. Leveraging this network, FDA identified 11 shortages related to testing, which are published on their website.
As the pandemic progressed, CDRH began to operationalize the information gathered from its monitoring network. Supply chain issues were discussed during daily huddles to inform current review priorities. The CDRH Office of Strategic Partnerships and Technology Innovation (OST) also played a key role in supply chain activities by initially providing analysis of products flagged by review teams as possibly experiencing a supply shortage. Eventually, both the analytical process and the output data from it were formally incorporated into CDRH’s overall EUA review process in the form of a consult service (part of the front-end triage process) and internal shortage dashboard, complementing the public-facing shortage list, enabling CDRH to prioritize submissions experiencing supply chain issues. For example, information obtained by OST informed CDRH’s response to nasal swab shortages, allowing CDRH to pivot and prioritize tests that used saliva specimens.
*Review Tracks*
In Fall 2020, CDRH developed two review tracks for EUA requests: an Express Track and Standard Track. Tests eligible for the Express Track included those for which there was a critical need (e.g., no alternatives available, including other EUA authorized devices) or the subject device is significantly better in terms of improved performance or safety compared with the alternatives. This allowed the most impactful devices to be reviewed not only first, but more quickly as each track had its own review milestone goals. Generally, files on the Express Track are not closed with requests for information but instead information is requested interactively. The goal is for the review team to make recommendations within 30 days. Files on the Standard Track follow a similar review process, although these submissions are lower in the queue, may be closed with requests for information if additional information is needed that cannot be provided in a timely manner, and have a longer final recommendation goal (i.e., 60 days). Regardless of the review track, recommendations from the Office of Health Technology 7 (OHT7) for authorization or denial are sent to the Office of the Chief Counsel (OCC) and the Office of Counterterrorism and Emerging Threats (OCET) for review, and OCET provides the final sign off on such decisions. Decisions to Decline to Issue an EUA are signed off by OHT7.
*Content Screen and Closing with Requests for Information*
CDRH observed that some EUA requests frequently lacked information that was recommended in publicly available documents (e.g., EUA guidance or templates). As a result, the Center implemented a content screen in Fall 2020\. Occurring after the front-end triage and prioritization process, these screens follow a checklist to determine if various criteria are met, including administrative (e.g., the submission is written in English and a description of the product and its intended use) and technical requirements such as the inclusion of a device description and performance data (e.g., evaluation using clinical specimens). These screens were implemented to identify EUA requests with sufficient information for review that could quickly move through the EUA process as well as requests with major issues that could not be addressed quickly. In such cases, FDA closed the files with requests for information, which the requestor could provide in an amended submission. By reducing the need for lengthy back-and-forth interactive review of submissions missing basic information, this provided staff with the opportunity to focus their time reviewing high-impact devices with complete submissions. Of the Original IVD EUA requests CDRH received since implementing the content screen, about two-fifths (144/357) of the files did not pass the content screen (as of April 23, 2021). Ultimately, CDRH intends to use the results of these content screens, noting specifically which information is most frequently being missed or requirements not followed, to inform an update to the interactive review templates, emphasizing and clarifying CDRH’s expectations.
**VARIOUS FACTORS IMPACTED REVIEW TIMES OVER THE COURSE OF THE PUBLIC HEALTH EMERGENCY**
**Allocation of Staff to Support COVID-19 Response**
As the PHE progressed, CDRH continued to receive a high volume of EUA requests, regular workload continued to accrue, and inexperienced EUA requestors required extensive support from FDA. These challenges led FDA to develop processes to refocus resources from lower impact EUA requests to higher impact EUA requests. Additional reviewers were allocated to help address the COVID workload and support the response. Some came from within OHT7, but CDRH also leveraged reviewers from other offices and hired term employees. The specialized nature of IVD scientific expertise and regulatory experience limits how quickly a large volume of staff can be quickly or easily trained in this area. Training of reallocated staff requires time from the IVD specialists which pulls them away from review work.
**Figure 3-2. Percentage of OHT7 Working on COVID-19**
_Bar chart showing the monthly percentage of OHT7 staff working on COVID-19 from April 2020 through March 2021, with values rising from around 62% in Spring 2020 to 84% by February–March 2021._
*excludes Division of Radiological Health and Division of Mammography Quality Standards
The number of staff conducting review of COVID-19 tests fluctuated throughout the pandemic. In Spring 2020, CDRH directed some reviewers of other medical devices from other offices to focus on COVID-19 work. In Fall 2020, additional IVD reviewers performing non-COVID-19 work were shifted to focus on review of COVID-19 tests. Figure 3-2 shows a representative piece of the larger picture, showing the percentage of OHT7 staff (excluding the Division of Radiological Health and Division of Mammography Quality Standards) working on the COVID-19 response.16 These data include review and non-review work, but they do not indicate the percentage of a *person’s time* dedicated to COVID-19. Data were not available for contractors or staff from other Offices of Health Technology (OHTs) or Centers who provided OHT7 with assistance in the review of COVID-19 tests.
Reallocating staff and resources from product areas less impacted to those with increased submission volume presents a trade-off in meeting other priorities, even with others picking up extra non-COVID-19 work to support the response. This has resulted in review delays for non-COVID-19 work, and CDRH is declining to review IVD pre-submissions that are not related to COVID-19, companion diagnostics, a breakthrough designation, or significant public health impact.
**Submission Volume Surpassed All Prior PHEs**
As of April 2021, CDRH reviewed and closed out over 2,000 EUA requests, including Original EUAs and Supplements (i.e., requests for revisions to previously authorized tests), Authorizing or Acknowledging 812 requests as of April 12, 2021\. Acknowledged decisions reflect files where CDRH concurs with changes in Supplements or Amendments that do not require an update to the Letter of Authorization (e.g., addition of a new laboratory instrument, extraction method, or sample type). Supplements that result in changes to the Letter of Authorization are reauthorized by OCET and include changes that commonly involve new indications such as home collection or screening. The number of Original Authorized EUA requests (360) dwarfs the number of tests authorized during all previous PHEs combined (Figure 3-3). Figure 3-4 shows the trends in authorization by month. In addition to these authorized tests, several tests had submitted notification to FDA and were marketing their tests while FDA reviewed their EUA requests. This substantially increased the volume of available tests, particularly in Spring 2020.
**Figure 3-3. Authorized IVDs During Previous PHEs**
_Bar chart comparing the number of authorized IVDs across seven PHEs, with prior emergencies ranging from 1 to 20 authorizations each, dwarfed by COVID-19's 360 authorized Original EUAs._
*IVDs includes serology, molecular, and antigen tests. Prior PHE values represent authorized devices. COVID-19 value represents authorized Original EUAs. Data as of April 12, 2021.
**Figure 3-4. EUA Authorizations and Acknowledgements by Month**
_Bar chart showing monthly EUA authorization and acknowledgement counts from February 2020 through March 2021, with separate series for all test types and molecular-only, peaking at 104 total authorizations in September 2020._
*Includes authorized Original EUAs and Supplements. Time is month FDA made decision, not month submitted. Data as of April 12, 2021.
Table 3-6 shows a breakdown of decisions made on EUA requests, both for all COVID-19 test types (i.e., including molecular, serology, and antigen) as well as molecular diagnostics in particular since they represented the majority of CDRH’s files reviewed. As of April 12, 2021, 2,133 EUA requests were closed out. Of these, 61% (1,294) were molecular diagnostic tests, 29% (623) were serology and 9% (199) were antigen tests. Molecular IVD EUA requests were split evenly between Commercial Manufacturers and Laboratories, with more Original requests than Supplements. Overall, molecular tests were Authorized or Acknowledged more and Denied/Declined, Withdrawn, or Closed with Requests for Information slightly less frequently than all tests combined. While only a small percentage of molecular tests were either Denied or Declined to Issue due to concerns with the EUA request (e.g., regarding test validation), CDRH Declined to Review a larger proportion of low-priority files (e.g., low-volume tests) that were deemed to have a smaller impact on the PHE. Withdrawn files were done so at the request of the requestor for a variety of reasons (e.g., after receiving deficiencies from FDA or utilizing the flexible policy that does not require an EUA when bridging to an authorized test).
**Table 3-6. COVID-19 Test EUA Breakdown by Decision**
| Decision | Description | All EUA Requests for COVID-19 Tests n (% of Column Total) | Molecular EUA Requests n (% of Column Total) |
|---|---|---:|---:|
| Authorized or Acknowledged | • Action taken to authorize Original EUA requests and Supplements for changes requiring reissuance of the Letter of Authorization (reauthorization)
• Action taken to acknowledge EUA Supplements for changes that do not require changes to the Letter of Authorization | 812 (38%) | 642 (50%) |
| Closed with Requests for Information | • Action taken to close an EUA request when additional information is needed to support authorization, but it is not readily available; the EUA request may be reopened at a later date if the requestor submits the additional information | 233 (11%) | 109 (8%) |
| Declined to Issue or Denied | • Action taken to close an EUA request with critical deficiencies that the requestor is unable to resolve in a reasonable period of time | 280 (13%) | 83 (6%) |
| Declined to Review | • Action taken to close EUA requests that are a low priority without complete review | 460 (22%) | 315 (24%) |
| Withdrawn | • Action taken to close EUA requests when the requestor voluntarily withdraws their request | 348 (16%) | 145 (11%) |
| Total* | | 2,133 | 1,294 |
||
*\*Data as of April 12, 2021*
Figure 3-5 shows the trend of all files submitted in that month, including Original EUA requests and Supplements, as well as 1,070 Pre-EUA requests. This includes all files received each month between March 2020 and March 2021, including those that have been closed and those that remain under review, and represents the total number (3,672) of COVID-19 IVD submissions for CDRH to review. This demonstrates a large influx in the early months of the pandemic with sustained numbers throughout the Summer, then leveling out in the Winter. As submission volume grew, CDRH pivoted to focus efforts on authorizing tests that would make the largest impact on public health, as described in Section 3.2.
**Figure 3-5. Number of IVD EUA Requests Received by Month**
_Stacked bar chart showing monthly IVD EUA request volumes broken down by Pre-EUA, Original EUA, and Supplement requests from February 2020 to March 2021, peaking at 554 total submissions in April 2020 and declining to around 150–200 per month by Winter._
* These include Pre-EUA requests as well as requests for Original EUAs and Supplements: all test types and all developers. Time is the month submitted, not the month FDA began active review. Data as of June 9, 2021.
† In February 2020, there were 21 Pre-EUA requests and two Original EUA requests received.
**Trends in Review Time**
As shown in Figure 3-6, review times for denied EUA requests were initially much higher than for authorized EUAs, which reflects the many layers of review in the denial process. CDRH implemented its Decline to Review and streamlined Decline to Issue processes for IVD EUAs in October 2020 (as described above), which deprioritized a large volume of low-priority tests and tests with validation or performance concerns, reducing burden on staff and allowing them to focus on high impact submissions. Review times for authorized tests steadily increased during the Fall months, corresponding to the high volume of requests received. In addition, EUA requests for tests available through the notification process were not as highly prioritized as others which were not already in use, unless the triage revealed performance or safety concerns. Review times for authorized tests ultimately decreased and then remained steady throughout the Winter as process improvements were implemented (e.g., content screen, closing incomplete files with requests for information), Center staff were reallocated, and the number of new requests submitted each month began to decrease. Median review times may increase as more files are closed out.
**Figure 3-6. Review Times of Original EUA Requests (Authorized and Declined to Issue or Denied)**
_Bar chart showing median review times in days by month submitted (February 2020–March 2021) for authorized versus declined/denied Original EUA requests, illustrating that denial review times were initially much higher (peaking at 186 days) before dropping after streamlined deprioritization processes were introduced in October 2020._
*These are EUA Originals: all test types and all developers. Time is the month submitted, not the month FDA began active review. Data as of April 12, 2021.
Review times for authorization/acknowledgement of Supplements compared to Originals were relatively fast in the early months of the pandemic, during which there were relatively fewer Supplements received. As developers began to modify their tests (e.g., using saliva as a specimen type, seeking authorization for at-home collection or POC settings for use in asymptomatic patients), review times for both types increased. Although Supplements made up only one-third of EUA requests reviewed for COVID-19 tests, Figure 3-7 shows that Supplements can take as long (if not longer) to review than Original EUA requests. While some Supplements included changes in the device use (e.g., at-home collection or POC settings), others included changes to add instruments, extraction methods, or indications for sample pooling and screening. Validating these changes can involve new clinical and analytical studies, similar to or beyond that of the Original Authorization. Many of these changes were implemented immediately upon submission of validation data to FDA under CDRH’s modification policy. As a result, many Supplements were not high priorities for review.
**Figure 3-7. Review Times of Authorized and Acknowledged EUA Requests (Originals and Supplements)**
_Bar chart comparing median review times for Original versus Supplement EUA requests by month submitted (February 2020–March 2021), showing that Supplements could take as long as or longer than Originals to review, with both peaking in the Fall 2020 months._
*These are EUA Originals and Supplements: all test types and all developers. Time is the month submitted, not the month FDA began active review. Data as of April 12, 2021.
Figure 3-8 and Figure 3-9 show how review times for Original molecular EUA requests varied by month, broken down by decision and manufacturer type. Similar to observations presented in Figure 3-6, denials initially took much longer than authorizations for both Laboratories and Commercial Manufacturers, although review times for requests from Commercial Manufacturers tended to be longer compared to those from Laboratories, except during the Summer months. The decrease in review times for tests approaching Fall 2020 highlights the impact the streamlined Decline to Issue process had on review times.This could possibly be explained by the higher number of tests from Laboratories submitted early in the pandemic and certain Laboratories’ relative inexperience in preparing EUA requests. Review times for authorized tests were initially longer for tests from Laboratories than those from Commercial Manufacturers, although they began to converge in the Summer and then the trend reversed in the Fall and Winter months.
**Figure 3-8. Review Times of Original Molecular EUA Requests from Laboratories (Authorized and Declined to Issue or Denied)**
_Bar chart showing median review times for Laboratory-submitted Original molecular EUA requests by month (February 2020–March 2021), with authorized test review times ranging from 1 to 73 days and declined/denied times spiking to 216 days in July 2020 before dropping sharply after the streamlined Decline to Issue process was implemented._
*These are EUA Originals: Molecular tests from Laboratories. Time is the month submitted, not the month FDA began active review. Data as of April 12, 2021.
**Figure 3-9. Review Times of Original Molecular EUA Requests from Commercial Manufacturers (Authorized and Declined to Issue or Denied)**
_Bar chart showing median review times for Commercial Manufacturer–submitted Original molecular EUA requests by month (February 2020–March 2021), with authorized test review times rising from 1 day in February to a peak of 100 days in October 2020, and declined/denied times peaking at 255 days in May 2020._
*These are EUA Originals: Molecular tests from Commercial Manufacturers. Time is the month submitted, not the month FDA began active review. Data as of April 12, 2021.
Figure 3-10 shows a subset of the graph above, comparing review times of Original EUA requests from Commercial Manufacturers and Laboratories that were authorized while overlaying the number of submissions (regardless of test type or decision) submitted in each month. The figure demonstrates the large number of new submissions received each month, particularly at the beginning of the pandemic. The number of EUA requests submitted peaked at over 550 in April, declining into the early Summer, and then becoming relatively stable in October.
**Figure 3-10. Review Times of Original, Authorized, Molecular EUA Requests (Commercial Manufacturers and Laboratories) with Overlay of Number of IVD EUA Requests by Month**
_Dual-axis chart with grouped bars showing median review times for authorized Original molecular EUA requests from Laboratories and Commercial Manufacturers, overlaid with a line showing total monthly IVD EUA request volume peaking above 550 in April 2020._
*Review Time bars are EUA Originals: Molecular tests. Volume line includes Pre-EUAs as well as EUA Originals and Supplements: all test types and all developers. Time is the month submitted, not the month FDA began active review. Data as of April 12, 2021.
Figure 3-11 shows that a greater percentage of Original EUA requests from Commercial Manufacturers were authorized (37%) compared to those from Laboratories (25%). In addition, requests from Commercial Manufacturers were Declined to Issue or Denied (15%) at a higher rate than those from Laboratories (3%). The Decline to Review rate for Laboratories (48%) is higher compared to Commercial Manufacturers (22%) because as the pandemic progressed, LDTs were deprioritized in October 2020 following HHS’ statement on LDTs.
**Figure 3-11. Distribution of Original Molecular EUA Requests by Decision (Commercial Manufacturers and Laboratories)**
_Grouped bar chart showing the percentage of Original molecular EUA requests by decision type — Authorized (25% Labs, 37% Commercial), Declined to Issue or Denied (3% Labs, 15% Commercial), and Declined to Review (48% Labs, 22% Commercial) — highlighting the higher deprioritization rate for Laboratory-submitted requests following HHS's October 2020 LDT statement._
*These are EUA Originals: Molecular tests. Data as of April 12, 2021.
**STAKEHOLDER PERSPECTIVES AND LESSONS LEARNED**
To help inform current and future public health needs, Table 3-7 outlines stakeholder perspectives and lessons learned on the approach to process improvements and review times.
**Table 3-7. Stakeholder Perspective on the Approach to Process Improvements and Review Times**
| Focus Areas | Key Takeaway and Lessons Learned |
|---|---|
| Process and Review Times | • Stakeholders shared positive feedback about interactions with review teams and their dedication to providing support throughout the EUA process.
• Stakeholders relied on direct communications with review teams for updates. Stakeholders shared that they frequently asked about timelines for follow up with reviewers, information on review times, and contacted other groups at FDA (e.g., EUA mailboxes) if they did not hear back from them.
• Stakeholders noted that response times were faster in the beginning and as volume increased, interactions became less frequent.
• Stakeholders asked frequently about prioritization factors, which FDA later posted on their website and discussed during the weekly Town Hall sessions. |
||
### 3.3 Approach to test validation, postmarket actions, and evaluation of real-world test performance
**VALIDATION AND USE OF REFERENCE PANEL TO DEMONSTRATE PERFORMANCE**
**Developed Flexible Validation Process to Establish Performance**
During preparation of EUA requests, requestors must validate their test by conducting a series of studies that demonstrate the product may be effective. These include both analytical studies, for example determining the smallest concentration of virus the test can detect and differentiating between other pathogens, and clinical evaluations, focusing on the real world ability of the test to detect the virus in human samples. CDRH provides recommendations for these studies in guidance, which incorporates each of the ten EUA templates, although developers may propose alternative study designs as long as they adequately demonstrate that the test is accurate and reliable.
Based on experience with prior PHEs, CDRH anticipated some challenges related to test validation. For example, understanding that clinical specimens are difficult to find early in an outbreak, the January 2020 template provided flexibility to validate tests with contrived specimens instead. Contrived specimens can be made with either genetic material taken from the virus itself or from synthetic genetic material matching the virus. FDA later saw that validation with certain types of contrived specimens masked performance issues for some tests.
FDA coordinated (with other U.S. government agencies) shipment of viral material (produced by culturing the virus in a laboratory) to developers working on tests in February 2020\.18 Subsequently, FDA authorized 59 COVID-19 diagnostic tests based on validation data using contrived samples between February and May.19 However, validation with contrived samples is not as robust a validation study as those performed with clinical specimens; as availability of both standardized commercial samples and natural clinical specimens increased, CDRH recommended in a May 11, 2020 policy update that developers obtain and use these for validation.
**Developed Reference Panel to Assess Comparative Performance**
Recognizing the limitations of the type of validation that can reasonably be accomplished early in an outbreak, CDRH has developed reference panels for this and prior PHEs. Reference panels are composed of common, independent, and well characterized reference material that allow for a more precise comparison of the analytical performance of different molecular IVDs.20 CDRH began collaborating with the Center for Biologics Evaluation and Research (CBER) on development of a reference panel for SARS-CoV-2 molecular diagnostic tests in January 2020\. The team obtained viral material when it became available in February 2020\. The reference panels and accompanying protocol for evaluation by test developers became available on May 27, 2020\. More than 1,000 reference panels were produced for SARS-CoV-2 compared to approximately 80 produced for Zika virus, reflecting the difference in scale between the PHEs.
Starting with the first authorization in February 2020, CDRH established conditions of authorization requiring requestors of all authorized EUAs to submit their test’s performance data on FDA-recommended reference materials. Once the reference panel was available, FDA contacted all developers with EUAs to request they evaluate the reference panel per the established condition of authorization. Results were submitted as EUA Supplements and are made available on FDA’s website, allowing comparisons across tests. Once final results were released by CDRH, requestors updated their labeling information with the new performance data and the Supplements were closed. Results were first posted on FDA’s website on September 15, 2020 and last updated in December 2020 (Table 3-8). As of this date, three-quarters of developers either had data currently under review or published on FDA’s website 21 (147/195); just under one-fourth (48/195) had either not provided shipping information or returned data, or had presented uninterpretable data, although no EUAs have been revoked for these reasons.
**Table 3-8. Molecular Diagnostic Reference Panel Results**
| Reference Panel Results Status | Number of Tests* |
|---|---:|
| No shipping information | 17 |
| Data not returned | 26 |
| Data uninterpretable | 5 |
| Under interactive review | 21 |
| Data published | 126 |
| Total | 195 |
||
*\*All data as of December 2020 update*
Development of the molecular reference panel differed from the approach to the evaluation of serology tests, which involved a collaboration beginning in April 2020 with the National Institutes of Health’s (NIH) National Cancer Institute (NCI). One difference in approach was that developers ran the molecular reference panel themselves, but serology tests were sent to NCI so the government could conduct its own evaluation against a standard set of samples. Similar to the molecular reference panel approach, results from the NCI evaluation of serology tests and underlying validation data are made publicly available on FDA’s website22 and openFDA,23 which allows test developers to compare their in-house data to the validated results of other developers’ tests, provides additional information to clinicians, and promotes increased transparency to the public. The partnership with NCI represents a collaborative model that could streamline data analysis and improve the response to future PHEs.
**USING REAL-WORLD EVIDENCE TO CONFIRM TEST PERFORMANCE**
**Established Postmarket Reporting Requirements to Support Monitoring**
CDRH has had to strike a balance between timely access to tests and assurance of real-world test performance. The EUA process allows FDA to authorize tests with less data than typical review pathways, which underscores the importance of postmarket monitoring. Allowing for this type of process underscores the need for reporting mechanisms. The primary way CDRH is able to monitor trends in performance is through the established postmarket reporting requirements communicated to requestors under conditions of authorization in the Letters of Authorization. Requestors are required to have appropriate processes in place and, pursuant to Code of Federal Regulations Title 21 Part 803 and the conditions of authorization, to track and report to FDA adverse events (AEs), including any occurrence of false results (i.e., false positives, false negatives) or any significant deviations from established performance characteristics. Many of the requestors already had and used existing mechanisms in place to report results, which is standard practice for medical devices.
It is unclear how well EUA requestors and their authorized Laboratories are complying with the reporting requirements at this time. For example, authorized Laboratories are required to collect information on test performance and report it to FDA through the designated email inbox CDRH-EUA-Reporting@fda.hhs.gov. As this is a non-traditional reporting mechanism, not all Laboratories have processes in place to do this reporting.
EUA requestors are also required to comply with labeling requirements under FDA regulations, and document where and how many tests have been distributed. In some instances, CDRH required postmarket studies as a condition of authorization in an attempt to provide requestors with some flexibility with their pre-authorization data package (e.g., requiring prospective clinical study when contrived samples were used for validation). The additional data and study requests, which include performing the reference panels as outlined in the previous section, are included in the Letter of Authorization and in some cases also outlined in the EUA templates.
**Conducted Postmarket Surveillance and Enforcement Activities**
Device manufacturers, including those of diagnostic tests, must follow certain conditions of authorization once their products are marketed such as reporting malfunctions and AEs. Surveillance allows FDA to monitor these incoming data and determine what actions, if any, need to be taken in assessing tests’ real-world test performance by reviewing information submitted to identify network signals, evaluate potential risks to the public, and conduct follow up investigations when necessary. These reports contain data from a variety of sources including: (1) Medical Device Reports (MDRs), mandatory AE and device malfunction reports from manufacturers; (2) MedWatch, FDA’s voluntary device safety reporting program for health care providers and consumers; (3) Medical Product Safety Network (MedSun), CDRH’s mandatory AE reporting system for hospitals and other health care facilities; and (4) publicly available reporting mailboxes (e.g., CDRH-EUA-Reporting@fda.hhs.gov). As of May 2021, over 6,000 MDRs have been reported for COVID-19 tests, each including information about the device, who reported it, and the problem experienced (e.g., false positive/negative). CDRH reads incoming reports daily and conducts weekly analysis to identify potential trends or emerging safety issues. As more COVID-19 tests were authorized, CDRH observed a steady increase in report submission starting in Summer 2020 (between 650 and 1,050 reports per month); to handle the increase in volume, the Center reallocated resources from other areas and implemented process improvements (e.g., automating part of the data entry process to summarize MDRs).
Surveillance efforts can lead to postmarket actions (e.g., EUA revocation, removal from the notification list, Warning Letters issued). Many of these postmarket activities pertain to serology tests and were informed by real-world performance identified by CDRH’s surveillance activities. A breakdown of all the actions and communications taken by CDRH as of June 11, 2021 during the PHE are summarized in Table 3-9.
**Table 3-9. EUA Postmarket Actions**
| Postmarket Action/Communication | Description | Number^24 |
|---|---|---:|
| EUA Revoked | The criteria for issuance are no longer met or other circumstances make such revocation appropriate to protect the public health or safety. | 3^25 |
| Notification Removal List – Laboratories with Diagnostic Tests | Diagnostic tests developed by Laboratories and offered under the notification policy that may have significant problems that cannot be addressed in a timely manner and should no longer be used. | 2 |
| Notification Removal List – Commercial Manufacturers with Diagnostic Tests | Diagnostic tests developed by Commercial Manufacturers and offered under the notification policy that may have significant problems that cannot be addressed in a timely manner and should no longer be used. | 18 |
| Notification Removal List – Commercial Manufacturers with Serology Tests | Serology tests developed by Commercial Manufacturers and offered under the notification policy that may have significant problems that cannot be addressed in a timely manner and should no longer be used. | 266 |
| Warning Letters | Letters sent to developers that have adulterated or misbranded products related to COVID-19. | 36 |
| Letters to Health Care Providers | Letters sent to health care providers about safety concerns and recommendations for medical devices used in health care facilities. | 7 |
| Safety Communications | FDA posts Medical Device Safety Communications to describe FDA’s current analysis of an issue and contain specific regulatory approaches and clinical recommendations for patient management. | 4 |
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One of the postmarket actions taken is the revocation of an EUA. This has resulted primarily due to the criteria for issuance of authorization no longer being met (e.g., the known and potential benefits of the product no longer outweigh the known and potential risks, such as due to poor performance) or the availability of adequate approved alternatives(e.g., as a result of subsequent premarket authorization through 510(k) clearance, De Novo classification, or PMA approval). For example, two EUAs for serology tests for COVID-19 have been revoked. CDRH notified the requestors of poor performance issues between the NCI evaluation of serology tests and the clinical and analytical data submitted with their applications. The requestors were provided an opportunity to provide information to refute FDA’s findings. Once a decision was made to revoke the EUA, the requestor was notified via letter and notice of the revocation was published in the Federal Register. This process thereby removes the ability of the test to be legally marketed and further informs the public of FDA’s intent to take strong action against poor-performing tests. The previous PHEs also had a small number of tests revoked due to performance issues: one antigen test for Ebola and one molecular test for Zika virus.
**Collaborated on Real-World Evidence Generation**
CDRH participated in various collaborations focused on gathering and analyzing real-world data (RWD) and real-world evidence (RWE) to help inform its COVID-19 response. Table 3-10 describes ongoing collaborations with stakeholders from the medical device industry, academia, non-profit organizations, and other U.S. government agencies that seek to better understand how to use data to improve testing quality and incorporate data into evaluation of COVID-19 diagnostic and antibody tests to better inform population testing strategies and understand patterns of disease transmission.
**Table 3-10. Collaborations to Evaluate the Potential Application of RWE During a PHE**
| Collaboration | Partners | Research Objectives | Anticipated Outcomes |
|---|---|---|---|
| Systematic Harmonization and Interoperability Enhancement of Lab Data (SHIELD) | Federal agencies, industry, Laboratories, Electronic Health Record vendors, standards developers, academia | Promote harmonized application and implementation of diagnostic data standards | Enable rapid data sharing between different data sources to facilitate evaluation of RWD/RWE |
| Diagnostic Evidence Accelerator | Reagan Udall Foundation, Friends of Cancer Research | Encourage collaboration and development of data linkages within the research community, critically discuss findings from different data sources, and develop key research questions that multiple teams can address simultaneously | Provide actionable information on specific populations and highlight individual risk factors for patients, improve the understanding of disease to tailor public health interventions and strategies to mitigate risk, identify supply chain issues, and provide RWE of test performance |
| Informatics-driven real-world analysis of SARS-CoV-2 serologic response and IVD accuracy | Yale University-Mayo Clinic Center of Excellence in Regulatory Science and Innovation | Correlate diagnostic test results with clinical disease using RWD to better understand serologic results | Address questions about the COVID-19 immune response, including how long patients remain infected, the accuracy of serology test methods over time, formation of antibodies, and how long an individual may be immune after infection^27 |
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**STAKEHOLDER PERSPECTIVES AND LESSONS LEARNED**
To help inform current and future public health needs, Table 3-11 outlines stakeholder perspectives and lessons learned on the approach to test validation, postmarket actions, and evaluation of real-world test performance.
**Table 3-11. Stakeholder Perspective on the Approach to Test Validation, Postmarket Actions, and Evaluation of Real world Test Performance**
| Focus Areas | Key Takeaway and Lessons Learned |
|---|---|
| Postmarket Performance | • Stakeholders had questions regarding expectations for test validation and the degree of flexibility in the validation recommendations.
• Stakeholders noted it was helpful to talk through validation study options with reviewers during the Pre-EUA process.
• Stakeholders had many questions around Supplements and Amendments, with common themes including asymptomatic testing, pooling, and at-home/POC validation expectations.
• Stakeholders noted that molecular reference panel was a helpful tool; however, some had technical issues running the panel. Commercial Manufacturers expressed concerns about not having a reference panel until May 2020. International EUA requestors indicated challenges receiving the reference panel.
• Experienced stakeholders leveraged postmarketing reporting processes they already had in place. |
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### 3.4 Approach to communication with requestors, clinical community, and the public
**ESTABLISHED MULTIPLE COMMUNICATION CHANNELS**
**Established Weekly Town Halls for EUA Requestors**
In March 2020, CDRH started to host weekly, hour-long Town Hall meetings as an opportunity for OHT7 Leadership, including the OHT7 Director, to provide updates and answer questions for test developers. By the end of April 2021, CDRH had hosted 53 Town Halls that have been well attended (\>40,000 attendees to date). Transcripts, slides, and recordings of the Town Halls are posted to the FDA’s website, typically within one week after being recorded. The Town Halls are ongoing and provide an opportunity for test developers to have an open dialogue on EUA policies and guidance, tools and resources (e.g., Templates, FAQs, CDRH mailboxes), validation and postmarket performance procedures, test development recommendations, review time expectations and prioritizations. For example, when new policies and policy updates have been announced, such as new or updated guidance documents and EUA templates, FDA has responded to stakeholder questions and concerns about policy implementation. OHT7 Leadership provides specific feedback and directs requestors to reach out to the EUA template mailbox or their reviewer for details on highly technical questions. For example, in response to requestor questions on validation, OHT7 Leadership provides insight into analytical and clinical validation expectations including the number of positive samples developers are expected to evaluate while explaining that these expectations may be dependent on specific details of the test, which may not all be apparent in the brief discussion on the Town Hall. In addition, OHT7 uses the Town Halls as a platform to provide information on CDRH’s review and prioritization processes and test development recommendations. For example, FDA began to encourage development of POC and at-home tests in Summer 2020, and also encouraged the development of multi-analyte panels to prepare for the upcoming flu season. Similarly, OHT7 Leadership has discussed in the Town Halls the significance and limitations of serology tests, and the focus on different types of tests at different stages in the pandemic.
**Created Central Mailbox for Inquiries**
CDRH developed a public-facing email inbox to collect questions from EUA requestors and requests for submission templates, which provided CDRH an opportunity to track the pipeline of interested requestors. In addition, EUA requestors could submit electronic submissions through the mailbox, COVID19DX@fda.hhs.gov, starting February 20, 2020 as opposed to mailing physical submission packages to the Document Control Center. Mailboxes are also a primary way of obtaining feedback from requestors, enabling CDRH to identify communication or expectation gaps and informing future Town Hall topics and template revisions. Between March and May 2020, CDRH received over 120,000 emails to the COVID19DX@fda.hhs.gov inbox. By October 2020, there were over 170,000 inquiries. CDRH deployed two dedicated full time employees and other part-time staff to triage and respond to inquiries, process submissions, and filter submissions to the appropriate contact. The questions received related to how to submit an EUA request, specific data requirements, and how enforcement policies outlined in guidance apply to a specific test. CDRH quickly established additional mailboxes enabling more specialized information to be quickly directed to various stakeholders. By May 2020, CDRH had an EUA template mailbox for Pre-EUA questions, template inquires and general questions about COVID-19 tests, a fraud mailbox to report false labeling, and a SHIELD mailbox for insight into data harmonization and the SHIELD program. As with prior emergencies, CDRH also used mailboxes for external stakeholders (e.g., hospitals, group purchasing organizations) to report shortages in diagnostic test supplies and other supply disruptions.
**Developed FAQs and 24/7 Hotline**
CDRH established several additional mechanisms for communicating with EUA requestors, including a 24/7 phone hotline to communicate expectations for test developers, information related to shortages and alternative supplies, and issues related to safety and test performance. In addition, CDRH posted FAQs on the FDA website to educate EUA requestors on the development and performance of COVID-19 tests. Over 300 FAQs have been posted so far across nine websites (i.e., Notifications and Emergency Use Authorizations, Removal Lists of Tests that Should No Longer Be Used and/or Distributed for COVID-19, Test Development and Review, Test Settings, Test Uses, Test Supplies, 3D Printed Swabs, COVID-19 Related Test Data and Reporting, and Serology/Antigen Tests). The FAQs are updated as needed and include other resources for test developers. For example, FDA has published an interactive Testing Supply Substitution Strategies resource that includes validated supply alternatives that Laboratories can use to continue performing testing when there is a supply issue with some components of a molecular test. As information needs evolved, FDA added websites to cover topics including scientifically valid alternative testing supplies during shortages28 and pooling strategies.
**Communicated Surveillance Information to Developers and Health Care Providers Through Multiple Channels**
In addition to using surveillance efforts to inform postmarket actions, FDA also communicates information about tests and test performance in a variety of ways. These communications convey information on tests’ real-world performance trends to EUA developers, the clinical community, and the general public. FDA communicated this information through Letters to Health Care Providers, Safety Communications, other press releases, weekly Town Halls, and updates to FDA’s website.
Letters to Health Care Providers and Safety Communications are similar communication mechanisms used to provide information about test issues, potential impacts on performance, and recommendations on how these tests should be used. Seven Letters to Health Care Providers have been issued as of June 11, 2021\. The first Letter to Health Care Providers was published on April 17, 2020 on the use of serology tests. These letters are posted to the FDA website in addition to being sent to the health care community. Each one provides background information, recommendations, FDA actions taken, mechanisms for reporting additional problems, and additional information such as linking to the EUA, appropriate FDA websites, and updates on instructions. Safety Communications are similar but are targeted at the general public. Four have been issued as of June 11, 2021\. Both Letters to Health Care Providers and Safety Communications are intended to inform the appropriate audiences on trends to watch for and instruction updates.
FDA has closely tracked the potential impact of emerging viral mutations on COVID-19 test performance by routinely comparing the genetic sequences of each new mutation to the target sequences of currently marketed tests. FDA has publicly posted the tests whose performance could be impacted by SARS-CoV-2 viral mutations, along with general information for clinical laboratory staff and health care providers on the potential for false negatives. As of June 11, 2021, FDA has identified four molecular diagnostic tests for COVID-19 potentially impacted by SARS-CoV-2 mutations.30 FDA has also issued guidance for test developers to evaluate the potential impact of emerging and future viral mutations on COVID
19 tests for the duration of the COVID-19 PHE.
There are a variety of examples where CDRH’s surveillance efforts have detected trends using real-world performance and communicated accordingly. For example, CDRH quickly determined there were inaccuracies with the Abbott ID Now POC tests based on the AE reports received. As a result, CDRH was able to alert the public through a press release and the clinical community through a Letter for Health Care Providers, and to work with Abbott to update the Instructions for Use, all within a month of the test’s Original Authorization. Another example involves Becton, Dickinson and Co (BD) SARS-CoV 2 Reagents for the BD Max System test, which was granted authorization in April 2020\. Analysis of real-world performance data showed a false positive rate of about 3%. CDRH worked with BD to identify the issue and address it through updates to labeling and the Factsheet for Health Care Providers. CDRH also issued a Letter to Health Care Providers on July 7, 2020 alerting them of the potential for false positives and recommending positive results be confirmed with an alternate authorized test.
FDA maintains lists on their website of previously notified tests that should no longer be used and that have been removed from the lists of notified tests. A test may be placed on the removal list for a variety of reasons: (1) failure to submit an EUA request in a reasonable amount of time as outlined in guidance; (2) poor test performance or inadequate validation; and (3) voluntary withdrawal of the EUA request by the requestor. FDA expects that tests on this list will not be distributed unless and until an EUA is issued for the test. This process may also facilitate the withdrawal of poor-performing tests from the market. The vast majority of tests on the removal lists are serology tests, which may be a reflection of serology developers taking advantage of the notification policy to a greater extent than commercial developers of diagnostic tests (i.e., antigen and molecular).
To address an influx of firms marketing fraudulent tests with false or misleading claims, FDA issued Warning Letters to companies for adulterated and misbranded products related to COVID-19. Warning Letters are issued when FDA finds that a manufacturer has violated FDA regulations (e.g., poor manufacturing practices, unsubstantiated claims). These Warning Letters are published on FDA’s website and provide information on the tests and the company that produced it.33 These companies are provided 48 hours to explain how they have addressed their violations. The first Warning Letter for a COVID-19 test was issued on June 10, 2020, and a total of 36 Warning Letters have been issued, as of June 21, 2021, for firms offering violative COVID-19 tests.34 19 of the firms that were issued Warning Letters have ceased marketing of their violative COVID-19 tests. The public is encouraged to submit tips of potential fraud through the appropriate channels like the Fraud Email and Office of Criminal Investigations. FDA stated that it has provided companies with regulatory flexibility but would not tolerate fraud or conduct that puts the health of Americans at risk.
**Communicated with the Public Through Various Mechanisms**
FDA used a variety of communications to increase transparency and understanding of the EUA process. Since January 27, 2020, FDA has issued press releases,36 often daily, with the latest information on COVID-19. These releases cover topics such as key authorizations, descriptions of policy decisions, safety concerns, and guidances. In addition to these press releases, FDA has provided updates through other communication channels. For example, Dr. Jeff Shuren, Director of CDRH, published an article 37 on the “FDA Voices” page on July 21, 2020, describing FDA’s ongoing work to support diagnostic test accuracy and availability. Similarly, FDA published three medical device consumer updates related to COVID-19,38 translated into five other languages, which describe regulatory terminology, potential for fraudulent products, and testing basics. FDA has supplemented these resources with videos and infographics to further clarify information.
FDA has developed communications to promote transparency of real-world test performance to further bolster confidence in the EUA process for COVID-19 diagnostic tests. CDRH publicly posts reference panel results for COVID-19 molecular diagnostic tests on FDA’s website,39 allowing for direct comparison of available tests’ performance for the public. Similarly, results from NCI’s validation studies on serology tests were made public,40 which provides the opportunity to see the objective performance of each test. FDA also shared lessons learned with the public through multiple avenues, including peer-reviewed publications on molecular diagnostic tests41 and antibody tests,42 blog posts of expert opinions on CDRH’s strategy to facilitate COVID-19 test development and authorization,43,44 and a report of FDA’s analysis of South Korea’s COVID-19 response.
**STAKEHOLDER PERSPECTIVES AND LESSONS LEARNED**
To help inform current and future public health needs, Table 3-12 outlines stakeholder perspectives and lessons learned on the approach to development, review, and authorization of COVID-19 tests.
**Table 3-12. Stakeholder Perspective on the Approach to Communication with Requestors, Clinical Community, and the Public**
| Focus Areas | Key Takeaway and Lessons Learned |
|---|---|
| Communications | • Stakeholders shared that frequent communications were beneficial. Specifically, stakeholders found the Town Halls very informative, appreciated the opportunity to ask questions, and often had representation at the meetings to bring back information to their teams.
• Stakeholders leveraged the FAQs and other FDA websites often, many of the EUA requestors kept them bookmarked to frequently check for updates.
• Stakeholders appreciated the convenience of electronic EUA requests and hoped that electronic submissions would be implemented permanently.
• Some stakeholders noted technical issues with file type and size constraints when submitting their EUA request electronically.
• Stakeholders indicated the need for greater clarity on certain issues, specifically: (1) when a change to the test requires filing an EUA Supplement; (2) how to get authorized; and (3) updates to templates since it likely impacts development programs. |
||
## 4\. BEST PRACTICES AND PRIORITY RECOMMENDATIONS
Booz Allen identified areas where CDRH could build on lessons learned and successful improvements as well as priority recommendations to further strengthen the EUA process.
We observed best practices, outlined in Table 4-1, that CDRH should continue to leverage as well as areas for additional improvement to further strengthen and optimize the EUA process.
**Table 4-1. Best Practices Identified by Booz Allen to Support the EUA Process**
| Focus Area | Best Practices |
|---|---|
| Best Practices | • Rapid updates to guidance and policy regarding different test types and developers, allowing CDRH to strike a balance between urgent need for tests and assurance of test performance
• Use of publicly available templates to provide guidance on the EUA requests and continue to gather feedback from stakeholders on the templates
• Factors to prioritize submission review, including test capacity, accessibility, novelty, and supply chain considerations, to focus review resources on the most impactful requests
• Development and required use of a reference panel for assurance of performance
• Collaboration on validation and performance testing; generation and evaluation of RWD; and supply chain monitoring
• Hosting Town Halls to communicate interactively and frequently
• Electronic submission to facilitate the process for EUA requestors |
||
Table 4-2. outlines priority recommendations that would allow FDA to capitalize on its previous success, enhance current processes and procedures, and facilitate the next steps to strengthen FDA’s public health infrastructure to respond to future PHEs.
**Table 4-2. Priority Recommendations Identified by Booz Allen to Support the EUA Process**
| Key Observation | Priority Recommendation | Intended Impact |
|---|---|---|
| Precise tracking of new review metrics was encumbered by the IT system, which is not optimized to account for updated EUA processes | Consider ways to optimize the IT system to account for EUA processes | Fully automate submission and tracking of EUA requests (e.g., linking Pre-EUA to EUA; lags while awaiting additional information from requestors; lags due to backlog or priority designation) to provide more comprehensive picture of review time from EUA submission to decision for review efficiency, performance monitoring, prioritization, process improvements, and workload management |
| The approach to staff allocation was difficult to systematically quantify and analyze, making it difficult to determine what events or criteria triggered shifts in staff and how shifts were coordinated to address the triggering event or criteria | Consider developing a systematic approach (i.e., strategy and plan) for allocation and tracking of staff during PHE | Quick determination of staffing needs and deployment of the right staff to the right place at the right time to maximize review efficiency. Identification of most likely areas for future PHEs (e.g., emerging infectious diseases) and development of process for cross-training to prepare a subset of staff in those areas in the event of a PHE |
| There was limited understanding in the test developer community on how to appropriately validate a diagnostic test | Consider developing a framework for how to conduct validation of diagnostic tests for emerging pathogens in the setting of a declared PHE | Earlier access to appropriate, effective diagnostic tests |
||
## 5\. APPENDIX
### 5.1 Glossary
**Table 5-1. Glossary of Abbreviations and Acronyms**
| Abbreviation or Acronym | Definition |
|---|---|
| AE | Adverse Event |
| BARDA | Biomedical Advanced Research and Development Authority |
| BD | Becton Dickinson |
| CBER | Center for Biologics Evaluation and Research |
| CARES | Coronavirus Aid, Relief, and Economic Security |
| CDRH | Center for Devices and Radiological Health |
| CLIA | Clinical Laboratory Improvement Amendments |
| COVID-19 | Coronavirus Disease 2019 |
| EUA | Emergency Use Authorization |
| FAQ | Frequently Asked Question |
| FD&C Act | Federal Food, Drug, and Cosmetic Act |
| FDA | Food and Drug Administration |
| HHS | Health and Human Services |
| IDE | Investigational Device Exemption |
| IO | Immediate Office |
| IVD | *In Vitro* Diagnostic |
| LDT | Laboratory Developed Test |
| MDIC | Medical Device Innovation Consortium |
| MDR | Medical Device Report |
| MedSun | Medical Product Safety Network |
| NCI | National Cancer Institute |
| NIH | National Institutes of Health |
| OCC | Office of the Chief Counsel |
| OCET | Office of Counterterrorism and Emerging Threats |
| OHT | Offices of Health Technology |
| OHT7 | Office of Health Technology 7 - In Vitro Diagnostics and Radiological Health |
| OPEQ | Office of Product Evaluation and Quality |
| OST | Office of Strategic Partnerships and Technology Innovation |
| PHE | Public Health Emergency |
| POC | Point of Care |
| RWD | Real-World Data |
| RWE | Real-World Evidence |
| SARS-CoV-2 | Severe Acute Respiratory Syndrome Coronavirus 2 |
| SHIELD | Systematic Harmonization and Interoperability Enhancement of Lab Data |
| SOP | Standard Operating Procedure |
||
**About Booz Allen**
Booz Allen Hamilton has been at the forefront of strategy and technology for governments, and not-for-profits across the globe. Booz Allen partners with public and private sector clients to solve their most difficult challenges through a combination of consulting, analytics, mission operations, technology, systems delivery, cybersecurity, engineering, and innovation expertise.
With international headquarters in McLean, Virginia, the firm employs more than 22,600 people globally and had revenue of $5.41 billion for the 12 months ended March 31, 2016\. To learn more, visit BoozAllen.com. (NYSE: BAH)
© 2021 Booz Allen Hamilton Inc.
# 6,335 2022-07-01_FDA Report - FDAs Work to Combat the COVID-19 Pandemic.md
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summary_short: The FDA “Work to Combat the COVID-19 Pandemic” overview (data current as of April 2022) summarizes FDA’s cross-center actions on vaccines, therapeutics, diagnostics/devices, supply chain resilience, inspections/fraud enforcement, and regulatory science. It highlights scale and mechanisms such as EUAs and postmarket monitoring, expanded data infrastructure and real-world evidence efforts, device/test oversight and communications, and initiatives to prevent shortages and intercept fraudulent or contaminated products. It also notes crosscutting research and equity-focused work intended to strengthen preparedness for future public health emergencies.
CONTENT
***INTERNAL TITLE:*** FDA’s Work to Combat the COVID-19 Pandemic
July 2022
## Introduction
On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic. The pandemic has caused unimaginable harms, with over 1,000,000 American lives lost to the disease. These two years have also seen unprecedented progress in pandemic preparedness across the U.S. government, particularly at the U.S. Food and Drug Administration. The FDA continues to build on the foundation of scientific rigor, thoughtfulness, and adaptability in rising to this challenge. The agency is deeply appreciative of Congress’ support to ensure the American public’s access to medical products they need to diagnose, treat, and prevent COVID-19.
The FDA is responsible for monitoring the continued performance, safety, availability, and effectiveness of the COVID-19-related products on the market now, as well as in the years to come. To accomplish this long-range mission, the FDA is hiring and training new talent, building large data infrastructure and analytic capacity, modifying processes, and developing new partnerships. These efforts improve the resiliency of the agency and the health of Americans, responding to the COVID-19 pandemic and preparing for future crises such as public health emergencies, supply chain disruptions, geopolitical changes, and natural disasters.
This document outlines much of the broad range of work the FDA is undertaking to combat the COVID-19 pandemic and prepare for future emergencies.
## Contents
Vaccines ........................................................................................................ 3
Pharmaceuticals ............................................................................................. 4
Devices, including Tests and Personal Protective Equipment .............................. 5
Resilient Supply Chains .................................................................................. 7
Advanced Manufacturing and Innovation ............................................................. 9
Inspections, Investigations, Imports, and Fraud ............................................... 11
Crosscutting Research .................................................................................... 13
## Vaccines
Vaccines save lives by preventing disease, hospitalizations, and deaths. Given the COVID-19 public health emergency (PHE), development timelines for COVID-19 vaccines were shortened without compromising safety and effectiveness standards. The FDA’s Center for Biologics Evaluation and Research (CBER), in close partnership with industry and governmental partners, facilitated the needed scientific studies and manufacturing process validations to support this timeline. CBER issued an Emergency Use Authorization (EUA) for the first COVID-19 vaccine within eight months of the declaration of a PHE and licensed the first COVID-19 vaccine within two years, less than 100 days from the Biologics License Application submission. Typical vaccine development and approval can take 10 years or longer.
Over 570 million doses of vaccines have been administered in the U.S., and 82.2% of the American public over age five has received at least one dose of a vaccine per CDC data.
After authorization, CBER tracks the safety and performance of these vaccines in the real world. Even very large clinical trials are sometimes too small to detect extremely rare side effects and may not be designed to learn about the efficacy of a vaccine in certain groups, like patients with cancer. Real World Evidence (RWE) is the analysis of anonymous health information for millions of people collected through multiple sources such as electronic health records, insurance claims, reports, and public health databases. The FDA uses RWE and multiple other tools to detect potential safety issues early and mitigate them, as well as to answer critical questions around vaccine effectiveness, duration of protection, impacts of variants and mutations, and more.
CBER conducted 24 research studies in FY 2020 and 2021 which have produced more than 58 publications,° with wide-ranging implications for evaluating antibody and vaccine effectiveness, relevant for COVID-19 and for future vaccine development and regulation.
**The FDA has:**
* Issued EUAs for three vaccines, two of which are authorized for the population age 6 months and up.
* Approved two vaccines.
* Reviewed over 1,300 EUA amendments to authorized COVID-19 vaccines.
* Held nine advisory committee meetings regarding COVID-19 vaccines.
* Issued five draft, updated, or final guidances, related to COVID-19 vaccines.
* Continually reviewed and updated EUAs to include authorizations for boosters, immunocompromised people, and other special circumstances.
* **The Vaccine Adverse Events Reporting System (VAERS)** relies on healthcare providers, vaccine recipients, and parents of vaccine recipients to send in reports of their experiences. CBER received 812,147 VAERS reports in FY 2021 relating to the COVID-19 vaccines, a 1,488% increase over the FY 2020 reports.
* **The Biologics Effectiveness and Safety System (BEST)** and the Centers for Medicare & Medicaid Services data systems are tracking 16 potential rare adverse reactions in data representing 120 million people. The FDA detected four such potential reactions (pulmonary embolism, acute myocardial infarction, immune thrombocytopenia, and disseminated intravascular coagulation) and issued a protocol and public communication.
## Pharmaceuticals
Treatments are crucial for saving lives from COVID-19 infection. Congress established a process called Emergency Use Authorization (EUA) to make appropriate treatments available to patients as quickly as possible during PHEs when certain criteria are met. The FDA’s Coronavirus Treatment Acceleration Program (CTAP) uses multiple methods to expedite development of treatments including targeted guidance, communications, and interdisciplinary teams to assist drug sponsors with trial design and data submissions.
The FDA has been closely monitoring data from multiple sources to rapidly identify emerging potential safety issues associated with drugs and biologics used to treat or prevent COVID-19. These include safety issues that may not have been captured in a clinical trial, or those that arise from the misuse or off-label use of these products. The FDA can use this information to revise EUAs including updating the authorized Fact Sheets; communicate with the public, health care professionals, and other stakeholders; or act against fraudulent products. To accomplish this, the FDA uses two main systems:
* The FDA Adverse Event Reporting System (FAERS), enables healthcare professionals, consumers, and manufacturers to submit adverse event reports, medication error reports and product quality complaints. In 2021, the FDA launched a new COVID-19 EUA FAERS Public Dashboard to provide the public with easy access to COVID-19 EUA products adverse event data.
* The FDA Sentinel System and other Real World Data (RWD) systems, which assess potential safety signals in health records, insurance claims, and other RWD. The FDA enhanced these systems in response to the COVID-19 pandemic to include new electronic health records data and to increase the speed of signal detection. This supports the FDA's efforts to characterize the natural history of COVID-19 and to better understand the use and performance of drugs and biologics used to treat or prevent COVID-19. As of June 1, 2022, Sentinel completed 62 COVID-19 related analyses in the Sentinel Distributed Databases and associated electronic health record sources.
700+ Drug development programs in planning stages
460+ Trials reviewed by FDA
13 COVID-19 treatments currently authorized for Emergency Use
2 Treatments currently approved by FDA for use in COVID-19
Antivirals: > 23 million courses of two types of antiviral pills have been purchased by the federal government for 2022. Millions of doses of an IV antiviral medication have been administered.
Antibodies: 7.1 million courses of antibody treatments have been distributed by the federal government.
* Treatment: 65-90 % reduction in hospitalization or death depending on the product.
* Prevention: 77% reduction in infection in those who cannot respond to vaccinations.
## Devices, including Tests and Personal Protective Equipment
Medical diagnostics and other devices are necessary in combatting the pandemic:
* Tests allow people to seek early care, get the appropriate medications, quarantine to prevent infecting others, and return to travel and work more safely.
* Personal Protective Equipment (PPE) like masks, respirators, and gloves protect against infection.
* Other devices, like ventilators and syringes, are needed to treat sick patients.
Many of these were in short supply at the beginning of pandemic, so the FDA leveraged the EUA regulatory pathway to make tests and other devices available to patients as quickly as possible while assuring that they are appropriately safe and effective.
Many of the manufacturers of these products are new and unfamiliar with the FDA's policies and procedures, which required the FDA Center for Devices and Radiological Health (CDRH) to organize significant outreach to prepare them for regulation. CDRH has hired new reviewers, conducted town hall meetings, created new validation templates and guidances, assembled a software SWAT team, partnered with sister agencies (such as the National Institutes of Health (NIH) and Biomedical Advanced Research and Development Authority) to support development and FDA authorization of devices with novel technologies, and created new review mechanisms.
**The FDA has:**
* Reviewed > 8,000 EUA device submissions (> 5,000 for tests), which is 100 times more than in any prior public health emergency.
* Issued EUAs for >800 devices, 450 of which are for tests, including 19 OTC tests.
* Approved/cleared 706 PPE devices, 109 ventilators, and 635 other devices such as infusion pumps and syringes through non-EUA pathways.
CDRH managed >400,000 inquiries and interactions related to COVID products, and held 105 town hall webinars for >53,000 participants.
The FDA and firms have taken postmarket actions, including EUA revocation and recall for many devices.
COVID-19 DEVICE POSTMARKET METRICS
45 WARNING LETTERS ISSUED (2021)
64 DEVICES RECALLED (2021)
263 EUAS REVOKED (COVID-19 PHE TOTAL)
315 TESTS REMOVED FROM NOTIFICATION LISTS (COVID-19 PHE TOTAL)
Tracking real-world performance of tests is important for the FDA to be able to continue to make sure that the available tests are working correctly. To accomplish this, test results need to be captured consistently; results for most over-the-counter (OTC) rapid tests and tests performed at a hospital or laboratory are not always structured in the same ways, and do not always align with the systems that store health information from electronic medical records and insurance claims. To solve these issues, the FDA is leading efforts, such as the Systematic Harmonization and Interoperability Enhancement for Laboratory Data (SHIELD), to capture and integrate test data, laboratory data, and patient health data. The FDA is also collaborating with NIH’s Variant Task Force (VTF) program to identify and prioritize tests that can detect circulating variants, assess how current tests perform with new variants, and model the anticipated effect of new mutations on multiple different kinds of tests.
Over 630,000 CDRH staff hours have been spent on COVID-19 work in 2020-2021.
OTC Tests: Hundreds of millions of COVID-19 tests have already been performed in the U.S., and over are being contracted by the Biden Administration. The FDA focused particularly on the authorizations of 18 home-use tests as they are relatively inexpensive, allow people to stay in quarantine during testing, and provide faster results. A rollout of home-based testing at this scale is unprecedented, and the FDA's experience regulating novel technologies during this pandemic will facilitate a fast and robust response to a future crisis and to emerging variants.
## Resilient Supply Chains
COVID-19 highlighted vulnerabilities in the medical supply chain. Supply chain disruptions == for products like ventilators, pharmaceuticals, active ingredients, and PPE were already beginning to occur before COVID-19 cases were identified in the U.S. As demand increased, stockpiling occurred globally, and manufacturing was disrupted. Although the agency has intervened where possible to mitigate medical product shortages, responding to the massive shortages complicated by the pandemic has required establishing new or much more comprehensive programs, focused on three areas:
* Monitoring and visualization of supply, demand, and the availability of supplies by integrating data from a wide variety of sources, such as active ingredient manufacturers, product manufacturers, distributors, suppliers, and end-users like hospitals and pharmacies.
* Prediction of products at risk of shortage using statistical methods and artificial intelligence.
* Prevention or mitigation of shortages with evidence-based strategies such as enforcement discretion; expedited review of manufacturing supplements, generic drug applications, or premarket devices; and requesting that manufacturers identify alternative suppliers, redistribute stock, or increase manufacturing.
* The programs developed are expected to be beneficial for preventing future shortages including in other emergencies like natural disasters (hurricanes and winter storms), labor disputes, and shipping disruptions.
### PHARMACEUTICALS
* CDER’s Drug Supply Chain Surveillance System is being developed to provide enhanced insight into the drug supply chain—from active ingredient suppliers to clinical settings such as hospitals and pharmacies. This system will utilize existing as well as new data sources to identify early signals that may indicate shortages so they can be prevented and mitigated.
o CDER was able to work with manufacturers to prevent 482 potential shortages in 2020-2021. Consequently, there was no increase in the number of shortages: 46 in 2019, 43 in 2020 and 38 in 2021.
o CDER accomplished this in part by expediting review and approval of > 1,300 manufacturing supplements and > 100 generic drugs.
For example, starting in April 2020, there were shortages of Cisatracurium, a necessary medication for some patients on ventilators with dangerously low oxygen levels. The FDA identified this shortage and expedited the review of a generic version of the drug to increase supply. CDER also issued temporary guidances on compounding to allow for a wider array of compounding formulations to address certain supply disruptions.
### VACCINES AND BIOLOGICS
* CBER’s shortages program was able to work with manufacturers to prevent 34 potential shortages in calendar years 2020 and 2021. CBER accomplished this, in part, by expediting review and approval of 17 biologics license application supplements and 15 lot release submissions for CBER-regulated products.
### ANIMAL DRUGS
* The FDA Center for Veterinary Medicine (CVM) Animal Drug and Manufacturing System is launching in 2022 and will generate reports with necessary data for the analysis of potential animal drug shortages, which have more than tripled during pandemic.
### DEVICES
* CDRH’s new Resilient Supply Chain Program (RSCP) program aims to develop and apply state-of-the-art supply chain intelligence to predict and prevent supply chain shortages. CDRH has implemented the reporting authority that requires manufacturers to report the shortage of certain medical devices utilizing a newly created webform, and actively maintains a medical device shortage list. In addition, CDRH has integrated internal and external data sources for supply chain analysis and modeling to inform shortage mitigations.
o The RSCP has performed outreach to >1000 manufacturers in 12 countries to perform impact assessments and inform mitigation strategies.
o CDRH has performed hundreds of shortage assessments on PPE, COVID-19 testing supplies and equipment, ventilators, and other related device shortages, and has provided evidence- based data to support both regulatory and non- regulatory mitigations.
For example, CDRH, in partnership with the Biomedical Advanced Research and Development Authority and the U.S. Department of Defense, helped to coordinate a series of military airlifts of millions of testing swabs during a severe shortage.
### IMPORT IMPROVEMENTS
* The FDA Office of Regulatory Affairs is investing in import modernization with our partner government agencies. For example, FDA continues to work with U.S. Customs and Border Protection to refine existing data interfaces and with the U.S. Postal Service to develop a data exchange to better track and target international mail. These efforts should enable more effective efficient legitimate trade, while intercepting potentially harmful products before they enter the U.S.
## Advanced Manufacturing and Innovation
The COVID-19 pandemic has revealed that most existing manufacturing systems, which depend on a limited number of facilities fed by long and complex global supply chains, can be disrupted by delays, shortages of raw materials, contamination events, or other disturbances. In some cases, this can lead to shortages of much-needed medical products.
Advanced manufacturing is a set of manufacturing technologies and principles that can allow for products to be manufactured in a new or innovative way, such as novel technological approaches that permit production through a distributed network of smaller plants capable of responding in an agile and adaptable way to supply chain threats. Advanced manufacturing techniques can help protect against emerging threats, public health emergencies, natural disasters, and economic supply chain shifts by:
* Matching supply to meet demand by creating agile and high-throughput production systems that can scale to respond to new threats and changes in demand.
* Improving supply chain resilience by integrating independent operations end to end so that a single plant can depend on fewer input sources and is thus less susceptible to shortages.
* Creating cost-effective small-footprint plants that may make the manufacture of medications, including those for rare diseases, more financially viable and may lead to cost savings for consumers.
* Increasing product quality, manufacturing, consistency, and output through improving process design and process controls that can detect non-conforming materials in real time.
There are multiple production techniques that could be considered “advanced,” and there is explosive growth in the development of new techniques. Evaluating and regulating advanced manufacturing is complex: the array of different manufacturing techniques is vast, many technologies are designed to be adapted to changing circumstances, and the amounts of data collected can be staggering. Yet, the potential of these technologies is extraordinary, and the FDA has a critical role in facilitating this innovation with respect to medical product manufacturing.
* For **pharmaceutical manufacturing**, the chemical reactions and purification steps to make active ingredients typically occur in different rooms, different plants, different companies, or even different countries. The blending, weighing, compressing, and coating of a pill may occur somewhere else altogether. There are many advanced manufacturing techniques in development to integrate these steps, incorporate real-time quality controls, and transform physical plant infrastructure. During the pandemic, CDER and CBER partnered to launch the Center for the Advancement of Manufacturing Pharmaceuticals and Biopharmaceuticals. The FDA has conducted COVID-related research projects exploring active pharmaceutical ingredient manufacturing processes, smart data analytics for product quality, techniques to make monoclonal antibodies, and more. addition, the FDA has increased its support of targeted research, testing, and training in advanced manufacturing technologies.
* For **vaccine manufacturing**, messenger RNA (mRNA) vaccines leukemia, asthma, and two have emerged as a powerful platform technology. These critical drugs needed during vaccines have several advantages: the vaccine antigen can COVID-19. be redesigned relatively easily to target new diseases or new variants and can be simpler to manufacture. Still, they present several new unique manufacturing challenges, such as the need for suitable delivery vehicles (for example lipid nanoparticles), very cold storage, and reliance on specialized materials (reagents). Production of these, and other vaccines, may benefit from several advanced manufacturing techniques. For example, distributed manufacturing in decentralized or mobile units could allow vaccines to be produced near the site of distribution, reducing the cost and risks of transportation. CBER is working to launch a demonstration project for mRNA vaccine manufacturing which will focus on best practices in integrated and continuous vaccine manufacturing. This work is relevant for multiple vaccines, including influenza, COVID-19 variants, and other pathogens.
* For **medical device manufacturing**, new robotics, additive manufacturing (also known as 3D printing), and digital design tools can allow changes in a manufacturing process in response to a new need. Robotics and design tools can also be used to reconfigure a device to be able to use anew part without any loss of effectiveness. CDRH has invested in the Medical Device Information Analysis and Sharing Initiative to integrate data from patients, providers, payers, device manufacturers and regulators to understand “blind spots” in product safety and manufacturing quality that can be improved with advanced manufacturing techniques. CDRH also initiated two programs to work directly with manufacturers on “proof-of- concept” manufacturing technologies, called the Advanced Manufacturing Technology Clearinghouse and the Voluntary Improvement Program.
The FDA is a global leader in advanced manufacturing regulation, supporting the development of two International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use guidelines on continuous manufacturing and Manufacturing using cell lines.
CDER held > 150 meetings with drug manufacturers and approved 15 applications and supplements, which use new technologies (e.g., continuous manufacturing and 3D printing) to manufacture products _used in the treatment of cystic fibrosis, HIV/AIDS, breast cancer, leukemia, asthma, and two critical drugs needed during COVID-19.
One CDRH and industry collaboration reduced technology implementation time from 18 to eight months, resulting in a reduction in non-conformances of 45% and projected savings of $30 million.
**The Ventilator Digital Twin Project.** A digital twin is a model of all the objects, people, designs, processes, and systems involved in the creation of a complex device. This allows one to virtually “try out” a new technique. The Ventilator Digital Twin can model the impact of disruptions like social distancing or parts shortages on ventilator production and come up with solutions.
## Inspections, Investigations, Imports, and Fraud
Inspections and examinations of firms, manufacturing facilities, and imported products, are a critical component of the FDA’s strategy to protect the public from harmful or fraudulent products.
The need for these field activities, which are led by ORA in partnership with the relevant centers, only continues to grow. As one example, the number of imported medical product lines increased by 42% in FY 2015-2021, including a 9% increase during pandemic (FY 2020-2021). The pandemic brought about additional unique challenges:
* Inspections were initially significantly limited due to travel bans and risk to personnel, though mission critical inspections were continued throughout.
* Accelerated growth in the vaccine industry necessitated new inspection programs.
* Online marketplace revenue grew from $360 billion in 2019 to $768 billion in 2021, including ~$56 billion in health products, increasing the potential for fraudulent online activities.
To **facilitate inspection activities**, the FDA is initiating a new inspection planning system that will be more efficient, transparent, and adaptable to changing needs. This will help prioritize high-impact inspections such as those for facilities manufacturing COVID-19 vaccines or ingredients used in multiple critical products, as well as the inspections needed for clinical trials of COVID-19 drugs. The FDA is also developing new approaches to inspect firms utilizing novel advanced manufacturing techniques.
To **identify fraudulent products**, ORA has begun a proof of concept using handheld, field-deployable, fraud detection tools including Raman Spectrometers (Progeny) and counterfeit detection devices (CD5). Additionally, ORA is standing up 2-person satellite laboratories at selected international mail facilities. These hand-held devices and satellite laboratories can be used to analyze the chemical composition of a product to verify authenticity and detect potential contamination directly on site. The ORA’s Forensic Chemistry Center experts can then review this field-generated data in real time. If successful, one or more of these pilots could allow field staff to decide about admitting an imported product much faster than if they need to send samples to a fixed laboratory and wait hours or days for a result. This could reduce the time it takes for the FDA to intercept fraudulent products, expedite legitimate trade, and potentially promote mitigation of supply chain issues.
**The FDA has:**
* Identified > 1,706 fraudulent and/or unapproved medical products related to
COVID-19.
* Issued > 219 warning letters to companies and individuals selling unproven products and >70% of recipients took voluntary action in response.
* Identified 340 contaminated hand sanitizers (see Box 4).
* Continued mission-critical inspections throughout.
* Reinvigorated a system to conduct > 1,400 domestic and > 500 foreign remote
assessments.
* Conducted domestic inspections at standard operational levels since October 2021.
* Resumed foreign facility surveillance inspections in March 2022.
**Combatting False Marketing:**
The Genesis II Church of Florida falsely marketed a chlorine dioxide formulation, a bleach-like disinfectant, as a treatment for a range of conditions including COVID-19. The FDA sent a joint warning letter with the Federal Trade Commission, which the manufacturer defied. The FDA then successfully pursued in court a temporary restraining order, a preliminary injunction, and, ultimately, a permanent injunction, which enjoins the manufacturer from labeling, holding, or distributing the product.
The FDA launched a data system to track and flag online sales of potentially fraudulent COVID-19 related products.
To **prevent harm to consumers and animals from violative or fraudulent products**, the FDA takes multiple different actions. Illustrative examples include issuing consumer warnings about unapproved and unauthorized products distributed with fraudulent claims to treat or prevent COVID-19 in humans and animals; alerting healthcare providers on how to identify fraudulent PPE; and pursuing regulatory actions to stop the production, importation, distribution, and use of potentially harmful products like contaminated hand sanitizers.
**Combatting Fatal Contamination:** The FDA noted 2,660 cases of poisonings reported to the National Poison Data System’, including 18 confirmed deaths, from ingestion of contaminated hand sanitizers. The FDA saw a sharp increase in hand sanitizer products from Mexico that were labeled to contain ethanol (also known as ethyl alcohol) but, among other concerns, tested positive for methanol contamination; 84% of the samples of alcohol-based hand sanitizers imported from Mexico analyzed by the agency from April 2020 through December 2020 were not in compliance with the FDA's regulations, and more than half of the samples were found to contain toxic ingredients, including methanol and/or 1-propanol, at dangerous levels. The FDA worked with companies and retailers to recall dozens of violative products. In January 2021, due to safety concerns about alcohol-based hand sanitizers manufactured in Mexico, the agency placed all such products on an import alert, which was the first time the FDA had issued a countrywide import alert for any category of drug product. In addition, as part of the agency’s efforts to protect consumers from potentially dangerous or violative hand sanitizers, the agency published on its website a list of over 250 hand sanitizers that consumers should not use, released a guidance, developed safety toolkits in multiple languages, and issued warning letters.
## Crosscutting Research
### Crosscutting Activities
Regulatory science is the science of developing evidence-based tools, standards, and approaches to assess safety, efficacy, quality, and performance of all FDA-regulated products. Much research conducted at the ; . : . FDA is relevant to multiple different products and may involve more than one FDA center or office. The studies below have resulted in more than 60 publications:
* Laboratory standards and techniques such as the development of reagents, reference panels, and artificial intelligence (Al) to identify targets for new drug development.
* Immunology research including neutralizing antibody studies, cytokine studies, and a model of the interactions between the virus, immune system, and body tissues.
* Advanced manufacturing research including an analysis of the current advanced manufacturing landscape, 3D printing pilots, and IT and physical infrastructure plans.
* The RWD Research Lab including pilot projects to establish rapid-cycle analytic approaches and foster collaboration on topics such as understanding vaccine effectiveness.
* Transmission research including studies on SARS-CoV-2 transmission in food or on surfaces, and algorithms to link maternal and infant data to understand perinatal transmission.
The FDA has created translations of FDA health communications in numerous languages, including EUA fact sheets in multiple languages.
### Health Equity
Many diseases, including COVID-19, disproportionately impact racial and ethnic minority communities. The FDA Office of Minority Health and Health Equity (OMHHE) launched The Enhance EQUITY Initiative to advance diversity in clinical trials, increase equitable data efforts, and increase understanding of diverse stakeholder perspectives. OMHHE launched The COVID-19 and Health Equity Innovation Award which has funded five studies on topics such as understanding COVID-19 outcomes by different demographic variables, including ethnicity, race, age, and geography among others; racial and ethnic minority participation in COVID-19 clinical trials; and understanding diverse patient perspectives, preferences, and unmet needs. OMHHE also supported four additional COVID-19 research projects.
### Identifying Variants in Wastewater
Testing for SARS-CoV-2 in wastewater can indicate a surge one to two weeks before a rise in cases. Wastewater also gives a snapshot of a whole population served by a wastewater system, not just those who get tested. Most of the wastewater surveillance for SARS-CoV-2 tests only small fragments of the virus, which can indicate the quantity of the virus present but unfortunately does not give any indication about the proportion of variants within a sample. The FDA Center for Food Safety and Applied Nutrition’s (CFSAN) existing GenomeTrakr program uses whole genome sequencing to evaluate the genomes of pathogens in the food supply. CFSAN deployed a similar technology to sequence SARS-CoV-2 in > 50 sites in the U.S. geographic regions with high percentages of agricultural and food facility workers, whose health is critical for stability of the U.S. food supply chain. These data can be used to monitor circulating variants and their impact on vaccines, therapeutics, and diagnostics. Furthermore, the analysis software CFSAN developed has been adopted by other partners, including the U.S. Centers for Disease Control and Prevention (CDC).
### Understanding COVID-19 Spread from Animals
Approximately 75% of recently emerging infectious diseases affecting humans are of animal origin, including HIV, Ebola, and influenza. Mink, deer, and other animals are known to be reservoirs for SARS-CoV-2. Humans have transmitted SARS- CoV-2 back to animals, including some domestic dogs and cats. Researchers are currently exploring how environmental factors, including ground and wastewater, play a role in viral transmission. Recognizing that the health of people, animals, and the environment is intertwined, CVM is partnering with other government agencies, such as the U.S. Department of Agriculture and CDC, to solidify a One Health approach to the FDA’s human and animal public health work, and the FDA is standing up a One Health Center of Excellence. An example of CVM’s One Health approach is the work being done with other veterinary diagnostic laboratories to identify COVID-19 variants in animal populations and compare them to those in humans. This type of approach is to understanding not just COVID-19, but many other emerging threats, such as antimicrobial resistance.
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CONTENT
# _archive-combined-files_surveillance_33k (15 files, 33,458 tokens)
# 8,194 _AI_Covid_Surveillance_Testing_Screening_Report.md
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last updated: 2026-03-01
file_name: _AI_Covid_Surveillance_Testing_Screening_Report.md
file_date: 2026-03-01
title: FloodLAMP Surveillance, Testing, and Screening During the COVID-19 Pandemic
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notes: Created by ChatGPT Pro 5.2 Extended during archive preparation. **NOT HUMAN VERIFIED - MAY CONTAIN ERRORS** Comprehensive report on surveillance, testing, and screening regulatory history during the COVID-19 pandemic, covering U.S. regulatory architecture (FDA/CMS/CDC), key case studies (SCAN, SafeGuard/New Trier, FloodLAMP), operational patterns, and post-PHE transitions. Prompt not included.
summary_short: Regulatory history and analysis of surveillance, testing, and screening distinctions during the COVID-19 pandemic, focusing on how "surveillance testing" was defined, contested, and regulated across U.S. programs (2020--2023). Covers FDA/CMS/CDC frameworks, key case studies (SCAN, SafeGuard/New Trier, FloodLAMP), wastewater and genomic surveillance, and post-PHE transitions, with appendices mapping FloodLAMP archive documents and primary sources.
CONTENT
## Executive summary
During COVID-19, U.S. testing split into three overlapping purposes--**diagnosis**, **screening**, and **surveillance**, but institutions often used the word *surveillance* to describe programs that looked, functioned, and felt like **screening** (routine testing of asymptomatic people to make individual decisions). That semantic slippage mattered because, in U.S. law and agency practice, whether a program is "diagnostic/screening" versus "surveillance" affects:
- whether a site needs to operate as a **CLIA-certified laboratory** (or send testing to one),
- whether a method must be **FDA-authorized/marketed** (e.g., EUA during the PHE),
- what **results** may be returned to individuals,
- what **reporting** is required to public health agencies, and
- who has oversight authority (CMS, FDA, state agencies, IRBs, or local public health departments).
A central dynamic of the pandemic was the attempt to scale fast, low-cost testing in schools, universities, and workplaces **before** regulators had simple, stable frameworks for frequent testing of asymptomatic people. Many programs therefore sought "escape hatches":
- **Research framing** (IRB oversight; results sometimes handled differently),
- **De-identified public health surveillance** (aggregate reporting; no individual results),
- **Pooled testing + referral** (only "pool-level detection," with confirmatory individual diagnostic tests elsewhere),
- **State authorization** (especially early 2020) before federal processes matured.
The canonical early collision between these worlds occurred in Seattle: the **Seattle Flu Study** (a pre-pandemic influenza surveillance platform) and its COVID-era successor **SCAN** (Greater Seattle Coronavirus Assessment Network) encountered shifting FDA interpretations about home collection and the return of results. In mid-May 2020, FDA-directed pauses and press coverage created a durable "object lesson" for how a program can be described as "surveillance" but become regulated once it returns individual results.
By 2021--2022, CMS (CLIA) and FDA guidance became more explicit about these distinctions, and regulators began pushing back when "surveillance" language appeared to mask **individual-result** testing--an issue that also appears in FloodLAMP's archive (e.g., FDA website review and requests to remove language implying individual follow-up testing).
By 2023, as the federal COVID-19 PHE ended, mandatory nationwide reporting and many emergency flexibilities wound down. Surveillance increasingly shifted toward **sentinel systems**, especially **wastewater surveillance** and **genomic surveillance**, because case-based counting (and universal negative-result reporting) became less feasible as home testing expanded and public reporting requirements changed.
## 1. Why "surveillance" became a contested label
### 1.1 Pre-pandemic baseline meaning
Before COVID-19, **public health surveillance** primarily meant population-level monitoring--collecting and analyzing data to track disease trends, detect outbreaks, and guide interventions. Surveillance generally did **not** mean providing an individual with a clinical test result to guide personal decisions.
### 1.2 COVID-era expansion and semantic drift
During COVID-19, "surveillance" was sometimes used more broadly to describe:
- routine testing programs for **asymptomatic** people (e.g., schools/workplaces), and/or
- pooled testing programs where administrators wanted to claim they were not doing clinical testing even while **removing individuals from school/work** based on results.
This produced a recurring tension:
- **Regulators** tended to treat "returning individual results" as the key feature that makes testing *clinical* (diagnostic or screening).
- **Operators** often used "surveillance" to signal a public-health purpose and to reduce friction, cost, or compliance burdens--especially for high-frequency testing.
## 2. Key definitions that shaped policy
The FDA's "COVID-19 Test Uses" FAQ (content current as of **September 29, 2023**) summarizes the triad as follows (paraphrased):
- **Diagnostic testing:** testing an individual when there is reason to suspect infection (symptoms or known/suspected exposure).
- **Screening testing:** testing an individual even without suspicion or known exposure, with the intent to make **individual decisions** based on results (e.g., school/workplace testing to decide who returns).
- **Surveillance testing:** systematic activities to generate **population-level** information, generally not reporting results to a patient or provider.
Source (FDA): `regulatory/surveillance/FDA Website - COVID-19 Test Uses_ FAQs on Testing for SARS-CoV-2 (updated 2023-09-29).md`
https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-test-uses-faqs-testing-sars-cov-2
### 2.1 A practical "surveillance vs screening" test
In practice, a useful question was:
> **Will anyone use this test result to make an individual decision about one person?**
> If yes, regulators usually treated it as **screening or diagnostic**, not surveillance.
## 3. U.S. regulatory architecture in plain language
### 3.1 CLIA (CMS): "Are you operating a laboratory that returns patient-specific results?"
The Clinical Laboratory Improvement Amendments (**CLIA**) are administered by CMS and regulate laboratories that test human specimens for diagnosis, prevention, treatment, or health assessment. In general:
- If a program returns **patient-specific** results, it often triggers **CLIA** requirements.
- If a program is truly **de-identified** and results are not used for individual decisions, it can sometimes fall outside CLIA's clinical laboratory framework.
COVID-era complexity: CMS issued multiple FAQs and memos clarifying when pooled or surveillance workflows might proceed without a traditional CLIA certificate (often under time-limited enforcement discretion).
Post-PHE note: CMS emphasized that some flexibilities ended with the PHE and that its authority to require SARS-CoV-2 test reporting was linked to the federal PHE declaration.
Key sources:
- CMS QSO-23-15-CLIA (May 11, 2023): https://www.cms.gov/files/document/qso-23-15-clia.pdf
- CMS "CLIA FAQs: Post-PHE Guidance" (May 11, 2023): https://www.cms.gov/files/document/clia-post-phe-guidance-faqs-only.pdf
- CDC LOCS Lab Advisory on post-PHE CLIA reporting (May 19, 2023): https://www.cdc.gov/locs/2023/05-19-2023-Lab-Advisory-COVID-19_CLIA_Post-Public_Health_Emergency_Guidance.html
### 3.2 FDA: "Are you using an in vitro diagnostic (IVD) test for a clinical purpose?"
In the U.S., SARS-CoV-2 tests are **medical devices** (IVDs) overseen by FDA. During the COVID-19 emergency, most tests entered the market via:
- **Emergency Use Authorizations (EUAs)**, and/or
- FDA's evolving testing **policies** (including enforcement discretion windows).
A recurring flashpoint was **home collection** and "direct-to-consumer" workflows. Early in the pandemic, FDA's policies for home collection and home testing shifted repeatedly, contributing to confusion among research and public-health programs (and to headline-grabbing conflicts such as SCAN).
### 3.3 CDC and public health agencies: "What is the public health function?"
CDC guidance documents helped define and compare diagnostic, screening, and surveillance strategies; they also reinforced that:
- diagnostic/screening testing intended to return results to individuals comes with clinical lab and reporting expectations,
- surveillance testing is typically de-identified and not returned to individuals.
The FloodLAMP archive includes a CDC "Testing Strategies for SARS-CoV-2" document updated December 28, 2021, which contains a summary matrix comparing these strategies. **FLAG - add relative path to file**
## 4. Timeline of key events (selected)
> This timeline is intentionally "U.S.-regulatory centered." It highlights moments when agency interpretation or public controversy changed how surveillance and screening were discussed.
| Date | Event | Why it matters for surveillance vs. screening |
|---|---|---|
| **Nov 2018** | Seattle Flu Study (SFS) established as a community respiratory surveillance platform | Built "pre-pandemic" surveillance infrastructure later repurposed for SARS-CoV-2. |
| **Feb 2020 (early)** | Seattle Flu Study begins seeking permission to use existing sample bank for SARS-CoV-2 surveillance | Shows early friction when research surveillance intersects with clinical/public health needs (discussed in ethics literature). |
| **Feb 24, 2020** | First SFS SARS-CoV-2 community transmission case detected (specimen collected Feb 24) | Widely cited example of surveillance detecting community spread early; paper notes Gates Ventures support. |
| **Mar 23, 2020** | SCAN launched (Seattle Flu Study + Public Health -- Seattle & King County) | Explicitly framed as a "disease surveillance platform." Also the date SCAN later cited as the start of its EUA process. |
| **May 11--12, 2020** | FDA clarifies home self-collection policy; SCAN directed to pause returning results pending additional federal authorization | Key inflection: "surveillance" + **returning individual results** triggered FDA expectations for EUA/authorization. |
| **Jun 10, 2020** | SCAN resumes testing; explains pause and EUA pathway | SCAN publicly documents its regulatory posture: surveillance framing, but acknowledgement of EUA needs for home collection + results return. |
| **Aug 28, 2020** | CMS publishes university lab testing / surveillance FAQ (CLIA) | Institutional testing programs scale; CMS addresses pooled testing and surveillance workflows. |
| **Dec 2020** | CMS issues notice letter on CLIA surveillance testing | Clarifies that returning patient-specific results generally triggers CLIA; describes enforcement discretion constraints. |
| **Mar 19, 2021** | CMS publishes variant testing FAQ | Extends "surveillance without individual return" logic into genomic/variant sequencing. |
| **Mar 30, 2021** | NYT story on New Trier High School testing scrutiny | A high-profile example of school testing being treated as regulated screening when individual students are flagged. |
| **Oct 21, 2021** | CMS revises surveillance testing FAQ | More mature articulation of pooled surveillance testing risks and confirmatory testing expectations. |
| **Dec 28, 2021** | CDC updates testing strategies guidance | Reinforces definitions and operational boundaries between diagnostic/screening vs surveillance. |
| **Jan--Mar 2022** | FDA correspondence with FloodLAMP regarding website claims | Illustrates late-pandemic tightening on "surveillance" branding when individual follow-up pathways are implied. |
| **May 11, 2023** | Federal COVID-19 PHE ends | Reporting requirements and emergency flexibilities change; surveillance systems (wastewater/genomic) become relatively more central. |
| **Sep 29, 2023** | FDA updates "COVID-19 Test Uses" FAQ | A consolidated, post-crisis articulation of diagnostic vs screening vs surveillance definitions. |
Primary source links for the Seattle portion of this timeline are in the next section.
## 5. Case studies and major programs
### 5.1 Seattle Flu Study -> SCAN (Greater Seattle Coronavirus Assessment Network)
**Why this matters:** This is one of the clearest public examples of a pre-pandemic *influenza surveillance* platform being repurposed for SARS-CoV-2, and then colliding with regulatory boundaries when results were returned.
#### 5.1.1 Seattle Flu Study as "pandemic surveillance platform"
A short NEJM letter by Chu et al. describes the Seattle Flu Study as a multi-institutional pandemic surveillance platform established in **November 2018**, and reports early detection of SARS-CoV-2 community transmission through that infrastructure. The letter's disclosure footnote notes **Gates Ventures** support.
- NEJM (full text): https://www.nejm.org/doi/full/10.1056/NEJMc2008646
- Open-access mirror (PMC): https://pmc.ncbi.nlm.nih.gov/articles/PMC7206929/
#### 5.1.2 Launch of SCAN as a public health surveillance program
Public Health -- Seattle & King County announced SCAN on **March 23, 2020**, describing it as a disease surveillance platform to better understand how COVID-19 was spreading.
- Public Health Insider (Mar 23, 2020): https://publichealthinsider.com/2020/03/23/introducing-scan-the-greater-seattle-coronavirus-assessment-network/
- SCAN Technical Report (Apr 17, 2020 PDF): https://publichealthinsider.com/wp-content/uploads/2020/04/SCAN-Technical-Report-v1-17-APR-2020.pdf
#### 5.1.3 The May 2020 pause and "the surveillance/screening collision"
In May 2020, SCAN paused returning results after FDA clarified policy for **home-based, self-collected samples** and indicated that **a separate federal EUA** was required to return results for self-collected tests.
Primary/near-primary sources documenting this sequence:
- Public Health Insider "SCAN resumes" explanation (Jun 10, 2020): https://publichealthinsider.com/2020/06/10/greater-seattle-coronavirus-assessment-network-scan-resumes-covid-19-testing/
- Reuters coverage of the pause (May 16--17, 2020): https://www.reuters.com/article/world/u-s-fda-suspends-gates-backed-at-home-covid-19-testing-program-idUSKBN22S0R7/
- STAT analysis and quotes from FDA + experts (May 27, 2020): https://www.statnews.com/2020/05/27/coronavirus-testing-seattle-bill-gates-fda/
**Key regulatory lesson illustrated:**
Even if a program's *purpose* is public health surveillance, **returning results to individuals**--especially in a home-collection workflow--pulled the program into FDA/CMS compliance expectations typical of screening/diagnostic testing.
#### 5.1.4 Ethical framing: research infrastructure repurposed for public health
Legal/ethics scholarship used the Seattle Flu Study as an example of the complexities of using research infrastructure for urgent public health purposes, including result return and reporting mandates.
- Doerr et al. (Journal of Law and the Biosciences, 2020; open access): https://pmc.ncbi.nlm.nih.gov/articles/PMC7381975/
### 5.2 School-based saliva surveillance: Ed Campbell (SafeGuard) and the New Trier example
**Why this matters:** K-12 schools became a major arena where "surveillance testing" was used colloquially to mean frequent testing, but regulators often treated it as **screening** because individual students were identified and acted upon.
#### 5.2.1 Ed Campbell and SafeGuard surveillance / Safeguard Solutions
Multiple media and case-study sources describe Dr. **Ed Campbell** (a virologist and Loyola University Chicago faculty member) as an organizer of school testing efforts under the company **Safeguard Solutions** (which later obtained CLIA certification) and link the saliva test lineage to collaboration with U Madison scientist **David (Dave) O'Connor**.
- Hinsdale Magazine profile (Apr 2021): https://hinsdalemag.com/keeping-the-doors-open/
- Gilson "Safeguard Solutions: A COVID-19 Student Testing Operation" (case study): https://www.gilson.com/us/case-study-safeguard-solutions-a-covid-19-student-testing-operation
#### 5.2.2 New Trier High School and "surveillance" vs "screening"
The New York Times story
`regulatory/surveillance/2021-03-30_NY Times - Why Virus Tests at One Elite School Ran Afoul of Regulators.md`
https://www.nytimes.com/2021/03/30/us/covid-school-testing-fda.html
is frequently cited because it shows the operational boundary regulators cared about:
- If a test flags **specific students** and triggers individual action (send home, isolate, etc.), regulators tend to treat that as **screening/clinical testing**, not de-identified public health surveillance.
- The resolution pathway described in coverage often involved moving toward CLIA-aligned operations and qualified oversight.
### 5.3 Dave O'Connor (University of Wisconsin): mobile RT-LAMP surveillance and genomic surveillance
**Why this matters:** O'Connor's work appears in two "surveillance" modes:
1) **frequent, low-friction saliva testing** (often RT-LAMP) to support safer schools/workplaces, and
2) **genomic surveillance** (sequencing) to track viral spread and variants.
#### 5.3.1 Mobile saliva RT-LAMP as a surveillance tool (summer--fall 2020)
UW researchers evaluated a mobile, outdoor RT-LAMP workflow using saliva samples from volunteers, emphasizing that it was oriented toward surveillance and rapid turnaround rather than traditional clinical diagnostics.
- Newman et al., "Initial evaluation of a mobile SARS-CoV-2 RT-LAMP testing strategy" (open access, 2021): https://pmc.ncbi.nlm.nih.gov/articles/PMC7809916/
- (Paper describes surveillance samples collected July--Nov 2020.)
UW communications also described RT-LAMP as not yet approved for clinical diagnosis and advised confirmatory PCR for people who screened positive:
- UW News (Aug 6, 2020): https://news.wisc.edu/uw-researchers-develop-new-method-to-test-for-covid-19/
Popular media coverage captured the "DIY/surveillance" framing and the regulatory barrier:
- WIRED (Jul 23, 2020): https://www.wired.com/story/a-wisconsin-city-experiments-with-a-faster-diy-covid-19-test
#### 5.3.2 Scaling school testing and related grants
Wisconsin-focused reporting described efforts to improve school testing (including interest in methods like RT-LAMP):
- Pediatrics Wisconsin (Jul 23, 2021): https://pediatricswi.org/new-grant-aims-to-improve-testing-in-wisconsin-schools/
#### 5.3.3 Genomic surveillance leadership in Dane County
University of Wisconsin communications described how researchers (including David O'Connor) contributed to viral sequencing surveillance in Dane County, positioning the area as unusually advanced in surveillance density during outbreaks.
- UW--Madison / Wisconsin.edu story (Oct 8, 2020): https://news.wisc.edu/residence-hall-outbreak-shows-virus-can-spread-quickly-even-when-precautions-taken/
### 5.4 FloodLAMP pooled "non-diagnostic surveillance testing" and 2022 FDA correspondence (archive-based)
**Why this matters:** FloodLAMP's archive reflects an approach many pandemic-era programs attempted: structure testing as **non-diagnostic surveillance**--often pooled--where results are not returned as patient-specific positives/negatives, and individuals are referred to CLIA diagnostic testing when a pool indicates SARS-CoV-2 presence.
Relevant FloodLAMP Archive files include:
- **Internal regulatory framing memos** (Aug 2021, Jan 2021, Sept 2021) arguing that pooled surveillance with non-patient-specific reporting can fall outside CLIA/FDA requirements if individual results are not returned.
- **A "Non-Diagnostic Surveillance Testing Materials Acknowledgment and Waiver"** describing participant notification/referral, non-FDA authorization status, and a liability waiver.
- **FDA email correspondence (Jan--Mar 2022)** in which FDA staff flagged website language that seemed to imply individual clinical follow-up testing by FloodLAMP and requested revisions to align with FDA's policy framing of surveillance vs screening.
**Interpretive note:**
These materials fit into a broader pandemic pattern: many operators sought to preserve speed/scale by using "surveillance" logic (aggregate reporting + referral), while regulators focused on whether the program's real-world operations or marketing implied individual diagnosis/screening.
(See Appendix A for the archive file list and where each document fits.)
## 6. Other major U.S. surveillance modalities that expanded during COVID
The term "surveillance" during COVID often refers to wastewater surveillance or genomic/variant surveillance.
### 6.1 Wastewater surveillance
Wastewater surveillance measures SARS-CoV-2 RNA shed into sewage, providing community-level signals that are independent of clinical testing access and not impacted by whether individuals seek tests.
CDC launched the **National Wastewater Surveillance System (NWSS)** in **September 2020** and continued to expand it.
- CDC AMD "Wastewater Surveillance: A New Frontier" (Apr 15, 2024; includes launch date + scale claims): https://www.cdc.gov/advanced-molecular-detection/php/success-stories/wastewater-surveillance.html
- CDC NWSS "About" page: https://www.cdc.gov/nwss/about.html
- CDC NWSS national data view: https://www.cdc.gov/nwss/rv/COVID19-national-data.html
Late-pandemic significance: when many infections were detected via home tests that never entered official reporting systems, wastewater became a key "sentinel" indicator.
### 6.2 Genomic/variant surveillance
Genomic surveillance tracks viral evolution and spread by sequencing SARS-CoV-2. The U.S. scaled genomic surveillance substantially after a slow start.
Federal coordination examples:
- CDC press release launching **SPHERES** consortium (May 1, 2020; archived): https://archive.cdc.gov/www_cdc_gov/media/releases/2020/p0501-SARS-CoV-2-transmission-map.html
- CDC "SPHERES" success story (Apr 12, 2024): https://www.cdc.gov/advanced-molecular-detection/php/success-stories/spheres.html
A major CDC-affiliated pipeline is the **National SARS-CoV-2 Strain Surveillance (NS3)** program:
- APHL NS3 overview: https://www.aphl.org/programs/infectious_disease/SARS-CoV-2/Pages/Sequence-Based-Surveillance-Submission.aspx
- CDC "Variants and Genomic Surveillance" page (updated Aug 28, 2025): https://www.cdc.gov/covid/php/variants/variants-and-genomic-surveillance.html
### 6.3 Serosurveillance (antibody surveys)
Because case counts under-captured true infection prevalence--especially early--serosurveillance programs used blood donors and residual sera to estimate the proportion of the population with SARS-CoV-2 antibodies.
Examples of CDC-supported data products:
- CDC Data: Nationwide Commercial Laboratory Seroprevalence Survey: https://data.cdc.gov/Laboratory-Surveillance/Nationwide-Commercial-Laboratory-Seroprevalence-Su/d2tw-32xv
- CDC Data: 2020--2021 Nationwide Blood Donor Seroprevalence Survey: https://data.cdc.gov/Laboratory-Surveillance/2020-2021-Nationwide-Blood-Donor-Seroprevalence-Su/wi5c-cscz
### 6.4 Syndromic surveillance and "non-test" data streams
As routine lab reporting became less comprehensive, syndromic surveillance (e.g., emergency department data) and other indicators were increasingly used to track trends. Media coverage around the end of the federal PHE highlighted a shift from "count every case" toward sentinel systems such as hospital admissions + wastewater.
(One accessible overview of this shift:)
- TIME (May 2023): https://time.com/6277396/covid-19-data-public-health-emergency-ends/
## 7. Operational patterns: how programs tried to stay on the "surveillance" side of the line
This section turns the definitions into concrete program design patterns seen in COVID-era "surveillance testing."
### 7.1 A simplified decision tree (conceptual)
```
TESTING PROGRAM
|
v
Are results used for individual decisions
or returned to a person/provider?
|
YES | NO
v v
DIAGNOSTIC or SCREENING Are specimens de-identified and
| only aggregate/cohort results reported?
| |
|---> CLIA-certified YES | NO / UNCLEAR
| testing site v v
| (or send to PUBLIC HEALTH HIGH RISK of being
| CLIA lab) SURVEILLANCE treated as screening
| PARADIGM / clinical testing
|---> FDA-authorized/ |
| marketed test |---> Often described as outside
| (e.g., EUA during | FDA/CLIA clinical frameworks
| PHE) | if no individual results
| |
|---> Individual reporting |---> Still may require public health
+ public health coordination, ethics review,
reporting and careful communication
```
**Caution:** During COVID, agencies also cared about *marketing/communications* (how a program described itself) and whether a "surveillance" workflow *functionally* produced patient-specific outputs (even if framed carefully).
### 7.2 A common "pooled surveillance + referral" workflow
Many programs used a structure like:
1. **Collect samples** (often saliva or anterior nares) from a defined group (classroom, team, work unit).
2. **Pool samples** (combine into one test reaction).
3. If the pool shows evidence of SARS-CoV-2, **notify the group** (or the institution) at a cohort level.
4. **Refer individuals** to a CLIA-certified diagnostic test for confirmatory individual results.
Regulatory rationale:
- Step (3) attempts to avoid returning **individual** results while still enabling mitigation.
- Step (4) is designed so that any individual medical decision rests on a CLIA/FDA-compliant diagnostic test.
This logic appears in multiple CMS CLIA surveillance documents (in your archive) and in many school/university programs.
### 7.3 The "communication failure mode"
In multiple high-profile controversies (SCAN, school programs, later FDA website reviews), a recurring issue was when a program:
- described itself as "surveillance," but
- provided participant-facing language that implied **individual follow-up testing** by the same non-CLIA/non-EUA pathway, or implied that results could be used as diagnostic information.
This "communication layer" is often where programs were challenged, even when their technical workflow was intended to remain surveillance-oriented.
## 8. Late-pandemic transition and follow-up events (2022--2025 context)
### 8.1 Post-PHE CLIA reporting changes (May 2023)
CMS emphasized that:
- its authority to require SARS-CoV-2 test result reporting was tied to the federal PHE declaration, and
- certain enforcement discretions/flexibilities would terminate with the PHE.
Primary sources:
- CMS QSO-23-15-CLIA memo (May 11, 2023): https://www.cms.gov/files/document/qso-23-15-clia.pdf
- CMS post-PHE CLIA FAQs (May 11, 2023): https://www.cms.gov/files/document/clia-post-phe-guidance-faqs-only.pdf
- CDC LOCS advisory (May 19, 2023) advising labs to check state reporting requirements: https://www.cdc.gov/locs/2023/05-19-2023-Lab-Advisory-COVID-19_CLIA_Post-Public_Health_Emergency_Guidance.html
### 8.2 The "surveillance backbone" becomes wastewater + sentinel sampling
As case counting and universal lab reporting became less comprehensive, surveillance increasingly leaned on:
- wastewater (NWSS),
- sentinel lab networks,
- syndromic surveillance (ED data),
- and genomic surveillance pipelines.
This was not a sudden invention; rather, COVID accelerated investment and normalization of these methods, which then persisted because they remained informative even as individual testing behavior changed.
## 9. Lessons learned (research framing)
These are research/archival interpretations - useful as themes for an archive, not as prescriptions.
1. **Terminology needs operational anchors.** "Surveillance" should not be defined by intent alone; it must be defined by whether individual results are returned or used for individual decisions.
2. **Regulators respond to the full system, not just the assay.** Sample collection logistics, lab certification, reporting pipelines, and participant communications can each "flip" a program into the clinical category.
3. **Home collection is a special sensitivity.** SCAN shows how home-collection workflows triggered heightened FDA attention early in the pandemic.
4. **Pooled surveillance + referral was a scalable compromise.** It offered a way to monitor and mitigate spread while keeping clinical result return in CLIA-certified settings.
5. **Late-pandemic surveillance is increasingly environmental + sentinel.** Wastewater and genomic surveillance became critical as home testing eroded case-based counting.
6. **Archival value:** programs like FloodLAMP, SafeGuard, and SCAN are valuable not only technically but as evidence of how institutions navigated ambiguous regulatory boundaries under emergency conditions.
## Appendix A -- FloodLAMP archive pointers (regulatory/surveillance subcategory)
Below is the list you provided (file names + short summaries). These documents are useful "anchor texts" for reconstructing the surveillance-testing regulatory story as experienced by operators.
1. **2021-03-30_NY Times - Why Virus Tests at One Elite School Ran Afoul of Regulators.md**
NYT narrative of New Trier High School testing scrutiny; highlights confusion between "surveillance" and regulated screening.
2. **CDC - Testing Strategies for SARS-CoV-2 (includes Surveillance 12-28-2021).md**
CDC definitions/contrast of diagnostic, screening, and public health surveillance testing, including a summary matrix.
3. **CMS - CLIA SARS-CoV-2 Variant Testing Frequently Asked Question (2021-03-19).md**
CMS positions sequencing-based surveillance as potentially non-CLIA if not reported to individuals; discusses limited enforcement discretion for public health reporting.
4. **CMS - CLIA Surveillance Testing SARS-CoV-2 Frequently Asked Questions (2021-10-21).md**
CMS description of pooled surveillance testing, risks, and confirmatory testing expectations.
5. **CMS - CLIA University Lab Testing FAQ (2020-08-28).md**
CMS explanation of when surveillance testing requires CLIA, including pooled cohort reporting and enforcement discretion pathways.
6. **CMS Notice Letter - RE CLIA SURVEILLANCE TESTING (Dec 2020).md**
Clarifies when a facility becomes a CLIA-regulated lab and describes temporary enforcement discretion for surveillance workflows.
7. **FDA Warning Emails to FloodLAMP - Re_ Testing Clinical COVID-19 Samples (March 2022).md**
FDA outreach after reviewing FloodLAMP's website; requests revisions where surveillance language implied individual follow-up testing by FloodLAMP.
8. **FDA Website - COVID-19 Test Uses_ FAQs on Testing for SARS-CoV-2 (updated 2023-09-29).md**
FDA definitions and examples of diagnostic vs screening vs surveillance; setting/CLIA mapping for EUAs and traditional authorizations.
9. **FloodLAMP Non-Diagnostic Surveillance Testing Materials Acknowledgment and Waiver.md**
Entity-facing agreement clarifying non-diagnostic status, no individual results, and referral requirements; includes liability waiver.
10. **FloodLAMP Surveillance FAQ and Links (June 2022 DRAFT).md**
Contrasts diagnostic and surveillance testing; quotes CMS/FDA guidance about surveillance being outside CLIA/FDA when no individual results returned.
11. **FloodLAMP Surveillance Information (Aug 2021 INTERNAL).md**
Internal memo on regulatory framing for pooled non-diagnostic surveillance; cites CMS enforcement discretion and research-lab exemptions.
12. **Memo - Surveillance Authority Plain-language Research (Jan 2021 from Senior Medical Director in Healthcare Industry).md**
Plain-language digest of FDA/CMS surveillance framing and conditions under which presumptive positives may be routed to CLIA confirmatory testing.
13. **Memo - USA Surveillance Strategy (Sept 2021 from non-FloodLAMP Healthcare Attorney).md**
Notes surveillance testing generally not regulated when de-identified and no individual results returned; recommends coordination with public health and careful cohort sizing.
## Appendix B -- Selected primary sources and "high-signal" reading list
### B1. FDA (definitions, policies, and context)
- FDA "COVID-19 Test Uses: FAQs on Testing for SARS-CoV-2" (definitions; updated 9/29/23):
`regulatory/surveillance/FDA Website - COVID-19 Test Uses_ FAQs on Testing for SARS-CoV-2 (updated 2023-09-29).md`
https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-test-uses-faqs-testing-sars-cov-2
- FDA "FAQs on Testing for SARS-CoV-2" (developer-focused; updated 11/8/23):
https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2
- FDA "Historical Information about Device Emergency Use Authorizations" (revoked/expired EUAs, revocation letters; updated 2026):
https://www.fda.gov/medical-devices/emergency-use-authorizations-medical-devices/historical-information-about-device-emergency-use-authorizations
### B2. CMS / CLIA (post-PHE guidance and key memos)
- CMS QSO-23-15-CLIA (post-PHE changes; 5/11/2023): https://www.cms.gov/files/document/qso-23-15-clia.pdf
- CMS post-PHE CLIA FAQs (5/11/2023): https://www.cms.gov/files/document/clia-post-phe-guidance-faqs-only.pdf
- CMS "Infectious diseases" landing page (links to CLIA COVID PDFs, including surveillance testing FAQ):
https://www.cms.gov/about-cms/what-we-do/emergency-response/past-emergencies/infectious-diseases
### B3. Seattle surveillance (Seattle Flu Study / SCAN) -- the FDA/Gates touchpoint
- NEJM: "Early Detection of Covid-19 through a Citywide Pandemic Surveillance Platform" (Chu et al.):
https://www.nejm.org/doi/full/10.1056/NEJMc2008646
- Public Health Insider: SCAN launch (Mar 23, 2020):
https://publichealthinsider.com/2020/03/23/introducing-scan-the-greater-seattle-coronavirus-assessment-network/
- Public Health Insider: SCAN resumes + pause explanation (Jun 10, 2020):
https://publichealthinsider.com/2020/06/10/greater-seattle-coronavirus-assessment-network-scan-resumes-covid-19-testing/
- Reuters: FDA suspends Gates-backed at-home COVID-19 testing program (May 2020):
https://www.reuters.com/article/world/u-s-fda-suspends-gates-backed-at-home-covid-19-testing-program-idUSKBN22S0R7/
- STAT: "Experts decry FDA's halting of a high-profile Covid-19 study..." (May 27, 2020):
https://www.statnews.com/2020/05/27/coronavirus-testing-seattle-bill-gates-fda/
### B4. School/community surveillance linked to Ed Campbell and Dave O'Connor
- Hinsdale Magazine: "Keeping the Doors OPEN" (SafeGuard; Campbell + O'Connor linkage):
https://hinsdalemag.com/keeping-the-doors-open/
- Gilson case study: Safeguard Solutions student testing operation:
https://www.gilson.com/us/case-study-safeguard-solutions-a-covid-19-student-testing-operation
- UW News: UW researchers develop saliva RT-LAMP testing method (Aug 6, 2020):
https://news.wisc.edu/uw-researchers-develop-new-method-to-test-for-covid-19/
- Newman et al. (2021, open access): mobile RT-LAMP testing strategy:
https://pmc.ncbi.nlm.nih.gov/articles/PMC7809916/
- WIRED: Wisconsin DIY/LAMP testing + O'Connor quotes (Jul 23, 2020):
https://www.wired.com/story/a-wisconsin-city-experiments-with-a-faster-diy-covid-19-test/
- UW story on Dane County outbreak + sequencing surveillance (Oct 8, 2020):
https://news.wisc.edu/residence-hall-outbreak-shows-virus-can-spread-quickly-even-when-precautions-taken/
### B5. Wastewater & genomic surveillance (late-pandemic backbone)
- CDC NWSS overview: https://www.cdc.gov/nwss/about.html
- CDC wastewater surveillance success story (includes 2020 launch claim):
https://www.cdc.gov/advanced-molecular-detection/php/success-stories/wastewater-surveillance.html
- CDC SPHERES launch press release (May 1, 2020; archived):
https://archive.cdc.gov/www_cdc_gov/media/releases/2020/p0501-SARS-CoV-2-transmission-map.html
- APHL NS3 overview:
https://www.aphl.org/programs/infectious_disease/SARS-CoV-2/Pages/Sequence-Based-Surveillance-Submission.aspx
### B6. Legal/policy analysis (useful for contextualizing archival documents)
- Yale Law Journal Forum: "Deadly Delay: The FDA's Role in America's COVID-Testing Debacle" (Rao, 2020):
https://yalelawjournal.org/essay/deadly-delay-the-fdas-role-in-americas-covid-testing-debacle
# 1,749 _context-commentary_regulatory-surveillance.md
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last updated: 2026-03-01 RT
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## Context
#### Testing Types: Diagnostic, Screening, and Surveillance
During the COVID-19 pandemic, U.S. testing was categorized into three overlapping purposes:
- **Diagnostic testing**: Testing an individual when there is reason to suspect infection (symptoms or known exposure). Results are returned to the individual and their healthcare provider. The test must be FDA-authorized and performed in a CLIA-certified laboratory.
- **Screening testing**: Testing an individual without symptoms or known exposure, with the intent of making individual decisions based on results (e.g., return to school or work). Like diagnostic testing, screening requires FDA-authorized tests and CLIA-certified labs, and results are returned to individuals.
- **Surveillance testing**: Population-level monitoring, often but not always using de-identified specimens. Results are not returned to individuals and are not used for individual decision-making. Surveillance testing does not require FDA authorization or CLIA certification.
The critical practical distinction: if a test result is used to make a decision about a specific person, regulators generally treated it as screening or diagnostic.
#### Clarification: "Surveillance" in This Archive
Throughout this subcategory and elsewhere in the FloodLAMP archive, "surveillance" refers to non-diagnostic, non-clinical testing programs designed to detect and limit the spread of COVID-19 in schools, workplaces, and communities. It does not refer to wastewater surveillance or genomic variant surveillance, both of which are distinct modalities covered in the AI-generated report referenced below. The absence of a clear regulatory category and standardized terminology for this type of frequent, pandemic stop-the-spread testing is itself a significant gap in pandemic preparedness and response frameworks. There is no good name for it and no established regulatory pathway — an unsolved problem that affected programs like FloodLAMP throughout the pandemic.
#### Key Documents in This Subcategory
For the authoritative regulatory definitions, two government documents provide the clearest framing:
- **FDA "COVID-19 Test Uses: FAQs on Testing for SARS-CoV-2" (updated 2023-09-29)** — The FDA's post-crisis summary of diagnostic, screening, and surveillance definitions, including examples and CLIA/setting requirements.
- **CDC "Testing Strategies for SARS-CoV-2" (updated 2021-12-28)** — Includes a summary matrix comparing the three testing strategies across settings, reporting requirements, and whether results may be returned to individuals.
FloodLAMP's own framing of how it operated under surveillance guidance is documented in:
- **FloodLAMP Surveillance FAQ and Links (June 2022 DRAFT)** — Contrasts diagnostic and surveillance testing, cites CMS/FDA guidance, and explains FloodLAMP's compliance posture. Includes FAQ-style responses prepared for the Coral Springs pilot program.
- **FloodLAMP Surveillance Information (Aug 2021 INTERNAL)** — A detailed internal memo on the regulatory framing for pooled non-diagnostic surveillance, including CMS enforcement discretion citations, an exchange between NIH Director Francis Collins and CMS Administrator Seema Verma on referral pathways, and the eCFR research-lab exemption.
Two outside analyses by professionals that were shared with us are also included:
- **Memo — Surveillance Authority Plain-language Research (Jan 2021 from Senior Medical Director in Healthcare Industry)** — A plain-language digest of FDA/CMS surveillance framing and the conditions under which presumptive positives may be routed to CLIA confirmatory testing.
- **Memo — USA Surveillance Strategy (Sept 2021 from non-FloodLAMP Healthcare Attorney)** — Guidance confirming that surveillance testing is generally not regulated when de-identified and no individual results are returned, and recommending coordination with local public health officials.
For a comprehensive treatment of the surveillance testing regulatory landscape during COVID-19 — including the Seattle Flu Study/SCAN case study, school-based surveillance controversies (SafeGuard/New Trier), and the post-PHE transition to wastewater and genomic surveillance — see the AI-generated report: `_AI_Covid_Surveillance_Testing_Screening_Report.md`.
## Commentary
#### Navigating the Surveillance Framework
Surveillance testing was a regulatory gray area, and operating FloodLAMP's testing programs under this framework was a significant challenge. At the same time, the surveillance designation provided meaningful flexibility.
#### Communicating Results Without Giving "Results"
The central operational challenge was adhering to the requirement that surveillance programs not deliver "individual patient results." FloodLAMP's approach was to take the FDA's and CMS's language literally: when a sample indicated the presence of SARS-CoV-2, participants were told only that they were "referred to follow-up clinical testing." FloodLAMP did not tell participants they were positive or negative, and the company emphasized this distinction and terminology with program administrators.
This approach was informed by what happened at other programs. The CMS notice letter in this archive (December 2020) was sent to surveillance program operators instructing them to stop using the language "results of potential clinical significance." It was FloodLAMP's understanding, received secondhand, that this terminology had been adopted by operators attempting to comply while still communicating something to participants. In practice, everyone involved — operators, participants, and regulators — likely understood that phrasing to mean the surveillance test was positive. FloodLAMP chose to use the FDA's language, and a "referral to follow-up (clinical) testing", along with the explanation that we were not allowed to give "positive/negative" results to individual participants. The resulting communication was initially confusing for participants and program admins, but after a few repetitions they then understood. This kind of linguistic dance does not serve the public interest during a pandemic.
#### The Fundamental Regulatory Gap
The core problem was that the FDA did not distinguish between two very different kinds of "individual decisions." On one hand, there are clinical medical decisions: using a test result as a diagnosis and relying on it for treatment. On the other hand, there are public health mitigation decisions such as going home from school/work, and isolating from family members, and getting a follow-up diagnostic test. In FloodLAMP's programs, the individual actions triggered by surveillance were of the second kind — participants went home, isolated, and in nearly all cases obtained confirmatory clinical testing (antigen, PCR, or both).
A better framework for pandemic screening would require that public health screening programs mandate follow-up confirmatory testing for flagged participants and that participants report those results back to the program. This would serve two purposes: providing the comparison data needed to evaluate the screening program's performance, and codifying the principle that screening test results should not be the basis for medical decisions.
#### The Coral Springs Experience
The uncertain regulatory status of surveillance nearly prevented FloodLAMP's first major program from proceeding. The Coral Springs pilot covered municipal staff and first responders in a city of approximately 140,000 people and represented FloodLAMP's first significant commercial engagement. The city attorney raised concerns requiring due diligence on the surveillance framework. FloodLAMP was not fully informed of the internal discussions but provided supporting documentation, such as that in the "FloodLAMP Surveillance FAQ and Links" file. The matter reportedly came to a head in a meeting involving city officials, the medical director, regulators (apparently from both FDA and CMS), and at least one elected representative (state or federal level). The outcome was a "green light" for the program, though FloodLAMP never received written confirmation of this decision. (For more on the Coral Springs pilot, see the `pilots/pilot-data` subcategory.)
#### Surveillance as a Fallback
Operating under the surveillance framework was not FloodLAMP's first choice — it was a fallback. The company had submitted its test to the FDA for Emergency Use Authorization and had applied to the RADx program, but could not secure authorization, engagement, or even substantive attention through either channel. The opportunity to operate surveillance programs came about through our contact with EMS leadership and the FTFC conference in South Florida in mid 2021, where we offered pooled testing and made a presentation. One of the key executives at FloodLAMP had prior experience with surveillance and relationships with other operators of surveillance programs. That combined with the pull we were getting from the EMS community, who simply needed better, more effective testing/screening for their critical first responders, led us to do the FloodLAMP surveillance "pilot programs". These programs were very effective for the organizations that implemented them.
The primary commentary on FloodLAMP's regulatory experience, including EUA submissions and FDA correspondence, is in the `regulatory/open-euas` subcategory.
# 2,222 2021-03-30_NY Times - Why Virus Tests at One Elite School Ran Afoul of Regulators.md
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summary_short: The New York Times article “Why Virus Tests at One Elite School Ran Afoul of Regulators” recounts how New Trier High School’s large-scale COVID testing program triggered scrutiny over whether it was conducting regulated screening without proper CLIA certification or an FDA-authorized test. It highlights the practical confusion between “surveillance” and “screening” when individual students are flagged and sent home, and describes how the investigation ended after the testing vendor sought federal lab certification and added qualified oversight.
CONTENT
***INTERNAL TITLE:*** Why Virus Tests at One Elite School Ran Afoul of Regulators
In the suburbs of Chicago, New Trier High School offers a lesson in just how complicated it can be to track the coronavirus in schools.
By Apoorva Mandavilli
Published March 30, 2021 Updated April 12, 2021
It was supposed to be a pandemic triumph, a way for a prestigious school to keep its doors open when many others could not. Instead, the coronavirus testing program at New Trier High School, outside Chicago, offers a cautionary lesson about what happens when educators are asked to take on public health responsibilities.
The Centers for Disease Control and Prevention has urged school administrators to implement regular testing of students in order to identify coronavirus outbreaks before they become more widespread. Late last year, New Trier, which serves families from some of Chicago's most affluent suburbs, rolled out a $1.3 million testing campaign, part of an ambitious plan to keep classrooms open for the school year regardless of rising infection rates in the community.
Administrators made testing mandatory for all 4,000 students on the school's two campuses. But the school chose a lab that had not been certified to run a testing program of its kind, led by a scientist who was not qualified under federal guidelines to run a diagnostic lab. The saliva test the lab used was neither vetted nor authorized by the Food and Drug Administration.
The test relies on a widely used technology, but a study describing its uses has not been published in a peer-reviewed journal nor validated by independent experts. According to federal guidelines, the assay should not be used to identify potentially infected students.
New Trier may have inadvertently violated federal regulations on testing, and the Illinois Department of Public Health opened an investigation into the lab.
"What concerns me is the lack of oversight on any quality," said Scott J. Becker, chief executive of the Association of Public Health Laboratories. "It sounds unkosher, and it just makes me uncomfortable."
In early March, after being contacted by The Times, the testing company, SafeGuard Screening, applied to federal authorities for lab certification and hired a scientist with credentials to run the operation. After SafeGuard applied for certification, the state health department ended its investigation, saying it was taking no action against the testing company.
The C.D.C. encourages K-12 schools to arrange for both diagnostic testing for students and staff members with symptoms of coronavirus infection, and weekly screenings for those without symptoms. (The only exceptions to the second recommendation are for those schools in areas with very low virus transmission rates; there are few communities in the United States that qualify.)
The few schools that have tried to implement testing programs have found it extraordinarily difficult, according to a recent analysis by the Rand Corp. To make testing possible, schools need access to rapid testing, additional personnel and substantial technical assistance, the authors found. Simply persuading staff and students to accept regular testing can be an enormous challenge.
Paul Sally, the superintendent at New Trier, believes his school has overcome the many obstacles that come with testing. "What we're most proud of is the fact that in our school, we don't have cases of transmission," he said.
But for several weeks this winter, infection rates in the towns around New Trier topped 200 cases per 100,000 per week, resulting in a test positivity rate of 13 percent. The school has recorded scores of cases. After a party on Feb. 6, for example, 48 New Trier students tested positive for the coronavirus and more than 200 were quarantined.
New Trier has remained open. By comparison, schools in New York City, the largest public school system in the country, are required to shut down after confirming just two cases.
*Image Caption:* "A lot of kids don't even want to come to school because apart from the Covid risk, it's also just not enjoyable to be at school," said Eva Roytburg, 18, a senior at New Trier. Taylor Glascock for The New York Times
The idea for the testing program formed last summer, when New Trier's administrators and a new reopening advisory board began planning ways to open the school and keep it that way.
School administrators started by looking for a company that could handle testing of the school's sizable population and deliver same-day results at a reasonable price. They settled on SafeGuard, a start-up that had launched in September, paying the company to conduct saliva testing on willing students and staff.
"At that moment, they were the only one available to do this type of screening in our environment," Dr. Sally said.
Edward Campbell, a microbiologist at Loyola University, started SafeGuard after learning of a virus test developed by researchers at the University of Wisconsin- Madison. SafeGuard serves about 30 school districts and runs roughly 30,000 tests per week, at $11 per test, Dr. Campbell said.
New Trier signed on, too, but the introduction of the test did not go smoothly. Tempers flared at school board meetings, with some arguing for the school to open, citing the harm being done to students' mental health. Others questioned the push to stay open despite skyrocketing Covid-19 rates in Illinois.
Some parents made T-shirts, set up a website and held a rally in support of reopening; a group of students countered with an online rally. The testing program roiled the community, pitting the administration against teachers, students against the administration, parents against teachers and parents against parents.
"A lot of kids don't even want to come to school because apart from the Covid risk, it's also just not enjoyable to be at school," said Eva Roytburg, 18, a senior at New Trier
Still, the school pushed ahead with testing. Dr. Campbell's lab analyzed saliva samples from New Trier students and delivered the results in a spreadsheet, flagging students who needed a confirmatory test by a certified lab.
Although SafeGuard technically did not deliver a diagnosis, the implication was clear — after rapid testing, some students were presumed to be infected, and they and their siblings were sent home.
The company and the school refer to this as surveillance. But while surveillance programs may gauge the prevalence of a disease or a pathogen at a population level — that 10 of every 1,000 students are infected, for example — they do not provide results for individuals.
The school and the company were instead "screening" students - flagging individual students who might be infected. And screening testing is subject to stringent regulation.
Since the start of the pandemic, the Food and Drug Administration has granted emergency use authorizations for dozens of coronavirus tests. The C.D.C. details which kinds of testing are appropriate for different purposes. And the Centers for Medicare & Medicaid Services certifies labs for testing through its Clinical Laboratory Improvement Amendments program.
School administrators wishing to implement testing must navigate through a maze of requirements from these agencies, keeping an eye on the subtle differences between surveillance, screening and diagnosis — or trusting a lab to do so for them. Surveillance does not require certification from C.L.I.A., for instance, but screening testing does.
Because of rising confusion, the F.D.A. this month released detailed guidance for schools, workplaces and communities on the differences between screening and diagnostic testing programs.
SafeGuard should have obtained C.L.I.A. certification for its tests, or New Trier should have applied for a waiver to implement its program, according to testing experts.
"It's not hard for a school system to get a C.L.I.A. waiver," Mr. Becker, of the Association of Public Health Laboratories, said. Nearly 300,000 labs are certified to perform testing, and many schools and universities are already relying on those labs and on authorized tests, he noted.
Dr. Campbell said that his lab operates well within current regulations, pointing to a new federal guideline saying that regulators will not cite a lab that is not C.L.I.A.-certified so long as the lab "does not report actual test results" but refers individuals for further testing instead.
But on Dec. 28, officials at the Centers for Medicare & Medicaid Services sent Dr. Campbell a letter clarifying the requirements. "If at any time a patient specific result is to be reported by a facility, a C.L.I.A. certificate must be obtained," the agency warned.
Dr. Campbell said his company had not requested emergency use authorization from the F.D.A. because of the expense and because the process was "so backlogged now."
*Image Caption:* A student walks past New Trier High School, where SafeGuard tests were used despite not being vetted or authorized by the Food and Drug Administration. Taylor Glascock for The New York Times
Stephanie Caccomo, a spokeswoman for the F.D.A., disputed the assertions. "There is no cost for submitting an E.U.A. request," she said, and companies can market their tests as soon as they validate them and notify the agency.
In interviews, Dr. Campbell and school officials said the Illinois Department of Health was aware of the program and had given its blessing. But Melaney Arnold, a spokeswoman for the department, said state regulators "did not approve the use of SafeGuard Screening to provide test results to individuals."
After initial publication of this article, Ms. Arnold contacted The Times to say that since SafeGuard had received federal certification, "at this time, there is no further recommended action."
Dr. Campbell and New Trier administrators insist the testing program is legal and is keeping the school's doors open.
"The guidance is very confusing," said Dr. Campbell. "What's a person trying to operate in good faith supposed to do?"
**A correction was made on April 6, 2021:** Because of an editing error, an earlier version of this article misstated the federal agency to which SafeGuard had applied for lab certification. Such certifications are reviewed by the Centers for Medicare and Medicaid Services, not the Food and Drug Administration.
**A correction was made on April 9, 2021:** An earlier version of this article included outdated information from the Illinois Department of Public Health about the status of its investigation into SafeGuard. After publication, the department responded to an earlier request from The Times about the investigation and said that it had ended its investigation in March, after SafeGuard received federal certification.
When we learn of a mistake, we acknowledge it with a correction. If you spot an error, please let us know at nytnews@nytimes.com. Learn more
**Apoorva Mandavilli** is a reporter focusing on science and global health. She is the 2019 winner of the Victor Cohn Prize for Excellence in Medical Science Reporting.
A version of this article appears in print on, Section A, Page 4 of the New York edition with the headline: Elite High School's Screening Program Runs Afoul of Regulators
# 1,412 CDC - Testing Strategies for SARS-CoV-2 (includes Surveillance 12-28-2021).md
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summary_short: The CDC “Testing Strategies for SARS-CoV-2” guidance (updated Dec. 28, 2021) defines and contrasts diagnostic, screening, and public health surveillance testing, including intended use, who should be tested, and whether results can be returned to individuals. It states that diagnostic and screening testing require CLIA-certified testing sites and FDA-authorized (or FDA-policy) tests with individual and public health reporting requirements, while public health surveillance testing uses de-identified specimens, is not for individual decision-making, and does not require FDA/CLIA compliance. It includes a summary matrix comparing allowable settings, reporting, and result return across the three testing strategies.
CONTENT
***INTERNAL TITLE:*** Testing Strategies for SARS-CoV-2
Updated Dec. 28, 2021
## Summary of Recent Changes
Updates as of August 13, 2021
- Updated information for fully vaccinated people given new evidence on the B.1.617.2 (Delta) variant currently circulating in the United States.
### Key Points
- This guidance describes and compares different types of testing strategies SARS-CoV-2 (the virus that causes COVID-19), including their intended use and applications, regulatory requirements, and reporting requirements.
- This guidance is intended for those who offer and perform SARS-CoV-2 testing.
## Diagnostic Testing
Diagnostic testing is intended to identify current infection in individuals and should be performed on anyone that has signs and symptoms consistent with COVID-19 and/or following recent known or suspected exposure to SARS-CoV-2.
Examples of diagnostic testing include:
- Testing anyone with symptoms consistent with COVID-19
- Testing vaccinated and unvaccinated people who were exposed to someone with a confirmed or suspected case of COVID-19
## Screening Testing
Screening tests are intended to identify unvaccinated people with COVID-19 who are asymptomatic and do not have known, suspected, or reported exposure to SARS-CoV-2. Screening helps to identify unknown cases so that measures can be taken to prevent further transmission.
Examples of screening include testing:
- Employees in a workplace setting
- Students, faculty, and staff in a school setting
- A person before or after travel
- Someone at home who does not have symptoms associated with COVID-19 and no known exposures to someone with COVID-19
## Public Health Surveillance Testing
Public health surveillance is the ongoing, systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practice. See CDC’s [Introduction to Public Health Surveillance](https://www.cdc.gov/training-publichealth101/php/index.html).
Public health surveillance testing is intended to monitor community- or population-level outbreaks of disease, or to characterize the incidence and prevalence of disease. Surveillance testing is performed on de-identifed specimens, and thus, results are not linked to individual people. Public health surveillance testing results cannot be used for individual decision- making.
Public health surveillance testing may sample a certain percentage of a specifc population to monitor for increasing or decreasing prevalence, or to determine the population effect from community interventions such as social distancing. An example of public health surveillance testing is when a state public health department develops a plan to randomly select and sample a percentage of all people in a city on a rolling basis to assess local infection rates and trends.
## Regulatory Requirements for Diagnostic, Screening, and Public Health Surveillance Testing
Any laboratory or testing site that performs diagnostic or screening testing must have a Clinical Laboratory Improvement Amendments ([CLIA](https://www.cdc.gov/clia/php/about/index.html)) certificate and meet all applicable CLIA requirements. For more information, see the Centers for Medicare & Medicaid Services [CLIA website](https://www.cms.gov/medicare/quality/clinical-laboratory-improvement-amendments?redirect=/clia) Emergency Use Authorization from the U.S. Food and Drug Administration (FDA) or be offered under the policies in FDA’s [Policy for COVID-19 Tests](https://www.fda.gov/media/135659/download)
Tests used for SARS-CoV-2 **public health surveillance** on de-identifed human specimens do not need to meet FDA and CLIA requirements for diagnostic and screening testing.
## Reporting Diagnostic, Screening, and Public Health Surveillance Testing Results
Both diagnostic and screening testing results should be reported to the people whose specimens were tested and/or to their healthcare providers.
In addition, laboratories that perform diagnostic and screening testing must report test results (positive and negative) to the local, state, tribal, or territory health department in accordance with Public Law 116-136, § 18115(a), the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The Department of Health and Human Services published guidance on [COVID-19 Pandemic Response, Laboratory Data Reporting CARES Act Section 18115](https://www.hhs.gov/sites/default/files/covid-19-laboratory-data-reporting-guidance.pdf)that specifies what data, in addition to results, laboratories and testing sites should collect and electronically report.
Public health surveillance testing results cannot be reported directly to the people whose specimens have been tested and are not reported to their healthcare providers. Public health surveillance testing results (test results that are de-identified) can
be reported in aggregate to local, state, tribal, or territory health departments upon request. Results from testing that is performed outside of a CLIA-certified facility or without an FDA-authorized test can only be reported to a health department if those results are used strictly for public health surveillance purposes, and not used for individual decision making.
## Summary of Testing Strategies for SARS-CoV-2
| | Diagnostic | Screening | Public Health Surveillance |
|---|---|---|---|
| Symptomatic | Yes | No | N/A |
| Unvaccinated or vaccinated with known or suspected exposure to SARS-CoV-2 | Yes | No | N/A |
| Unvaccinated and asymptomatic without known or reported suspected exposure to SARS-CoV-2 | No | Yes | N/A |
| Characterize incidence and prevalence in the community | N/A | N/A | Yes |
| Testing of personally identifiable specimens | Yes | Yes | No |
| Results may be returned to individuals | Yes | Yes | No |
| Results returned in aggregate to requesting institution | No | No | Yes |
| Results reported to state public health department | Yes | Yes | If requested |
| Testing can be performed in a CLIA-certified laboratory | Yes | Yes | Yes |
| Testing can be performed in a non-CLIA-certified laboratory | No | No | Yes |
| Test system must be FDA authorized or be offered under the policies in FDA’s guidance | Yes | Yes | No |
||
## Resources
- [Overview of Testing for SARS-CoV-2 (COVID-19)](https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html)
- [FDA FAQs on Testing for SARS-CoV-2](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2)
## Previous Updates
**Updates from May 25, 2021**
- Revised to align with [Interim Public Health Recommendations for Fully Vaccinated People](https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html)
Last Updated Dec. 28, 2021
# 1,012 CMS - CLIA SARS-CoV-2 Variant Testing Frequently Asked Question (2021-03-19).md
METADATA
last updated: 2026-03-05 by BA
file_name: CMS - CLIA SARS-CoV-2 Variant Testing Frequently Asked Question (2021-03-19).md
file_date: 2021-03-19
title: CMS CLIA - CLIA SARS-CoV-2 Variant Testing Frequently Asked Question
category: regulatory
subcategory: surveillance
tags:
source_file_type: pdf
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: https://drive.google.com/file/d/15jnDb6cPCPAOkYUlintP0s-kO8am2-Gp
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/surveillance/CMS%20-%20CLIA%20SARS-CoV-2%20Variant%20Testing%20Frequently%20Asked%20Question%20%282021-03-19%29.pdf
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license: public domain
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notes:
summary_short: The CMS CLIA “SARS-CoV-2 Variant Testing” FAQ (3/19/2021) outlines when sequencing-based surveillance for genetic variants can be done without a CLIA certificate, so long as results are not reported to individuals or their health care providers and are not used for individual decision-making. It describes CMS’s temporary enforcement discretion allowing non-CLIA facilities (and certain CLIA labs) to report patient-specific variant results to state/local public health departments for public health uses like outbreak detection and contact tracing. It also clarifies that if variant results are intended for diagnosis, prevention, treatment, or health assessment, testing must be performed in a CLIA-certified lab in compliance with CLIA requirements (including performance specifications expectations).
CONTENT
***INTERNAL TITLE:*** CLIA SARS-CoV-2 Variant Testing Frequently Asked Question Date: 3/19/2021
__Does a facility that performs surveillance testing to identify SARS- CoV-2 genetic variants need a CLIA certificate?__
CMS is temporarily exercising enforcement discretion under CLIA for SARS-CoV-2 genetic variant testing on identified specimens in which patient-specific results are reported to State or local Public Health Departments. As defined by Centers for Disease Control and Prevention (CDC), public health surveillance testing for SARS-CoV-2 is intended to monitor community- or population-level outbreaks of disease, or to characterize the incidence and prevalence of disease. Public health surveillance testing is performed on de-identified specimens, and thus results are not linked to individuals. Public health surveillance testing cannot be used for individual decision-making. See CDC’s [Testing Strategies for SARS-CoV-2 (Frequently Asked Questions about Coronavirus (COVID-19) for Laboratories)](https://www.cdc.gov/coronavirus/2019-ncov/lab/faqs.html#Testing-Strategies-for-SARS-CoV-2).
Generally, surveillance testing using sequencing technology to identify SARS-CoV-2 genetic variants can be performed in a facility that is NOT CLIA certified, provided that patient-specific results are not reported to (1) the individual who was tested or (2) their health care provider. If at any time a facility intends to perform testing on identified specimens and report a patient-specific SARS-CoV-2 genetic variant test result to the individual who was tested or to their health care provider, the facility must comply with CLIA and is thereby required to obtain the appropriate CLIA certificate in accordance with 42 CFR Part 493, laboratory requirements.
However, as indicated above, CMS will not take action against non-CLIA certified facilities that perform SARS-CoV-2 genetic variant testing on identified specimens and report patient-specific results to State or local Public Health Departments, provided that the facility only reports patient-specific results to a Public Health Department and the results are not intended to be used for purposes of an individual’s diagnosis, prevention, treatment, or health assessment. The Public Health Departments should only use these results for public health purposes, such as contact tracing, outbreak detection, etc. If at any time the SARS-CoV-2 genetic variant result is intended to be used for purposes of an individual’s diagnosis, prevention, treatment, or health assessment, the test must be performed in a CLIA certified laboratory and in compliance with all applicable CLIA regulations (42 CFR part 493).
CLIA-certified laboratories continue to be permitted to report patient-specific results to authorized persons, which may include the individual who was tested, their health care provider, or a Public Health Department1, as applicable, for SARS-CoV-2 genetic variant testing and other tests. If a CLIA certified laboratory performing SARS-CoV-2 genetic variant testing decides to report patient-specific results to an individual or their healthcare provider, then the laboratory must establish performance specifications for their assay. See 42 CFR §493.1253(b)(2). CLIA regulations are not prescriptive as to the number of samples required to establish performance specifications. When a genetic variant is discovered during a public health emergency, there may be very limited number of samples available for the establishment of performance specifications. This does not necessarily prevent laboratories from utilizing assays testing for the novel variant. When the number of samples that a laboratory would normally run for the establishment of performance specifications are not available, it is the responsibility of the laboratory director (LD) to ensure that procedures used are adequate to establish the accuracy, precision, and other pertinent performance characteristics of the method. While initially there may not be many samples to establish performance specifications, as time goes on, and as more samples become available, the LD may choose to enhance their assay to the level of other tests in their laboratory. However, CMS will not cite CLIA certified laboratories that perform SARS-CoV-2 genetic variant testing on identified specimens and report patient-specific variant results to State or local Public Health Departments without establishing performance specifications as required by §493.1253(b)(2), provided that the laboratory only reports patient-specific results to a Public Health Department and the results are not intended to be used for purposes of an individual’s diagnosis, prevention, treatment, or health assessment. If at any time the SARS-CoV-2 genetic variant result is intended to be used for purposes of an individual’s diagnosis, prevention, treatment, or health assessment, the test must be performed in a CLIA-certified laboratory and in compliance with all applicable CLIA regulations.
1: While most if not all public health departments would likely meet the CLIA definition of an "authorized person", see 42 CFR §493.2 ("Authorized person means an individual authorized under State law to order tests or receive test results, or both."), this would technically be determined on a case-by-case basis.
# 393 CMS - CLIA Surveillance Testing SARS-CoV-2 Frequently Asked Questions (2021-10-21).md
METADATA
last updated: 2026-03-05 by BA
file_name: CMS - CLIA Surveillance Testing SARS-CoV-2 Frequently Asked Questions (2021-10-21).md
file_date: 2021-10-21
title: CMS CLIA - Surveillance Testing SARS-CoV-2 Frequently Asked Questions
category: regulatory
subcategory: surveillance
tags:
source_file_type: pdf
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pdf_gdrive_url: https://drive.google.com/file/d/1FN0e5vbU3eJ2hMSewH9to42yvYhWisCn
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notes:
summary_short: The CMS CLIA “SARS-CoV-2 Surveillance Testing” FAQ (revised 10/21/21) explains when facilities using pooled surveillance testing with non-patient-specific cohort reporting do not need a CLIA certificate during the COVID-19 public health emergency. It highlights key risks of pooled surveillance testing (including dilution-related false negatives/positives) and states that any positive/inconclusive pool results must be confirmed via individual testing at a CLIA-certified facility. It also notes that because these facilities are not CLIA-certified, CMS does not have oversight authority over their quality and safety of result reporting.
CONTENT
***INTERNAL TITLE:*** Frequently Asked Questions: SARS-CoV-2 Surveillance Testing
*Revised 10/21/21*
1. **Does my facility need a CLIA certificate if we are performing SARS-CoV-2 surveillance testing using a pooled sampling procedure with non patient-specific reporting?**
A. During this COVID-19 Public Health Emergency, facilities performing SARS-CoV-2 surveillance testing using a pooled sampling procedure to report *non patient-specific SARS-CoV-2 cohort results* will not require CLIA certification. This testing is not considered by CMS to be diagnostic of SARS-CoV-2 infection, and participants should not rely on information received from this type of testing for decision making purposes.
If at any time a *patient specific result* is to be reported by your facility, you *must first obtain a CLIA certificate* and meet all requirements to perform testing.
2. **What are the potential risks of using a surveillance pooled sampling procedure?**
A. There may be a risk of obtaining false negative or false positive results when utilizing a pooled sampling testing model. According to the FDA website, “Surveillance with pooled or batched testing should be validated on a test platform and test of high sensitivity and positive tests should have a confirmatory test. Because samples are diluted, which could result in less viral genetic material available to detect, there is a greater likelihood of false negative results, particularly if not properly validated.” To possibly mitigate this risk, all positive and inconclusive SARS-CoV-2 results from pooled sampling must be confirmed by having each participant whose sample was contained within the cohort to be tested by a CLIA-certified facility.
3. **Will CMS have oversight of testing facilities that perform pooled surveillance SARS-CoV-2 testing?**
A. As these facilities are not CLIA certified, CMS will have no oversight authority to ensure quality and safety of result reporting.
# 727 CMS - CLIA University Lab Testing FAQ (2020-08-28).md
METADATA
last updated: 2026-03-05 by BA
file_name: CMS - CLIA University Lab Testing FAQ (2020-08-28).md
file_date: 2020-08-28
title: CMS CLIA - University Lab Testing FAQ (2020-08-28)
category: regulatory
subcategory: surveillance
tags:
source_file_type: pdf
xfile_type: NA
gfile_url: NA
xfile_github_download_url: NA
pdf_gdrive_url: https://drive.google.com/file/d/1tgBv4ypHFed2fe3T2KXxxGb3H7JoYMAS
pdf_github_url: NA
web_url: https://www.cms.gov/files/document/clia-university-lab-testing-8/28/2020.pdf
conversion_input_file_type: pdf
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license: Public Domain
tokens: 727
words: 566
notes:
summary_short: The CMS Q&A explains when SARS-CoV-2 surveillance testing requires CLIA certification, emphasizing that pooled, non-patient-specific cohort reporting is not considered diagnostic and does not require a CLIA certificate. It clarifies that reporting patient-specific results generally triggers CLIA requirements, but CMS exercised temporary enforcement discretion during the public health emergency if non-CLIA labs only issue presumptive positive/inconclusive referrals to a CLIA-certified lab rather than reporting definitive results. It also outlines pathways for universities to operate under an affiliated lab’s CLIA certificate (including temporary sites) or to apply for an expedited CLIA certificate with a qualified lab director.
CONTENT
**1. Does my facility need a CLIA certificate if we are performing SARS-CoV-2 surveillance testing using a pooled sampling procedure with non-patient-specific reporting?**
Facilities performing SARS-CoV-2 surveillance testing using a pooled sampling procedure to report non patient- specific SARS-CoV-2 cohort results will not require CLIA certification. This surveillance testing is not considered by CMS to be diagnostic of SARS-CoV-2 infection, and individuals undergoing testing should not rely on information received from this type of testing for decision making purposes.
**2. With some of the other surveillance platforms that use next-generation sequencing, there is no need for a pooling strategy (the samples are all bar-coded) – in that instance, is it acceptable for the university to notify a specific person that he or she should seek testing in a CLIA lab?**
Generally, SARS-CoV-2 surveillance testing can be performed in a facility that is NOT CLIA certified, and may use a test or technique NOT authorized by the FDA, provided that patient-specific results are not reported. If at any time a patient-specific result is reported, the facility is subject to CLIA and required to obtain an appropriate CLIA certificate in accordance with 42 CFR part 493.
However, CMS is temporarily exercising enforcement discretion under CLIA for SARS-CoV-2 surveillance testing where patient-specific results are reported (e.g., SARS-CoV-2 surveillance testing that does not utilize a pooling strategy). Specifically, neither CMS nor the State survey agencies on its behalf will cite non-CLIA certified facilities, such as university laboratories, that are performing such testing, provided that the facility does not report actual test results, but only refers an individual with a presumptive positive or inconclusive test result to a CLIA-certified laboratory for further testing.
**3. If my University lab is not currently CLIA certified, what options are available to become CLIA certified or operate under an existing CLIA certificate?**
As noted on our March 26, 2020 memorandum (https://www.cms.gov/files/document/qso-20-21-clia.pdf-0 ), CMS is committed to taking critical steps to ensure America’s clinical laboratories are prepared to respond to the threat of COVID-19 and to expand laboratory capacity during the public health emergency. University laboratories have several pathways to begin testing during the public health emergency:
- University labs may operate under the existing CLIA certificate of an affiliated University lab, including as a temporary remote location of an existing lab. During this public health emergency, CMS is not enforcing the requirement to have a separate certificate for laboratories that are located at a temporary testing site, provided that the designated primary site has such a certificate and the work being performed in the temporary testing site falls within the parameters of the primary site’s certificate.
- University labs may also apply for a CLIA certificate. CMS wants to ensure that laboratories located in the United States wishing to perform COVID-19 testing are able to begin testing as quickly as possible during the public health emergency, and have therefore expedited our review of CLIA certificate applications. Once the lab has identified a qualified lab director and has provided all required information, a CLIA number will be assigned and the lab can begin testing.
- University labs may utilize the same lab director as an existing University CLIA-certified lab, even if the laboratory director supervises from a different university location.
- Labs may also contract with a non-university affiliated lab director who meets CLIA requirements to operate the lab and fill the role of laboratory director.
# 741 CMS Notice Letter - RE CLIA SURVEILLANCE TESTING (Dec 2020).md
METADATA
last updated: 2026-03-05 by BA
file_name: CMS Notice Letter - RE CLIA SURVEILLANCE TESTING (Dec 2020).md
file_date: 2020-12-28
title: CMS Notice Letter - RE CLIA SURVEILLANCE TESTING (Dec 2020)
category: regulatory
subcategory: surveillance
tags:
source_file_type: gdoc
xfile_type: docx
gfile_url: https://docs.google.com/document/d/1LU0avTD5u8AQTM_Ybz_jY8mRwK7FVr11o_NR_6nfIM8
xfile_github_download_url: https://raw.githubusercontent.com/FocusOnFoundationsNonprofit/floodlamp-archive/main/regulatory/surveillance/CMS%20Notice%20Letter%20-%20RE%20CLIA%20SURVEILLANCE%20TESTING%20%28Dec%202020%29.docx
pdf_gdrive_url: https://drive.google.com/file/d/16GgSq3IeZElT55GLwFVo2iY8MUyiiiby
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/surveillance/CMS%20Notice%20Letter%20-%20RE%20CLIA%20SURVEILLANCE%20TESTING%20%28Dec%202020%29.pdf
conversion_input_file_type: docx
conversion: pandoc
license: CC BY 4.0 - https://creativecommons.org/licenses/by/4.0/
tokens: 741
words: 507
notes:
summary_short: The CMS CLIA Surveillance Testing notice (Dec. 28, 2020) explains when a facility is considered a CLIA-regulated laboratory and states that COVID-19 testing generally requires CLIA certification if patient-specific results are reported. It describes CMS’s temporary enforcement discretion for SARS-CoV-2 surveillance testing in non-CLIA facilities, allowing non-FDA-authorized methods so long as no individual results (e.g., negative/positive/inconclusive) are provided and individuals are only referred to CLIA-certified labs for follow-up.
CONTENT
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Division of Clinical Laboratory Improvement & Quality
Northeastern and Midwestern Operations Branch
Chicago Office
233 North Michigan Avenue, Suite 600
Chicago, IL 60601-551
Sent via email to:
IMPORTANT NOTICE – PLEASE READ CAREFULLY
December 28, 2020
\[Recipient Redacted\]
RE: CLIA SURVEILLANCE TESTING
\[Recipient Redacted\],
It has come to our attention that your facility \[Recipient Redacted\], is performing COVID-19 testing. In order to conduct COVID-19 testing, a facility must be a CLIA certified laboratory that meets applicable regulatory requirements appropriate for the complexity designation of the test. A CLIA certificate is required for any testing facility that meets the CLIA regulatory definition of a laboratory. The CLIA regulations at 42 CFR Part 493 define a laboratory as “a facility for the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body.
To become CLIA-certified, laboratories must comply with the accuracy, quality, and reliability requirements as dictated by the statute. The purpose of these requirements is to ensure that the information that patients or their health care providers receive from a clinical laboratory is accurate and reliable test results. Laboratories that wish to become CLIA certified must apply for a CLIA
Certificate. You may access the CLIA regulations at: https://www.ecfr.gov/cgi-bin/text-idx?SID=1248e3189da5e5f936e55315402bc38b&node=pt42.5.493&rgn=div5
If you elect to apply for CLIA certificate, a CLIA application may be obtained from:
\[State Public Health Department\]
Generally, SARS-CoV-2 surveillance testing can be performed in a facility that is NOT CLIA
certified, and may use a test or technique NOT authorized by the FDA, provided that patient-specific results are not reported. If at any time a patient-specific result is reported, the facility is subject to CLIA and required to obtain an appropriate CLIA certificate in accordance with 42 CFR part 493.
CMS is temporarily exercising enforcement discretion under CLIA for SARS-CoV-2 surveillance testing, specifically, neither CMS nor the State survey agencies on its behalf will cite non-CLIA certified facilities, provided that the facility does not report actual test results, but only refers an individual to a CLIA-certified laboratory for further testing. No individuals can be given a patient-specific result from any testing, that is from a sample that is negative, positive, inconclusive, presumptive positive, a result of clinical significance, or a result of potential clinical significance. If at any time a patient specific result is to be reported by a facility, a CLIA certificate must be obtained, and the facility must meet all requirements to perform testing. You may contact Raymond Castillo via electronic mail at: raymond.castillo@cms.hhs.gov should you have additional questions.
Sincerely,
Ronisha Blackstone, Manager
Division of Clinical Laboratory Improvement & Quality
Northeastern and Midwestern Operations Branch
(Chicago, Boston, New York and Philadelphia)
cc: IDPH
# 2,268 FDA Warning Emails to FloodLAMP - Re_ Testing Clinical COVID-19 Samples (March 2022).md
METADATA
last updated: 2026-03-05 by BA
file_name: FDA Warning Emails to FloodLAMP - Re_ Testing Clinical COVID-19 Samples (March 2022).md
file_date: 2022-03-01
title: FDA Warning Emails to FloodLAMP - Re_ Testing Clinical COVID-19 Samples (March 2022)
category: regulatory
subcategory: surveillance
tags:
source_file_type: pdf
xfile_type: NA
gfile_url: NA
xfile_github_download_url: https://raw.githubusercontent.com/FocusOnFoundationsNonprofit/floodlamp-archive/main/regulatory/surveillance/FDA%20Warning%20Emails%20to%20FloodLAMP%20-%20Re_%20Testing%20Clinical%20COVID-19%20Samples%20%28March%202022%29.NA
pdf_gdrive_url: https://drive.google.com/file/d/1dUoHPLqsXbjQIPnRv4NLXVP6on1OViS6
pdf_github_url: https://github.com/FocusOnFoundationsNonprofit/floodlamp-archive/blob/main/regulatory/surveillance/FDA%20Warning%20Emails%20to%20FloodLAMP%20-%20Re_%20Testing%20Clinical%20COVID-19%20Samples%20%28March%202022%29.pdf
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conversion: megaparse
license: CC BY 4.0 - https://creativecommons.org/licenses/by/4.0/
tokens: 2268
words: 1568
notes: Title says March 2022, so used 2022-03-01 as date.
summary_short: The FDA–FloodLAMP email thread (Jan–Mar 2022) documents FDA outreach after reviewing FloodLAMP’s website, requesting clarification on whether FloodLAMP was offering clinical COVID-19 testing, whether it held a CLIA certificate, and whether the method was EUA-authorized. FDA flagged website language suggesting individual follow-up testing with FloodLAMP after a positive pool as inconsistent with “surveillance” testing, and asked FloodLAMP to remove or revise claims and confirm plans to bring the site into compliance. The exchange ends with FloodLAMP stating it removed the individual follow-up FAQ language and FDA reiterating that FloodLAMP should review and align practices with the FDA’s revised COVID-19 testing policy guidance and that agency priorities may change.
CONTENT
***INTERNAL TITLE:*** Re: Testing Clinical COVID-19 Samples
## EMAIL 2022-03-24 From FDA to FloodLAMP
Condon, Peter *
To: Randy True
Thu, Mar 24, 2022 at 6:20 AM
Good Morning Randy,
Thank you for your cooperation in clarifying the services Floodlamp is offering. I do want to remind you that the FDA has published a guidance document entitled Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised November 2021). It can be located here; https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-during-public-health-emergency-revised. We recommend that you review the document to ensure that your practices are consistent with the guideline. I will also remind you again that policy may change as a result of the evolution of the pandemic and prioritization of response elements to the pandemic.
Thank you again for your cooperation.
Best regards,
Peter
Peter J. Condon, Ph.D.
In-Vitro Diagnostic Subject Matter Expert
Contractor, Tunnell Consulting, Inc.
Center for Devices and Radiological Health
OPEQ, OHT7
U.S. Food and Drug Administration
Peter.condon@fda.hhs.gov
Excellent customer service is important to us. Please take a moment to provide feedback regarding the customer service
you have received:
https://www.research.net/s/cdrhcustomerservice?ID=1930&S=E
This communication is consistent with 21 CFR 10.85 (k) and constitutes an informal communication that represents my best judgment at this time but does not constitute an advisory opinion, does not necessarily represent the formal position of FDA, and does not bind or otherwise obligate or commit the agency to the views expressed. This communication is intended for the exclusive use of the recipient(s) named in this correspondence. It may contain information that is protected, privileged, or confidential, and it should not be modified. It may not be disseminated, distributed, reproduced, or copied to persons not authorized to receive such information. If you are not the intended recipient, any dissemination, distribution, or copying is strictly prohibited. If you think you have received this communication in error, please immediately delete all copies from the saved sources and notify FDA by email at: CDRH-EUA-Templates immediately.
## EMAIL 2022-03-07 From FloodLAMP to FDA
From: Randy True
Sent: Monday, March 7, 2022 8:29 PM
To: Condon, Peter *
Subject: EXTERNAL Re: Testing Clinical COVID-19 Samples
CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you
recognize the sender and know the content is safe.
Hi Peter,
Apologies for the delay in replying, I was traveling for work last week.
We removed that question in our web FAQ regarding individual follow up testing to avoid any confusion. We're very
careful in all of our communications to emphasize our testing is surveillance and not diagnostic.
Best Regards,
Randy
## EMAIL 2022-03-03 From FDA to FloodLAMP
On Thu Mar 3 2022 at 6:57 AM Condon Peter wrote:
Dear Randy,
I wanted to follow up with you regarding my initial inquiry into the Floodlamp Testing Service.
You have indicated that you are offering a surveillance testing service and that your protocol was vetted during a conference call with representatives of CMS. I will point out that this conference was not attended by representatives of the FDA and therefore any information that you received does not indicate FDA's thinking on your testing methodology.
On your web page https://floodlamp.bio/#FAQ you indicate that if a pool is positive, you
recommend evaluating the individuals in the pool using the Floodlamp Molecular Test. Any
testing that would provide results for individuals would not be construed as surveillance testing. This statement is antithetical to your assertion that you are providing solely surveillance testing. Please remove any claims on your site that are not consistent with your stated policy of providing surveillance testing.
**What happens if a pool is positive?**
- If a pool is positive, we recommend immediate follow up testing of the individuals in the pool, both with our test and a diagnostic test. The exact protocol is decided by the organization, as well as which diagnostic test is used. The protocol may vary depending on the relationship
of the people in the pool (ie. whether they are family members or had exposure to each other). Follow up testing with antigen tests works
well to "rule-in" an individual as positive, but because our test has higher sensitivity, we also recommend running the individuals with FloodLAMP or another molecular test.
- Procedurally, when our lab staff reports a pool as positive in the system, it automatically notifies the administrators of the organization with the name and contact information for everyone in the pool. The administrators contact the individuals and instruct them on the next steps.
I would like to remind you that the response to the ongoing pandemic is evolving as the nature of the pandemic itself evolves. The information conveyed to you during the August 2021 conversation you had with CMS may become obsolete as the response to the pandemic becomes updated.
This note reflects issues noted by the FDA during review of your website. This may not be a fully comprehensive list. We recommend that you review the contents of your website to make sure it is compliant with all current requirements.
Please respond to this e-mail by March 8, 2022, to inform us of your plans to bring your website
into compliance.
Best regards,
Peter
Peter J. Condon, Ph.D.
In-Vitro Diagnostic Subject Matter Expert
Contractor, Tunnell Consulting, Inc.
Center for Devices and Radiological Health
OPEQ, OHT7
U.S. Food and Drug Administration
Peter.condon@fda.hhs.gov
Excellent customer service is important to us. Please take a moment to provide feedback regarding the customer service you have received:
https://www.research.net/s/cdrhcustomerservice?ID=1930&S=E
This communication is consistent with 21 CFR 10.85 (k) and constitutes an informal communication that represents my best judgment at this time but does not constitute an advisory opinion, does not necessarily represent the formal position of FDA, and does not bind or otherwise obligate or commit the agency to the views expressed. This communication is intended for the exclusive use of the recipient(s) named in this correspondence. It may contain information that is protected, privileged, or confidential, and it should not be modified. It may not be disseminated, distributed, reproduced, or copied to persons not authorized to receive such information. If you are not the intended recipient, any dissemination, distribution, or copying is strictly prohibited. If you think you have received this communication in error, please immediately delete all copies from the saved sources and notify FDA by email at: CDRH-EUA-Templates immediately.
## EMAIL 2022-01-04 From FloodLAMP to FDA
From: Randy True
Sent: Tuesday, January 4, 2022 2:40 PM
To: Condon, Peter
Subject: [EXTERNAL] Re: Testing Clinical COVID-19 Samples
CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe.
Hi Peter,
We operate surveillance not diagnostic programs. The first question in our FAQ explains that so I'm a bit confused. Did you see that and are you familiar with surveillance? We follow CMS guidance on surveillance testing.
Best,
Randy
**What is the difference between FloodLAMP's surveillance testing and diagnostic COVID testing?**
Diagnostic testing is within the medical framework, with exclusive focus on the individual and gaining information for the purpose of their care as a patient. Surveillance testing looks for infection in a population or community, and has expanded greatly during the COVID Public Health Emergency. The information from surveillance testing can be used for the purpose of stopping the spread of the disease and for managing risk mitigation measures for the group, such as wearing masks. No exchange of personal health information is required for surveillance. Further, a much greater degree of flexibility in where and how it's implemented enables programs such as FloodLAMP's to better meet the needs of groups looking to interact safely and protect their community.
## EMAIL 2022-01-04 From FDA to FloodLAMP
On Tue, Jan 4, 2022 at 11:28 AM Condon, Peter * Peter.Condon@fda.hhs.gov> wrote:
Dear Mr. True,
After evaluating your website https://floodlamp.bio/, and https://floodlamp.bio/#FAQ, you appear to be offering a testing service for COVID-19 clinical samples. We were unable to find a CLIA Identification Number associated with your organization. Could you please provide your CLIA Identification Number. Also could you please identify the testing method that you are using and indicate if the method has been authorized for emergency use?
Best regards,
Peter
Peter J. Condon, Ph.D.
In-Vitro Diagnostic Subject Matter Expert
Contractor, Tunnell Consulting, Inc.
Center for Devices and Radiological Health
OPEQ, OHT7
U.S. Food and Drug Administration
Peter.condon@fda.hhs.gov
Excellent customer service is important to us. Please take a moment to provide feedback regarding the customer service you have received:
https://www.research.net/s/cdrhcustomerservice?ID=1930&S=E
This communication is consistent with 21 CFR 10.85 (k) and constitutes an informal communication that represents my best judgment at this time but does not constitute an advisory opinion, does not necessarily represent the formal position of FDA, and does not bind or otherwise obligate or commit the agency to the views expressed. This communication is intended for the exclusive use of the recipient(s) named in this correspondence. It may contain information that is protected, privileged, or confidential, and it should not be modified. It may not be disseminated, distributed, reproduced, or copied to persons not authorized to receive such information. If you are not the intended recipient, any dissemination, distribution, or copying is strictly prohibited. If you think you have received this communication in error, please immediately delete all copies from the saved sources and notify FDA by email at: CDRH-EUA-Templates Covid19DX@fda.hhs.gov immediately.
# 1,739 FDA Website - COVID-19 Test Uses_ FAQs on Testing for SARS-CoV-2 (updated 2023-09-29).md
METADATA
last updated: 2026-03-05 by BA
file_name: FDA Website - COVID-19 Test Uses_ FAQs on Testing for SARS-CoV-2 (updated 2023-09-29).md
file_date: 2023-09-29
title: COVID-19 Test Uses_ FAQs on Testing for SARS-CoV-2 _ FDA
category: regulatory
subcategory: surveillance
tags:
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summary_short: The FDA “COVID-19 Test Uses: FAQs on Testing for SARS-CoV-2” explains where COVID-19 tests can be used (lab, point-of-care, home collection, and at-home) and how EUA-authorized settings map to CLIA requirements. It also defines diagnostic, screening, and surveillance testing and gives examples to clarify how intended use affects regulation and reporting.
CONTENT
***INTERNAL TITLE:*** COVID-19 Test Uses: FAQs on Testing for SARS-CoV-2
This page is part of the [FAQs on Testing for SARS-CoV-2](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2) and provides answers to frequently asked questions related to uses for different types of COVID-19 tests and the settings in which they can be used.
Questions and answers regarding other policies described in the [Policy for Coronavirus Disease-2019 Tests](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/policy-coronavirus-disease-2019-tests-revised) are found in other pages in [this section](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2).
## Q: In what settings can COVID-19 tests be offered or used? (9/29/23)
A: Each Emergency Use Authorization (EUA) for a COVID-19 test includes the settings in which the test is authorized.
The settings authorized in the EUAs are also noted in the EUA tables on the [In Vitro Diagnostics EUA](https://www.fda.gov/medical-devices/covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas) page.
- Tests that are noted with an "H" in the Authorized Settings are limited to use in laboratories certified under CLIA that meet requirements to perform high-complexity tests.
- Tests that are noted with an "H" and "M" in the Authorized Settings may be performed in laboratories certified under CLIA to perform high complexity and/or moderate complexity tests.
- Tests that are noted with a "W" in the Authorized Settings are deemed to be CLIA-waived for use in patient care settings operating under a CLIA Certificate of Waiver.
- Tests noted with an "H," "M," and "W" may be used in laboratories certified under CLIA that meet requirements to perform high complexity and/or moderate complexity tests and in patient care settings operating under a CLIA Certificate of Waiver.
In addition to COVID-19 tests issued EUAs, there are SARS-CoV-2 tests that have been authorized through [traditional premarket review pathways](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-tests-granted-traditional-marketing-authorization-fda). The setting in which each test is authorized is also included in the tables of COVID-19 tests granted traditional marketing authorizations.
### Facilities Performing COVID-19 Testing
- Facilities, including point-of-care settings such as health clinics, that perform COVID-19 testing must be certified as a laboratory under the Clinical Laboratory Improvement Amendments, or [CLIA, which is administered by the Centers for Medicare & Medicaid Services (CMS)](https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/).
- Such laboratories may perform tests for which they meet the qualifications of the authorized settings included in the authorization. Laboratories authorized to use EUA-authorized tests are subject to various conditions that can be found in the EUA.
### Point-of-Care Tests
Point-of-care (POC) settings include a variety of settings where testing can be performed near the patient, without transporting the sample for processing elsewhere, such as hospitals, physician offices, urgent care, outreach clinics, pharmacies, and temporary patient care settings that have appropriately trained personnel to perform the test. The term POC can generally be used to refer to near-patient testing with tests that are high, moderate, or waived complexity.
As discussed in the [Guidance for Industry and Other Stakeholders: Emergency Use Authorization of Medical Products and Related Authorities](https://www.fda.gov/regulatory-information/search-fda-guidance-documents/emergency-use-authorization-medical-products-and-related-authorities), when the FDA issues an EUA for a test, it can indicate whether the test can be performed at a POC setting or only in a laboratory able to handle more complex tests. The FDA must make certain determinations for tests to be deemed to be CLIA waived tests under an EUA, and, in the EUAs, a test authorized to be performed at a POC setting is generally deemed to be CLIA waived.
Generally, for the duration of the emergency declaration, such authorized tests can be performed in a patient care setting that is qualified to have the test performed there as a result of operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation.
Tests authorized for use at the point-of-care generally are not authorized for home specimen collection or at home testing unless otherwise specified.
### Home Sample Collection
Several tests have been authorized to be performed in a laboratory, but for which the samples can be collected at home and sent to the laboratory. Such tests include "Home Collection" in the Attributes column in the authorization tables.
### At-Home Tests
The FDA has also authorized COVID-19 tests that may be used at home, which is stated in the authorization. The Authorized Setting for such tests is noted as "Home" in the authorization tables. Tests authorized for home use can generally also be used for self-testing in settings outside of the home, such as offices or schools.
## Q: What is the difference between diagnostic, screening, and surveillance testing for COVID-19? (9/29/23)
A: **Diagnostic testing** for COVID-19 looks for infections in individual people when there is a reason to suspect that a specific person may be infected. This includes testing people with signs or symptoms of infection and people without symptoms who have a recent known or suspected COVID-19 exposure.
Some examples of diagnostic testing include testing symptomatic individuals presenting to their healthcare provider, testing individuals who indicate that they were exposed to an individual with a confirmed or suspected case of COVID-19, and testing all individuals present at an event where an attendee was later confirmed to have COVID-19.
**Screening testing** for COVID-19 looks for infections in individual people even if there is no reason to suspect the specific person has an infection or known COVID-19 exposure. This includes broad screening of people without symptoms (asymptomatic) without known exposure to COVID-19 with the intent of making individual decisions based on the test results. The intent of screening tests is to identify infected people before they develop symptoms or who may never develop symptoms so that steps can be taken to prevent those people from infecting others.
Some examples of screening testing include testing by a workplace or school of all employees, students, and/or faculty returning to the workplace or school regardless of exposure or signs and symptoms, with the intent of using those results to determine who may return or what protective measures to take on an individual basis.
**Surveillance testing** for COVID-19 includes ongoing systematic activities, including collection, analysis, and interpretation of health-related data, essential to planning, implementing, and evaluating public health practice. Surveillance testing is primarily used to gain information for a population of people (population level data), rather than for an individual person and does not report test results to a patient or their health care provider. It is generally used to monitor for an occurrence, such as an infectious disease outbreak, in a population or community, or to characterize the occurrence once detected, such as looking at the incidence and prevalence of the occurrence. Surveillance testing may be random sampling of a certain percentage of a specific population to monitor for increasing or decreasing infection rates, or prevalence, and determining the population effect from community interventions such as social distancing.
An example of surveillance testing is a testing plan developed by a State Public Health Department to randomly select and sample 1% of all individuals in a city on a rolling basis to determine local infection rates and trends.
## Q: Should SARS-CoV-2 antibody test results be used to assess immunity from COVID-19? (9/27/22)
A: No, antibody testing should not be used to assess immunity to COVID-19.
See [Antibody (Serology) Testing for COVID-19: Information for Patients and Consumers](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/antibody-serology-testing-covid-19-information-patients-and-consumers) for more information.
# 727 FloodLAMP Non-Diagnostic Surveillance Testing Materials Acknowledgment and Waiver.md
METADATA
last updated: 2026-03-05 by BA
file_name: FloodLAMP Non-Diagnostic Surveillance Testing Materials Acknowledgment and Waiver.md
file_date: 2022-08-20
title: FloodLAMP Non-Diagnostic Surveillance Testing Materials Acknowledgment and Waiver
category: regulatory
subcategory: surveillance
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pdf_gdrive_url: https://drive.google.com/file/d/1naqR7kPOfiVc3GvRZafSWpHx26AJKUF_
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summary_short: The FloodLAMP Non-Diagnostic Surveillance Testing Materials Acknowledgment and Waiver is an entity-facing agreement for using FloodLAMP-provided materials and protocols to run a non-diagnostic SARS-CoV-2 surveillance test without providing individual results. It sets participant notification and referral requirements, clarifies the test is not FDA-authorized or CLIA testing and should not be relied on for individual decision-making, and includes disclosure permissions plus a broad liability waiver and release for FloodLAMP.
CONTENT
***INTERNAL TITLE:*** FloodLAMP Non-Diagnostic Surveillance Testing Materials Acknowledgment and Waiver
The Entity understands and agrees to the following:
1. FloodLAMP Biotechnologies, PBC, a Delaware public benefit corporation (“**FloodLAMP**”) may provide materials to perform a non-diagnostic molecular surveillance test (the "**Test**") of samples from employees, contractors, students, or affiliated third parties (“**Participants**”) of the Entity to indicate the potential presence of SARS-CoV-2, the virus that causes COVID-19, or may provide materials, equipment, and protocols in order to perform the Test.
2. Entity agrees to ensure that Participants will not be given individual results from the Test. In the event an individual or pooled sample indicates the presence of the SARS-CoV-2 virus, Participants will be referred to take a diagnostic test.
3. The Entity agrees to notify Participants that a referral to a diagnostic test is not a substitute for diagnostic testing.
4. Information received from the Test should not be relied on for decision-making purposes.
5. The Entity agrees not to misrepresent the purpose of the Test.
6. The Test has not been authorized or approved by the FDA or CDC. The Test is not being performed in a CLIA laboratory and is not CLIA waived.
7. The purpose of the Test is to improve public health and to determine appropriate mitigation measures for a population. The Test is not for individual medical or diagnostic purposes.
8. The Test does not rule out the possibility that an individual may have been exposed to or is infected with SARS-CoV-2.
9. FloodLAMP is not acting as a medical provider and the Test does not replace treatment by a medical provider. The Entity agrees to advise Participants to seek medical advice, care, and treatment from a medical provider for questions or concerns.
10. Each sample will be used for the purpose of performing the Test. Results obtained will be used for the purpose of SARS-CoV-2 public health surveillance, as described herein.
11. The Entity agrees that FloodLAMP may disclose Test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be required or permitted by law.
12. The Entity expressly waives and releases FloodLAMP and its employees and agents from any and all rights, claims, lawsuits or damages of any nature whatsoever arising directly or indirectly from the Test or surveillance testing program.
13. Revocation of this waiver must be received by FloodLAMP by email at support@floodlamp.bio.
**Entity: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
By: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Doc Control ID: EAWM01
# 292 FloodLAMP Surveillance FAQ and Links (June 2022 DRAFT).md
METADATA
last updated: 2026-01-01 RT
file_name: FloodLAMP Surveillance FAQ and Links (June 2022 DRAFT).md
file_date: 2022-06-01
title: FloodLAMP Surveillance FAQ and Links (June 2022 DRAFT)
category: regulatory
subcategory: surveillance
tags:
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pdf_gdrive_url: https://drive.google.com/file/d/124Vk07Y-KUmMP3Sb-QIe59oyMyX2V8cf
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notes: edited text to remove redundant quoted sections and links and instead link to other FL archive file
summary_short: The surveillance vs. diagnostic testing explainer contrasts patient-focused diagnostic testing (clinical care and individual results under the medical/CLIA framework) with population-focused surveillance testing used to monitor and mitigate spread without reporting patient-specific results. It summarizes federal agency roles and quotes CMS and FDA guidance indicating surveillance testing can occur outside CLIA and outside FDA authorization when individual results are not returned, while individual asymptomatic screening with reported results remains regulated.
CONTENT
## What is the difference between surveillance testing and diagnostic testing?
Diagnostic testing is within the medical framework, with exclusive focus on the individual and gaining information for the purpose of their care as a patient. Surveillance testing looks for infection in a population or community, and has expanded greatly during the COVID Public Health Emergency. The information from surveillance testing can be used for the purpose of stopping the spread of the disease and for managing risk mitigation measures for the group, such as wearing masks. No exchange of personal health information is required for surveillance. Further, a much greater degree of flexibility in where and how it's implemented enables programs such as FloodLAMP's to better meet the needs of groups looking to interact safely and protect their community.
## What are the federal regulations regarding surveillance testing?
3 federal agencies are involved in regulating human disease testing: the Center for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), and Centers for Medicare and Medicaid Services (CMS) which governs clinical laboratories through the Clinical Laboratory Improvement Amendments (CLIA).
See [FloodLAMP Surveillance Information (Aug 2021 INTERNAL)](https://docs.google.com/document/d/1oh_RCaaB-9DOzv-k33xxkmhLUQdi2VPIlspGMpbeqLs)
FLOODLAMP ARCHIVE FILE PATH: regulatory/surveillance/FloodLAMP Surveillance Information (Aug 2021 INTERNAL).md
# 3,906 FloodLAMP Surveillance Information (Aug 2021 INTERNAL).md
METADATA
last updated: 2026-03-05 by BA
file_name: FloodLAMP Surveillance Information (Aug 2021 INTERNAL).md
file_date: 2021-08-01
title: FloodLAMP Surveillance Information (Aug 2021 INTERNAL)
category: regulatory
subcategory: surveillance
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summary_short: The regulatory overview and FAQ memo explains how FloodLAMP frames pooled COVID-19 surveillance testing as a non-diagnostic public health activity under CMS guidance, emphasizing that no patient-specific results (e.g., “positive/negative/inconclusive”) are reported and participants are referred to CLIA-certified diagnostic testing when SARS-CoV-2 is detected in a pool. It contrasts surveillance testing, LDTs, and FDA-authorized EUA tests, cites CMS enforcement discretion and an eCFR research-lab exemption, and includes prepared language and supporting federal links to justify compliance for a municipal surveillance program.
CONTENT
[CMS Surveillance FAQ 10-21-21](https://www.cms.gov/files/document/06-19-2020-frequently-asked-questions-covid-surveillance-testing.pdf)
[CMS Surveillance FAQ 10-21-21 2021-10-21_CMS CLIA - Frequently Asked Questions SARS-CoV-2 Surveillance Testing.pdf](https://drive.google.com/file/d/1FN0e5vbU3eJ2hMSewH9to42yvYhWisCn)
_FLOODLAMP ARCHIVE FILE PATH:_ regulatory/surveillance/CMS - CLIA Surveillance Testing SARS-CoV-2 Frequently Asked Questions (2021-10-21).md
[CMS - CLIA SARS2 Variant FAQ 3-19-21](https://www.cms.gov/files/document/clia-sars-cov-2-variant.pdf)
[2021-03-19_CMS CLIA - CLIA SARS-CoV-2 Variant Testing Frequently Asked Question.pdf](https://drive.google.com/file/d/15jnDb6cPCPAOkYUlintP0s-kO8am2-Gp)
_FLOODLAMP ARCHIVE FILE PATH:_ regulatory/surveillance/CMS - CLIA SARS-CoV-2 Variant Testing Frequently Asked Question (2021-03-19).md
[FDA FAQ](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-test-uses-faqs-testing-sars-cov-2)
[FDA Website - COVID-19 Test Uses_ FAQs on Testing for SARS-CoV-2 (updated 2023-09-29).pdf](https://drive.google.com/file/d/1s8uGXw7Lq90NiNlR3_XpmNiXOKoNDEtt)
_FLOODLAMP ARCHIVE FILE PATH:_ regulatory/surveillance/FDA Website - COVID-19 Test Uses_ FAQs on Testing for SARS-CoV-2 (updated 2023-09-29).md
[CDC FAQ](https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/sars-cov2-testing-strategies.html) (LINK DEAD)
## Regulatory Overview
- Surveillance test:
- Surveillance testing can be a useful tool for understanding infection in a population.
- Surveillance testing is not diagnostic, and positive and inconclusive results should be accompanied by a referral to a clinically diagnostic test.
- Surveillance testing must not furnish participants with patient specific diagnostic results.
- CMS which has regulatory oversight over CLIA labs posted this [FAQ about surveillance testing](https://www.cms.gov/files/document/06-19-2020-frequently-asked-questions-covid-surveillance-testing.pdf) .
[CMS Surveillance FAQ 10-21-21 2021-10-21_CMS CLIA - Frequently Asked Questions SARS-CoV-2 Surveillance Testing.pdf](https://drive.google.com/file/d/1FN0e5vbU3eJ2hMSewH9to42yvYhWisCn)
_FLOODLAMP ARCHIVE FILE PATH:_ regulatory/surveillance/CMS - CLIA Surveillance Testing SARS-CoV-2 Frequently Asked Questions (2021-10-21).md
- Surveillance testing can occur in CLIA and non CLIA labs.
- Laboratory Developed Test
- LDTs are developed in-house at CLIA labs.
- In some cases, samples can be processed in mobile or pop up labs.
- These tests can offer clinical diagnostic results.
- They are more expensive and require a partnership with a CLIA lab.
- FloodLAMP can work with CLIA labs to bring up this capability.
- EUA Test
- FloodLAMP has submitted its QuickColor™ COVID-19 Test to the FDA.
- The FDA has not authorized or approved the test at this time.
- EUA tests are authorized by the FDA to provide clinical diagnostic results for the intended use specified in the authorization documents.
- Medical providers and CLIA lab directors have the discretion to use FDA EUA tests off label.
## FAQ
**Is FloodLAMP Biotechnologies and the City of Coral Springs violating any federal regulations on testing?**
No federal regulations have been violated. Per CMS: “Generally, SARS-CoV-2 surveillance testing can be performed in a facility that is NOT CLIA certified, and may use a test or technique NOT authorized by the FDA, provided that patient-specific results are not reported. If at any time a patient-specific result is reported, the facility is subject to CLIA and required to obtain an appropriate CLIA certificate in accordance with 42 CFR part 493.” [https://www.cms.gov/files/document/clia-university-lab-testing.pdf](https://www.cms.gov/files/document/clia-university-lab-testing.pdf)
[CMS - CLIA University Lab Testing FAQ (2020-08-28).pdf](https://drive.google.com/file/d/1tgBv4ypHFed2fe3T2KXxxGb3H7JoYMAS)
_FLOODLAMP ARCHIVE FILE PATH:_ regulatory/surveillance/CMS - CLIA University Lab Testing FAQ (2020-08-28).md
**Will FloodLAMP Biotechnologies and the City of Coral Springs provide patient-specific results, deliver a diagnosis, or provide results?**
No, FloodLAMP Biotechnologies and the City of Coral Springs will not provide patient-specific results, provide a diagnosis, or provide diagnostic test results. None of the following terms are utilized by FloodLAMP based on direct guidance from CMS (see both the attached Castillo CMS guidance letter and the CMS guidance email contained below) “negative, positive, inconclusive, presumptive positive, a result of clinical significance, or a result of potential clinical significance”. Further, the test configuration uses pooled samples at the point of collection. Pooling is the process of several participant samples into one test reaction. Once this pooling has occurred it is not possible to determine which sample was furnished by which participant. The result is all participants in pools where SARS-CoV-2 is detected are referred to a clinical diagnostic test. Conversely, all participants in pools where SARS-CoV-2 is not detected are notified that the absence of that detection is not conclusive to determine a participant's medical status.
**What language can be used to provide the results of a non-diagnostic?**
Per the email below from CMS: **“A CLIA certificate will not be required if you refer a patient to a CLIA certified laboratory.”**
Dr. Campbell,
The guidance listed in the CMS letter that you received would be the most current guidance and I would like to summarize the contents of the letter within the framework of your email correspondence.
**A CLIA certificate will be required if you report, or provide any of the following diagnostic testing information from your surveillance testing:**
**Negative, Positive, Inconclusive, Presumptive positive, A result of clinical significance, or a result of potential clinical significance.**
**A CLIA certificate will not be required if you refer a patient to a CLIA certified laboratory.**
**CMS does not have any written instructions on the referral of a patient to a CLIA certified laboratory.**
Should you have a specific question, kindly forward the question for a written response.
Thank you,
Raymond Castillo
Clinical Laboratory Scientist
Centers for Medicare and Medicaid Services
233 N. Michigan, Suite 600
Chicago, Illinois 60601
**Are FloodLAMP Biotechnologies and the City of Coral Springs authorized to run a diagnostic test and a diagnostic lab?**
Per CMS guidelines, the city will run a non-diagnostic surveillance test and refer participants to diagnostic tests in CLIA certified laboratories, as indicated by those guidelines or to rapid EUA point of care molecular and antigen tests. The test can be performed at a CLIA lab and the City can submit a CLIA application and acquire a CLIA number if it chooses to perform diagnostic tests. At this time, using the FloodLAMP lab-developed-non-diagnostic test most appropriately suits the City’s public health surveillance needs.
**Is FloodLAMP preparing to file for an EUA or FDA approval?**
It is a common misconception that CLIA labs need to use FDA approved tests. This is not true. CLIA labs can perform internally validated, Lab Developed Tests (LDTs). FloodLAMP has submitted EUA's to the FDA but have not yet received authorization. When the FloodLAMP QuickColor™ test is authorized (we're confident it will be based on the performance and comparative EUAs), CLIA labs will be able to run the test to offer individual diagnostic results without the need for individual labs to independently validate the test. The EUA authorization will not have any impact on non-diagnostic public health uses of FloodLAMP's COVID-19 tests.
**Does FloodLAMP Biotechnologies and the City of Coral Springs provide surveillance or screening?**
The issue associated with these terms is that surveillance testing does not normally allow for the reporting of individual results to participants. However, the guidance clearly demonstrates that there is a mechanism to refer individuals to diagnostic tests in the context of surveillance, and we are extremely careful to adhere to this guidance. This clear CMS guidance was issued in the context of the COVID-19 pandemic, and absent this guidance, the service we are providing to clients could be construed as diagnostic screening. However, given the very clear CMS guidance, which states that surveillance testing can be used to refer individuals to diagnostic tests (attached). We remain firm in our good-faith commitment to this guidance, but should situations develop that force *FloodLAMP Biotechnologies and the City of Coral Springs* to leverage a CLIA certification, we are prepared to do this to minimize any interruption of service to ensure the City’s ability to provide safe in-person working environments. Doing so at this point would disrupt the workflow and materially increase the program cost and complexity.
**Have other groups used this test in this way?**
Yes, our colleagues in Chicago and Colorado have used identical test chemistry to offer well over 1 million surveillance tests to support in person learning in K-12 settings. They have recently published their test in eLife, a highly respected scientific journal. Relevant information regarding this test…. “The Saliva TwoStep test described herein identified infections with 94% sensitivity and >99% specificity in individuals with sub-clinical (asymptomatic or pre-symptomatic) infections.”
[https://elifesciences.org/articles/65113](https://elifesciences.org/articles/65113)
**Does the FDA regulate surveillance testing?**
No. “The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices.” The FloodLAMP QuickColor test would be regulated by the FDA if it was being used to support medical diagnosis for individuals or as part of a diagnostic screening program. The linked section on [Surveillance Testing](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19#pooled) (LINK DEAD) notes that surveillance testing is generally overseen by the rule making authority of CMS through their CLIA oversite. Our good faith and collaborative relationship with [CMS has yielded that surveillance testing can be conducted with non FDA tests at CLIA labs during the COVID-19 public health emergency provided that participants are referred to CLIA labs for follow up and never provided patient specific results.](https://www.cms.gov/files/document/06-19-2020-frequently-asked-questions-covid-surveillance-testing.pdf)
[CMS Surveillance FAQ 10-21-21 2021-10-21_CMS CLIA - Frequently Asked Questions SARS-CoV-2 Surveillance Testing.pdf](https://drive.google.com/file/d/1FN0e5vbU3eJ2hMSewH9to42yvYhWisCn)
_FLOODLAMP ARCHIVE FILE PATH:_ regulatory/surveillance/CMS - CLIA Surveillance Testing SARS-CoV-2 Frequently Asked Questions (2021-10-21).md
**What statute exempts FloodLAMP Biotechnologies and the City of Coral Springs from CLIA requirements for their surveillance testing program?**
[§493.3 (B) (2)](https://www.ecfr.gov/cgi-bin/text-idx?node=pt42.5.493&rgn=div5#se42.5.493_13) “Research laboratories that test human specimens but do not report patient specific results for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of individual patients”
The surveillance program is designed to manage city wide risk of COVID-19 infection. The program does not supplement, supplant or replace health care provider-directed clinical diagnostic testing for the diagnosis, prevention or treatment of COVID-19 at the individual level, nor does it support the assessment of the health of individual participants. CMS has provided explicit guidance in FAQ’s and letters how surveillance testing can be used during the COVID-19 public health emergency as indicated in this document.
**The following is an except of the regulatory section submitted for a review paper of the Global LAMP Consortium (gLAMP), authored by Randy True of FloodLAMP.**
**Surveillance and Asymptomatic Testing**
While the regulated pathways of COVID-19 testing have received most of the attention and funding, a completely unregulated pathway has opened up after being initially blocked. "Surveillance" testing is primarily used to gain information at a population level rather than an individual level. Surveillance testing may involve random sampling of a certain percentage of a specific population to monitor for increasing or decreasing prevalence and determining the population effect from community interventions such as social distancing. The FDA generally does not regulate surveillance testing. \[[Wellesley](https://wellesleyps.org/viral-testing/wps-covid-19-pool-surveillance-testing-plan-faqs/), [CMS Surveillance FAQ](https://www.cms.gov/files/document/06-19-2020-frequently-asked-questions-covid-surveillance-testing.pdf)\]
However, in mid May, after the U.S. was already experiencing one of the worst COVID-19 epidemics in the world, the FDA shut down the Gates Foundation's home testing effort in the Seattle area. "The study lacked two kinds of clearance," the FDA said: a federal Emergency Use Authorization (a type of pandemic-era green light used to speedily clear tests and medical devices during an emergency) and approval from an outside group of experts tasked with providing ethical oversight for research (an Institutional Review Board). Obtaining either clearance could have allowed the effort to go forward, according to the FDA. \[[StatNews 5-27-2020](https://www.statnews.com/2020/05/27/coronavirus-testing-seattle-bill-gates-fda/), [NYT 5-15-2020](https://www.nytimes.com/2020/05/15/us/coronavirus-testing-seattle-bill-gates.html)\]
The following exchange occurred in July of 2020 during a webinar entitled "Government-University Dialogue on COVID-19 Surveillance and Testing":
**Francis Collins (Director of the NIH):** *If you’re doing surveillance (as you’ve just described) in a non-CLIA environment and using pooling, and you get a positive pool (I’ve heard of some places that were like, “Well, we still have the original samples, so we could actually quickly run the components of that pool and we can figure out which one of them was actually responsible for the positive, and then we just reach out to that one person and say, ‘You need to get yourself checked out in a CLIA lab.’”) is that allowable?*
**Seema Verma (Head of CMS which governs CLIA):** *Yes, that would work because you’re not actually giving results. You’re still making the referral to that particular person to have the actual diagnosis performed in a CLIA lab. So they can repeat that, but just as long as they’re not telling somebody, "Yes, you are positive or negative,” and just saying, “We’re referring you, you need to have a confirmatory test in a CLIA-certified lab.”*
\[[NIH Webinar 7-24-2020](https://videocast.nih.gov/watch=38226)\]
Further, the following document was published by CMS on Aug 28:
*CMS is temporarily exercising enforcement discretion under CLIA for SARS-CoV-2 surveillance testing where patient-specific results are reported (e.g., SARS-CoV-2 surveillance testing that does not utilize a pooling strategy). Specifically, neither CMS nor the State survey agencies on its behalf will cite non-CLIA certified facilities, such as university laboratories, that are performing such testing, provided that the facility does not report actual test results, but only refers an individual with a presumptive positive or inconclusive test result to a CLIA-certified laboratory for further testing.*
\[[CMS - CLIA University Lab Testing 8-28-2020](https://www.cms.gov/files/document/clia-university-lab-testing.pdf)\]
[CMS - CLIA University Lab Testing FAQ (2020-08-28).pdf](https://drive.google.com/file/d/1tgBv4ypHFed2fe3T2KXxxGb3H7JoYMAS)
_FLOODLAMP ARCHIVE FILE PATH:_ regulatory/surveillance/CMS - CLIA University Lab Testing FAQ (2020-08-28).md
In November the FDA stated the following:
*When you refer to public health — if it’s totally a surveillance program where individual results are not returned to patients in a CLIA testing manner, but \[instead\] groups of people are referred to CLIA testing — surveillance testing as defined by the CDC, CMS, FDA websites is not something the FDA is regulating. When it comes to asymptomatic screening, when you want to return a CLIA lab result to an individual patient….That we do regulate.*
\[[FDA Town Hall](https://www.fda.gov/medical-devices/workshops-conferences-medical-devices/virtual-town-hall-series-coronavirus-covid-19-test-development-and-validation-01062021-01062021) 11-18-2020\]
Several universities and companies describe their testing programs using the term "surveillance". However, because surveillance testing is not formally regulated in the U.S., it is difficult to estimate the extent of testing being performed under this pathway.
# 713 Memo - Surveillance Authority Plain-language Research (Jan 2021 from Senior Medical Director in Healthcare Industry).md
METADATA
last updated: 2026-03-05 by BA
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summary_short: The plain-language CMS/FDA overview summarizes how “surveillance” COVID-19 testing is described in FDA guidance as population-level monitoring that FDA generally does not regulate, and explains conditions under which individual results may be returned if presumptive positives are routed to confirmatory testing in a CLIA-certified laboratory. It also cites CMS’s temporary enforcement discretion under CLIA for certain SARS-CoV-2 surveillance testing workflows, especially where non-CLIA facilities do not report definitive results but instead refer presumptive positives or inconclusives to a CLIA lab. It frames these points as a non-legal explanatory digest of agency guidance and notes that public health authorities may have additional powers to support population safety efforts.
CONTENT
## Plain Language Overview of CMS, FDA regulations and current guidance.
(This is not intended as legal advice. Rather - this is a simple plain-language explanation of currently available documents from FDA and CMS. No reader of this document should construe it as legal advice, or a suggestion that any methods described are reasonable, appropriate or legal.)
A 'surveillance' program with validation of results with a CLIA laboratory:
Surveillance testing is explicitly NOT regulated by the FDA ([cite](https://www.fda.gov/media/137599/download) and [cite](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/pooled-sample-testing-and-screening-testing-covid-19)). While surveillance testing typically does not permit the return of individual results, they are no longer enforcing this rule as long as positive results are sent to a CLIA laboratory. In addition, there is significant legal history that empowers public health authorities to protect the health and welfare of citizens.
The FDA defines a range of types of tests. Surveillance, Screening and Diagnostic testing. They are described here: [FDA on types of testing](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2#general-differences).
Surveillance testing is primarily used to gain information at a population level, rather than an individual level. Surveillance testing may be random sampling of a certain percentage of a specific population to monitor for increasing or decreasing prevalence and determining the population effect from community interventions such as social distancing. FDA generally does not regulate surveillance testing.
## Regulation and oversight of surveillance testing
Surveillance tests do NOT need to be approved by the FDA or used in a CLIA setting. [FDA on types of testing](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/faqs-testing-sars-cov-2#general-differences)
A: The FDA does not generally regulate the use of a test for surveillance purposes, such as determining the prevalence of acute infections in a population. The FDA understands that results have been returned to individuals tested for COVID-19 surveillance purposes. If surveillance testing is performed by a non-CLIA certified laboratory, an individual who tests positive for SARS-CoV-2 should have a confirmatory test performed by a CLIA-certified laboratory. Surveillance with return of results and surveillance with pooled or batched testing should be validated on a test platform and test of high sensitivity and positive tests should have a confirmatory test.
CMS further indicates [here](https://www.cms.gov/files/document/clia-university-lab-testing-8/28/2020.pdf):
However, CMS is temporarily exercising enforcement discretion under CLIA for SARS-CoV-2 surveillance testing where patient-specific results are reported (e.g., SARS-CoV-2 surveillance testing that does not utilize a pooling strategy).
Specifically, neither CMS nor the State survey agencies on its behalf will non-CLIA certified facilities, such as university laboratories, that are performing such testing, provided that the facility does not report actual test results, but only refers an individual with a presumptive positive or inconclusive test result to a CLIA-certified laboratory for further testing.
## Public health authorities
Public health authorities have additional powers to ensure the safety of populations. Some discussion of this [here](https://www.cdc.gov/eis/field-epi-manual/chapters/Legal.html).
# 826 Memo - USA Surveillance Strategy (Sept 2021 from non-FloodLAMP Healthcare Attorney).md
METADATA
last updated: 2026-03-05 by BA
file_name: Memo - USA Surveillance Strategy (Sept 2021 from non-FloodLAMP Healthcare Attorney).md
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summary_short: The follow-up email summarizes guidance that COVID-19 surveillance testing is generally not regulated by FDA or CLIA when samples lack unique identifiers and no individual results are returned, citing FDA and CDC language. It recommends coordinating with local public health officials, structuring groups large enough to support anonymized aggregate reporting, and ensuring testing is administered by appropriately trained personnel consistent with state law.
CONTENT
Gentlemen –
Following up from our discussion today, I did connect with my colleague who is our CLIA lab expert. We both agree that surveillance testing is not regulated either by FDA or under CLIA. See the following:
**FDA**
Surveillance for COVID-19 includes ongoing systematic activities, including collection, analysis, and interpretation of health-related data, essential to planning, implementing, and evaluating public health practice. It is generally used to monitor for an occurrence, such as an infectious disease outbreak, in a population or community, or to characterize the occurrence once detected, such as looking at the incidence and prevalence of the occurrence. Surveillance testing is primarily used to gain information at a population level, rather than an individual level. Surveillance testing may be random sampling of a certain percentage of a specific population to monitor for increasing or decreasing prevalence and determining the population effect from community interventions such as social distancing. FDA generally does not regulate surveillance testing. An example of surveillance testing is a testing plan developed by a State Public Health Department to randomly select and sample 1% of all individuals in a city on a rolling basis to determine local infection rates and trends.
[https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-test-uses-faqs-testing-sars-cov-2](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/covid-19-test-uses-faqs-testing-sars-cov-2)
**CLIA**
If a laboratory conducts surveillance testing on a specimen without a unique identifier and the results of that testing are not returned to the individual, or to the individual’s healthcare provider, employer, etc., that laboratory does not need a CLIA certificate. Surveillance testing results may be returned in aggregate to the institution that requested the study. In such cases, surveillance testing may indicate the need to conduct additional and perhaps more targeted diagnostic testing or screening at the individual level in a CLIA-certified laboratory to improve population or setting-specific health. If at any time a facility conducting surveillance testing intends to report a patient-specific testing result, it must first obtain a CLIA certificate and meet all CLIA requirements to perform that testing.
[https://www.cdc.gov/coronavirus/2019-ncov/lab/faqs.html](https://www.cdc.gov/coronavirus/2019-ncov/lab/faqs.html)
We have also not identified any requirement that surveillance testing be done **only** by a public health authority. As a result, we see no prohibition on surveillance testing being done by a private entity. This being said, we believe there are benefits to cooperating/coordinating with a local public health entity to get their buy in prior to initiating testing, even if their approval is not strictly required. Getting their buy in certainly would de-risk the scenario and we would therefore recommend we coordinate with local public health officials in advance. We would be happy to participate in those discussions.
As we discussed, we should ensure that the test results are not communicated to the individual and should ensure that the pods of people are large enough that the testing can be anonymized and be considered “surveillance testing”. (Note: there is no regulatory or official definition of “surveillance” such that the groups/pods need to be of a particular size but given the possibility this could be scrutinized by regulators (potentially including FDA), we would want them to be large enough that the testing can reasonably be described as surveillance testing.) This is another reason why having local public health officials on board early who can be supporters of the public health benefits of such a program.
The testing should be performed/administered by trained technicians that are permitted under state law to perform COVID tests (given they are not yet authorized for consumer use). We have not looked specifically at Florida state requirements but could do if needed. While this could be done by CLIA lab employees, it is not necessary.
Best regards,