Using SARS-CoV-2 nucleoprotein antibodies to detect (re)infection

We assessed the validity of serum total anti-nucleoprotein Immunoglobulin (N-antibodies) to identify SARS-CoV-2 (re)infections by estimating the persistence of N-antibody seropositivity and boosting following infection. From a prospective Dutch cohort study (VASCO), we included adult participants with ≥2 consecutive self-collected serum samples, 4-8 months apart, between May 2021-May 2023. Sample pairs were stratified by N-seropositivity of the first sample and by self-reported infection within the sampling interval. We calculated the proportions of participants with N-seroconversion and fold-increase (1.5, 2, 3, 4) of N-antibody concentration over time since infection and explored determinants. We included 67,632 sample pairs. Pairs with a seronegative first sample (70%) showed 89% N-seroconversion after reported infection and 11% when no infection was reported. In pairs with a seropositive first sample (30%), 82%-65% showed a 1.5- to 4-fold increase with a reported reinfection, and 19%-10% without a reported reinfection, respectively. After one year, 83% remained N-seropositive post-first infection and 93%-61% showed a 1.5-fold to 4-fold increase post-reinfection. Odds for seroconversion/fold increase were higher for symptomatic infections and Omicron infections. In the current era with limited antigen or PCR testing, N-serology can be validly used to detect SARS-CoV-2 (re)infections at least up to a year after infection, supporting the monitoring of COVID-19 burden and vaccine effectiveness.