Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study
Open accessAbstract
Background Spain is one of the European countries most affected by the COVID-19 pandemic. Serological surveys are a valuable tool to assess the extent of the epidemic, given the existence of asymptomatic cases and little access to diagnostic tests. This nationwide population-based study aims to estimate the seroprevalence of SARS-CoV-2 infection in Spain at national and regional level. Methods 35 883 households were selected from municipal rolls using two-stage random sampling stratified by province and municipality size, with all residents invited to participate. From April 27 to May 11, 2020, 61 075 participants (75·1% of all contacted individuals within selected households) answered a questionnaire on history of symptoms compatible with COVID-19 and risk factors, received a point-of-care antibody test, and, if agreed, donated a blood sample for additional testing with a chemiluminescent microparticle immunoassay. Prevalences of IgG antibodies were adjusted using sampling weights and post-stratification to allow for differences in non-response rates based on age group, sex, and census-tract income. Using results for both tests, we calculated a seroprevalence range maximising either specificity (positive for both tests) or sensitivity (positive for either test). Findings Seroprevalence was 5·0% (95% CI 4·7-5·4) by the point-of-care test and 4·6% (4·3-5·0) by immunoassay, with a specificity-sensitivity range of 3·7% (3·3-4·0; both tests positive) to 6·2% (5·8-6·6; either test positive), with no differences by sex and lower seroprevalence in children younger than 10 years (<3·1% by the point-of-care test). There was substantial geographical variability, with higher prevalence around Madrid (>10%) and lower in coastal areas (<3%). Seroprevalence among 195 participants with positive PCR more than 14 days before the study visit ranged from 87·6% (81·1-92·1; both tests positive) to 91·8% (86·3-95·3; either test positive). In 7273 individuals with anosmia or at least three symptoms, seroprevalence ranged from 15·3% (13·8-16·8) to 19·3% (17·7-21·0). Around a third of seropositive participants were asymptomatic, ranging from 21·9% (19·1-24·9) to 35·8% (33·1-38·5). Only 19·5% (16·3-23·2) of symptomatic participants who were seropositive by both the point-of-care test and immunoassay reported a previous PCR test. Interpretation The majority of the Spanish population is seronegative to SARS-CoV-2 infection, even in hotspot areas. Most PCR-confirmed cases have detectable antibodies, but a substantial proportion of people with symptoms compatible with COVID-19 did not have a PCR test and at least a third of infections determined by serology were asymptomatic. These results emphasise the need for maintaining public health measures to avoid a new epidemic wave. Funding Spanish Ministry of Health, Institute of Health Carlos III, and Spanish National Health System.
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At the end of the epidemic wave in Spain, seropositivity was 5.0% in a random population sample of 60,897.
“At the end of the epidemic wave in Spain, seropositivity was 5.0% in a random population sample of 60,897 (9).”
From Seroprevalence of anti–SARS-CoV-2 IgG antibodies in Kenyan blood donors (2021) · cites this paper as [9]
A substantial proportion (43%) of the Kenyan population is outside the age range (15 to 64 years) sampled in this study, and the seroprevalence in children <15 years and adults >65 years is often lower; thus the blood donor estimate may be higher than the estimate for the population as a whole.
“A substantial proportion (43%) of the population of Kenya is outside the age range (15 to 64 years) sampled in this study, and the seroprevalence in children <15 years and adults >65 years is often lower (9, 10); our estimate for blood donors may be higher than the estimate for the population as a whole.”
From Seroprevalence of anti–SARS-CoV-2 IgG antibodies in Kenyan blood donors (2021) · cites this paper as [9]
Seroprevalence did not vary significantly by sex, consistent with other studies.
“Consistent with other studies, seroprevalence did not vary significantly by sex (9, 10, 16); however, it peaked in 35- to 44-year-olds and was lowest for those ≥45 years, which is also consistent with existing reports in which seroprevalence was found to be lower in older adults (9, 10).”
From Seroprevalence of anti–SARS-CoV-2 IgG antibodies in Kenyan blood donors (2021) · cites this paper as [9]
SARS-CoV-2 seroprevalence in this study is comparable with estimates from large population-based serosurveys in China, Switzerland, Spain, and the United States after the initial epidemic peak and after many tens of thousands of deaths.
“SARS-CoV-2 seroprevalence in our study is comparable with estimates from large population-based serosurveys in China, Switzerland, Spain, and the United States after the initial epidemic peak and after many tens of thousands of deaths (9, 10, 17, 18).”
From Seroprevalence of anti–SARS-CoV-2 IgG antibodies in Kenyan blood donors (2021) · cites this paper as [9]
Seroprevalence peaked in 35- to 44-year-olds and was lowest for those ≥45 years, consistent with existing reports of lower seroprevalence in older adults.
“it peaked in 35- to 44-year-olds and was lowest for those ≥45 years, which is also consistent with existing reports in which seroprevalence was found to be lower in older adults (9, 10).”
From Seroprevalence of anti–SARS-CoV-2 IgG antibodies in Kenyan blood donors (2021) · cites this paper as [9]
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- Authors
- Pollán, M., Pérez-Gómez, B., Pastor-Barriuso, R., Oteo, J., Hernán, M. A., Pérez-Olmeda, M., Sanmartín, J. L., Fernández-García, A., Cruz, I., Fernández de Larrea, N., Molina, M., Rodríguez-Cabrera, F., Martín, M., Merino-Amador, P., León Paniagua, J., Muñoz-Montalvo, J. F., Blanco, F., Yotti, R., Blanco, F., Gutiérrez Fernández, R., Martín, M., Mezcua Navarro, S., Molina, M., Muñoz-Montalvo, J. F., Salinero Hernández, M., Sanmartín, J. L., Cuenca-Estrella, M., Yotti, R., León Paniagua, J., Fernández de Larrea, N., Fernández-Navarro, P., Pastor-Barriuso, R., Pérez-Gómez, B., Pollán, M., Avellón, A., Fedele, G., Fernández-García, A., Oteo Iglesias, J., Pérez Olmeda, M. T., Cruz, I., Fernandez Martinez, M. E., Rodríguez-Cabrera, F. D., Hernán, M. A., Padrones Fernández, S., Rumbao Aguirre, J. M., Navarro Marí, J. M., Palop Borrás, B., Pérez Jiménez, A. B., Rodríguez-Iglesias, M., Calvo Gascón, A. M., Lou Alcaine, M. L., Donate Suárez, I., Suárez Álvarez, O., Rodríguez Pérez, M., Cases Sanchís, M., Villafáfila Gomila, C. J., Carbo Saladrigas, L., Hurtado Fernández, A., Oliver, A., Castro Feliciano, E., González Quintana, M. N., Barrasa Fernández, J. M., Hernández Betancor, M. A., Hernández Febles, M., Martín Martín, L., López López, L.-M., Ugarte Miota, T., De Benito Población, I., Celada Pérez, M. S., Vallés Fernández, M. N., Maté Enríquez, T., Villa Arranz, M., Domínguez-Gil González, M., Fernández-Natal, I., Megías Lobón, G., Muñoz Bellido, J. L., Ciruela, P., Mas i Casals, A., Doladé Botías, M., Marcos Maeso, M. A., Pérez del Campo, D., Félix de Castro, A., Limón Ramírez, R., Elías Retamosa, M. F., Rubio González, M., Blanco Lobeiras, M. S., Fuentes Losada, A., Aguilera, A., Bou, G., Caro, Y., Marauri, N., Soria Blanco, L. M., del Cura González, I., Hernández Pascual, M., Alonso Fernández, R., Merino-Amador, P., Cabrera Castro, N., Tomás Lizcano, A., Ramírez Almagro, C., Segovia Hernández, M., Ascunce Elizaga, N., Ederra Sanz, M., Ezpeleta Baquedano, C., Bustinduy Bascaran, A., Iglesias Tamayo, S., Elorduy Otazua, L., Benarroch Benarroch, R., Lopera Flores, J., & Vázquez de la Villa, A.
- Affiliations
- Instituto de Salud Carlos III (ES)
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2020-08
- Volume
- 396
- Issue
- 10250
- Pages
- 535-544
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC7336131
- OpenAlex
- W3040552450
- Cited by
- 1,639
- References
- 27
- Citations by year
- 2026: 15 · 2025: 34 · 2024: 58 · 2023: 137 · 2022: 288 · 2021: 741 · 2020: 366
- FWCI
- 50.32
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Lancet (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- reponame:Expeditio Repositorio Institucional UJTL
- Funders
- Generalitat Valenciana
- Ministerio de Ciencia e Innovación
- Servicio Murciano de Salud
- Servicio Andaluz de Salud
- Instituto de Salud Carlos III
- Topics
- Health Sciences › Medicine › Infectious Diseases › SARS-CoV-2 and COVID-19 Research
- Physical Sciences › Mathematics › Modeling and Simulation › COVID-19 epidemiological studies
- Health Sciences › Medicine › Infectious Diseases › SARS-CoV-2 detection and testing
- Keywords
- SARS-CoV-2, COVID-19 pandemic, seroprevalence, IgG, serological survey, immunoassay, asymptomatic infection, anosmia, geographical variability, Spain, children, PCR-confirmed infection, assay sensitivity and specificity, post-stratification, household sampling, nonresponse bias
- MeSH terms
- Point-of-Care Testing, Betacoronavirus, COVID-19, SARS-CoV-2, Adolescent, Adult, Aged, Antibodies, Viral, Child, Child, Preschool, Female, Humans, Immunoglobulin G, Immunoglobulin M, Immunoassay, Infant, Infant, Newborn, Male, Middle Aged, Pneumonia, Viral, Risk Factors, Spain, Prevalence, Seroepidemiologic Studies, Coronavirus Infections, Young Adult, Pandemics
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