Page 1. Sample Collection Instructions: For all assays: Do not collect specimen at the posterior fornix.

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1 Precautions for BD MAX TM UVE Specimen Collection Kit (Catalog ) when collecting specimens for BD MAX TM Vaginal Panel (Catalog numbers and ) and/or BD MAX CT/GC/TV (443824, , ), BD MAX CT/GC (catalog # ) Patient Education: If the following recommendations are not given or followed, the clinician should still proceed with the collection of vaginal and/or endocervical swabs. If possible, patients should be counseled to refrain from using intravaginal medication, vaginal lubricants, douching, using tampons, or having sexual intercourse for at least 48 hours before the collection of swab specimens. They should also avoid scheduling their appointment during heavy menstrual bleeding. Sample Collection Instructions: For all assays: Do not collect specimen at the posterior fornix. For clinician-collected vaginal swabs for MAX Vaginal Panel: Collect swab prior to pelvic, speculum, or bimanual exam After parting the labia, gently slide the dry swab no more than 2 inches into the vagina, with gentle rotation, making sure the swab touches the walls of the vagina so that moisture is absorbed by the swab. Rotate the swab gently for seconds; withdraw the swab without touching the skin. No lubricant is used for collecting the vaginal swab sample. Do not collect specimen at the posterior fornix. For clinician-collected endocervical swabs for MAX CT/GC/TV: When using a speculum o Lukewarm water may be used to warm and lubricate the speculum. o If lubricant must be used, lubricant should be used sparingly (approximately 1.8mm diameter-sized) and applied only to the exterior sides of the speculum blades, avoiding contact with the tip of the speculum Avoid contact between the swab and speculum or lubricant. Insert the collection swab into the endocervical canal and rotate gently for seconds; withdraw the swab without touching the speculum. Do not collect specimen at the posterior fornix. Page 1

2 For clinician-collected swabs for MAX CT/GC/TV and MAX Vaginal Panel for the same patient: Use 2 specimen collection kits and collect 1 vaginal swab sample, and 1 endocervical swab sample, each placed in each of 2 tubes provided. Preferred collection method o Collect the MAX Vaginal Panel vaginal swab first, following the instruction above for MAX Vaginal Panel. o Collect the MAX CT/GC/TV assay endocervical swab second, following the instruction above for CT/GC/TV. Optional collection method, if a speculum has been inserted prior to collecting the Vaginal Panel swab o Lukewarm water may be used to warm and lubricate the speculum. o If lubricant must be used, lubricant should be used sparingly (approximately 1.8mm diameter-sized) and applied only to the exterior sides of the speculum blades, avoiding contact with the tip of the speculum o Avoid contact between the 2 swabs and the speculum or lubricant. o Insert the MAX Vaginal Panel collection swab to contact the vaginal sidewall, at least 2 inches within the vagina, rotate gently for seconds; withdraw the swab without touching the speculum. o Insert the MAX CT/GC/TV collection swab into the endocervical canal and rotate gently for seconds; withdraw the swab without touching the speculum. Patient self-collected vaginal swabs for MAX CT/GC/TV and MAX Vaginal Panel Do not provide a lubricant with the BD MAX UVE Specimen Collection Kit to aid in self-collection. Patient must collect their specimen before any vaginal exam is performed with a lubricant. Patients who will have both tests should receive 2 specimen collection kits and collect 2 vaginal swab samples, placed in each of 2 tubes provided. Patient self-collected vaginal swabs may be used for MAX Vaginal Panel testing and/or MAX CT/GC/TV assay testing. Footnote: Avoid use of lubricants that contain carbomer (or carbopol polymers). Technical Service and Support: contact your local BD representative or Page 2

3 Appendix 1 How to Use a Lubricant for the Collection of Vaginal or Endocervical Swabs Apply a 1.8 mm diameter-sized amount of lubricant on the speculum Apply only to exterior sides of the speculum, avoiding the tip Page 3

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5 Rev from Rev to Revisions JOB # BALTSO0191 Version 11.0 Template 4 Inserts Notes: 1. BD Catalog Number: Blank (Sheet) Size: Length: 11 Width: Number of Pages: 28 Number of Sheets: 7 4. Page Size: Length: 11 Width: 8.5 Final Folded Size: 8.5 x Ink Colors: No. of Colors: 1 PMS#: Standard Black 6. Printed two sides: Yes X No 7. Style (see illustrations below): # 5 W W W W W W W 8. Vendor Printed Online/In House Printed X Web 9. See specification control no. N/A for material information. 10. Graphics are approved by Becton, Dickinson and Company. Supplier has the responsibility for using the most current approved revision level. Label Design Proofer COMPANY CONFIDENTIAL. THIS DOCUMENT IS THE PROPERTY OF BECTON, DICKINSON AND COMPANY AND IS NOT TO BE USED OUTSIDE THE COMPANY WITHOUT WRITTEN PERMISSION. Becton, Dickinson and Company 7 Loveton Circle Sparks, MD USA Checked By Part Number: P0212 Category and Description Package Insert, BD MAX CT/GC Sheet: 1 of 29 Scale: N/A A

6 MAX CT/GC For In Vitro Diagnostic Use P0212(04) For use with the BD MAX System I Contact your local BD representative for instructions. / Свържете се с местния представител на BD за инструкзии. / Pokyny vám poskytne místní zástupce společnosti BD. / Kontakt den lokale BD repræsentant for at få instruktioner. / Die Packungsbeilage erhalten Sie bei Ihrer örtlichen BD-Vertretung. / Póngase en contacto con su representante local de BD para instrucciones. / Contacter le représentant local de BD pour les instructions. / Επικοινωνήστε με τον τοπικό αντιπρόσωπο της BD για οδηγίες. / Kasutusjuhiste suhtes kontakteeruge oma kohaliku BD esindajaga. / Ota yhteys lähimpään BD:n edustajaan ohjeiden saamiseksi. / Kontaktiraj lokalnog predstavnika BD za upute. / A használati utasítást kérje a BD helyi képviseletétől. / Rivolgersi al rappresentante BD di zona per istruzioni. / Нұсқаулар үшін жергілікті BD өкілімен хабарласыңыз. / Naudojimo instrukcijų teiraukitės vietos BD įgaliotojo atstovo. / Neem contact op met uw plaatselijke BD-vertegenwoordiger voor instructies. / Kontakt din lokale BD-representant for mer informasjon. / Aby uzyskać instrukcje użytkowania, skontaktuj się z lokalnym przedstawicielstwem BD. / Contacte o representante local da BD para instruções. / Pentru instrucţiuni, contactaţi reprezentantul local BD. / Для получения указаний обратитесь к местному представителю компании BD. / Inštrukcie získate u miestneho zástupcu spoločnosti BD. / Obratite se svom lokalnom predstavniku kompanije BD za uputstva. / Kontakta närmaste BD-representant för anvisningar. / Talimatlar için yerel BD temsilcinizle temasa geçin. / За інструкціями зверніться до місцевого представника компанії BD. INTENDED USE The BD MAX CT/GC assay as implemented on the BD MAX System, incorporates automated DNA extraction and real-time polymerase chain reaction (PCR) for the direct, qualitative detection of DNA from Chlamydia trachomatis (CT) and/or Neisseria gonorrhoeae (GC) in clinician-collected female endocervical swab specimens, patient-collected vaginal swab specimens (in a clinical setting), and male and female urine specimens. The assay is indicated for use with asymptomatic and symptomatic individuals to aid in the diagnosis of chlamydial urogenital disease and/or gonococcal urogenital disease. SUMMARY AND EXPLANATION OF THE PROCEDURE The World Health Organization estimates that million new cases of infection due to Chlamydia trachomatis are diagnosed each year. 1 Genital infection with Chlamydia trachomatis can cause long term sequelae in women such as pelvic inflammatory disease, ectopic pregnancy, infertility, and the birth of underweight babies. Asymptomatic infection with chlamydia is common among both men and women, and detection of the disease frequently relies upon screening of the populations considered to be most at risk of infection. Fifty percent of Chlamydia trachomatis-infected men are also asymptomatic and, in the absence of treatment, infection can result in acute urethritis or epididymitis and chronic proctitis. Transmission of Chlamydia trachomatis occurs through sexual contact but can also take place in the birth canal leading to neonatal conjunctivitis and/or chlamydial pneumonia. 2 Chlamydia trachomatis are gram-negative, obligate intracellular bacteria that form characteristic intracellular inclusions which can be observed in cell culture by fluorescence microscopy after antigen-specific staining is applied. 3 Current methods for diagnosis of Chlamydia trachomatis infection include culture and immunological assays, as well as the detection of nucleic acids by direct hybridization or amplification. Although historically culture has been the gold standard for detection of Chlamydia trachomatis, the enhanced sensitivity of amplified methods has led to their increasing adoption and contributed to the rise in the number of reported cases of infection. The World Health Organization estimates that million new cases of infection due to Neisseria gonorrhoeae are diagnosed each year. 1 Infection of women is often asymptomatic and if left untreated can lead to pelvic inflammatory disease, infertility, ectopic pregnancy and chronic pelvic pain. In men, symptoms of acute urethritis and dysuria usually cause infected individuals to present for treatment before serious sequelae result. Transmission of Neisseria gonorrhoeae occurs through sexual contact but can also take place in the birth canal leading to neonatal conjunctivitis. Neisseria gonorrhoeae are gram-negative, oxidase-positive diplococci that can be observed in Gram-stained smears of urethral discharge, usually within neutrophils. Culture of Neisseria gonorrhoeae can be difficult because the organism does not survive long outside the host and is highly susceptible to adverse environmental conditions such as lack of humidity and temperature extremes.

7 PRINCIPLES OF THE PROCEDURE The specimen is collected from the patient using the BD MAX UVE Specimen Collection Kit and transported to the laboratory under conditions of time and temperature that have been determined to maintain the integrity of the target nucleic acids. The sample is vortexed briefly and then heated on the BD Pre-warm Heater to dissolve mucous, homogenize the specimen matrix and lyse the target organisms. After cooling automatically, the BD MAX UVE Sample Buffer Tubes are recapped with a septum cap. A worklist is created and the BD MAX UVE Sample Buffer Tube, the BD MAX CT/GC Unitized Reagent Strip and the BD MAX PCR Cartridge are loaded on the BD MAX System. The BD MAX System automates sample preparation, including target organism lysis, DNA extraction and concentration, reagent rehydration, and target nucleic acid amplification and detection using real-time PCR. The BD MAX System performs results interpretation automatically. The assay also includes a Sample Processing Control that is present in the Extraction Tube. The Sample Processing Control monitors DNA extraction steps, thermal cycling steps, reagent integrity and the presence of inhibitory substances. Following cell lysis, the released nucleic acids are captured on magnetic affinity beads. The beads, with the bound nucleic acids, are washed using Wash Buffer and the nucleic acids are eluted by heat in Elution Buffer. Eluted DNA is neutralized using Neutralization Buffer and transferred to the Master Mix to rehydrate the PCR reagents. After reconstitution, the BD MAX System dispenses a fixed volume of PCR-ready solution containing extracted nucleic acids into the BD MAX PCR Cartridge. Microvalves in the BD MAX PCR Cartridge are sealed by the system prior to initiating PCR to contain the amplification mixture, thus preventing evaporation and contamination. The amplified DNA targets are detected using hydrolysis (TaqMan ) probes, labeled at one end with a fluorescent reporter dye (fluorophore), and at the other end, with a quencher moiety. Probes labeled with different fluorophores are used to detect amplicons for target analytes and the Sample Processing Control in three different optical channels of the BD MAX System. When the probes are in their native state, the fluorescence of the fluorophore is quenched due to its proximity to the quencher. However, in the presence of target DNA, the probes hybridize to their complementary sequences and are hydrolyzed by the 5ꞌ 3ꞌ exonuclease activity of the DNA polymerase as it synthesizes the nascent strand along the DNA template. As a result, the fluorophores are separated from the quencher molecules and fluorescence is emitted. The BD MAX System monitors these signals at each cycle and interprets the data at the end of the reaction to provide qualitative test results for each analyte (i.e., positive or negative). REAGENTS AND MATERIALS REF Contents Quantity BD MAX CT/GC Master Mix (B1) Oven-dried PCR Master Mix containing DNA polymerase, nucleotides and CT/GC specific molecular primers and probes along with Sample Processing Control-specific primers and probes. BD MAX CT/GC Unitized Reagent Strips containing all liquid reagents and disposable pipette tips necessary for specimen processing and DNA extraction. BD MAX CT/GC Extraction Tubes (B2) Oven-dried pellet containing DNA magnetic affinity beads, protease reagents and Sample Processing Control 24 tests (2 x 12 tubes) 24 tests 24 tests (2 x 12 tubes) Septum Caps 25 EQUIPMENT AND MATERIALS REQUIRED BUT NOT PROVIDED BD MAX System (BD, Cat. No ) BD Pre-warm Heater Kit (BD Heater and BD MAX Rack) (BD, Cat. No ) BD MAX PCR Cartridges (BD, Cat. No ) BD MAX UVE Specimen Collection Kit (BD, Cat. No ) BD MAX UVE Sample Buffer Tubes (BD, Cat. No ) Vortex Genie 2 (VWR*, Cat. No ) or equivalent Disposable gloves, powderless WARNGS AND PRECAUTIONS The BD MAX CT/GC assay is for in vitro Diagnostic Use. If patient-collected vaginal swabs or endocervical swabs are not immediately transferred into a BD MAX UVE Sample Buffer Tube, they must be transferred within 2 hours of collection when kept at 2 30 C. First void urine specimens kept at 2 30 C must be transferred from the collection cup to the BD MAX UVE Sample Buffer Tube within 4 hours of collection, or within 24 hours when stored at 2 8 C. Do not use expired reagents and/or materials. Do not use the kit if the label that seals the outer box is broken upon arrival. Do not use reagents if the protective pouches are open or broken upon arrival. Do not use reagents if desiccant is not present or is broken inside reagent pouches. Do not remove desiccant from reagent pouches. Close protective pouches promptly with the zip seal after each use. Remove any excess air in the pouches prior to sealing. Protect reagents against heat and humidity. Prolonged exposure to humidity may affect product performance. Do not use reagents if the foil has been broken or damaged. 2

8 Do not mix reagents from different pouches and/or kits and/or lots. Do not interchange or re-use caps, as contamination may occur and compromise test results. Check Unitized Reagent Strips for proper liquid fills (ensure that the liquids are at the bottom of the tubes) (refer to Figure 2). Check Unitized Reagent Strips to ensure that all pipette tips are present (refer to Figure 2). Proceed with caution when using chemical solutions as Master Mix and Extraction Tube barcode readability may be altered. Good laboratory technique is essential to the proper performance of this assay. Due to the high analytical sensitivity of this test, extreme care should be taken to preserve the purity of all materials and reagents. In cases where other PCR tests are conducted in the same general area of the laboratory, care must be taken to ensure that the BD MAX CT/GC assay, any additional reagents required for testing, and the BD MAX System are not contaminated. Avoid microbial and deoxyribonuclease (DNase) contamination of reagents at all times. Gloves must be changed before manipulating reagents and cartridges. To avoid contamination of the environment by amplicons, do not break apart the BD MAX PCR Cartridges after use. The seals of the BD MAX PCR Cartridges are designed to prevent contamination. The laboratory should routinely perform environmental monitoring to minimize the risk of cross-contamination. Performing the BD MAX CT/GC assay outside the time and temperature ranges recommended for specimen transport and storage may produce invalid results. Assays not performed within specified stability time ranges should be repeated with a new specimen. Additional controls may be tested according to guidelines or requirements of local, state, provincial and/or federal regulations or accrediting organizations. Always handle specimens as if they are infectious and in accordance with safe laboratory procedures such as those described in CLSI Document M29 4 and in Biosafety in Microbiological and Biomedical Laboratories. 5 Wear protective clothing and disposable gloves while handling all reagents. Wash hands thoroughly after performing the test. Do not pipette by mouth. Do not smoke, drink, chew or eat in areas where specimens or kit reagents are being handled. Dispose of unused reagents and waste in accordance with local, state, provincial, and/or federal regulations. Consult the BD MAX System User s Manual 6 and BD Pre-warm Heater Manual 7 for additional warnings, precautions and procedures. STORAGE AND STABILITY Specimen Stability First void urine specimens must be transferred from the collection cup to the BD MAX UVE Sample Buffer Tube within 4 hours of collection when kept at 2 30 C or within 24 hours of collection when stored at 2 8 C. Clinician-collected endocervical swab and patient-collected vaginal swab specimens must be transferred immediately (preferred) or within two hours after collection to the BD MAX UVE Sample Buffer Tube when kept at 2 30 C. Urine and swab specimens in BD MAX UVE Sample Buffer Tubes should be kept between -20 C and 30 C during transport and storage. Protect against exposure to excessive heat. Table 1: Specimen Stability Prior to Transfer into the BD MAX UVE Sample Buffer Tube Specimen Stability Prior to Transfer into BD MAX UVE Sample Buffer Tube Specimen Type Transport and/or Storage Temperature 2 30 C 2 8 C Urine 4 hours 24 hours Vaginal/Endocervical Swab 2 hours 2 hours Urine or swab sample in BD MAX UVE Sample Buffer Tubes can be transported and stored for up to 5 days at 2 30 C or up to 30 days at -20 C prior to pre-warm. Table 2: Sample Stability in BD MAX UVE Sample Buffer Tube Prior to Pre-Warm Sample Stability In BD MAX UVE Sample Buffer Tube (prior to pre-warm) Specimen Type Urine and Vaginal/Endocervical Swab Transport and/or Storage Temperature 2 30 C -20 C 5 days 30 days Once pre-warmed, samples previously stored at the 2 30 C condition (refer to Table 2) can be stored for an additional 5 days at 2 30 C or an additional 30 days at -20 C (refer to Table 3) before testing on the BD MAX System. Once pre-warmed, samples previously stored at the -20 C condition (refer to Table 2) can be stored for an additional 5 days at C (refer to Table 3) before testing on the BD MAX System. NOTE: Combined sample stability [prior to pre-warm (Table 2) and post pre-warm (Table 3)] cannot exceed a total of 35 days. 3

9 Table 3: Sample Stability in BD MAX UVE Sample Buffer Tube Post Pre-Warm Sample Stability Post Pre-warm (previously stored 2 30 C) Post Pre-warm (previously stored -20 C) Specimen Type Urine and Vaginal/Endocervical Swab Urine and Vaginal/Endocervical Swab Storage Temperature 2 30 C -20 C 5 days 30 days 5 days 5 days Reagent Stability BD MAX CT/GC components are stable at 2 25 C through the stated expiration date. Do not use expired components. BD MAX CT/GC Master Mix and Extraction Tubes are provided in sealed pouches. To protect product from humidity, immediately re-seal after opening. Reagent tubes are stable for up to 7 days at 2 25 C after initial opening and re-sealing of the pouch. Master Mix Table 4: Reagent Stability Kit Components Temperature Stability Sealed pouch (not opened) 2 25 C until printed expiration date Open pouch (resealed) 2 25 C 7 days a Extraction Tube Sealed pouch (not opened) 2 25 C until printed expiration date Open pouch (resealed) 2 25 C 7 days a Unitized Reagent Strip 2 25 C until printed expiration date a Once the original seal is broken, carefully close the pouch containing the desiccant with the zip seal after each use and store at the appropriate temperature. INSTRUCTIONS FOR USE Specimen Transport/Preparation Specimens should only be collected using the BD MAX UVE Specimen Collection Kit and following the BD MAX UVE Specimen Collection Kit package insert instructions. Wear clean gloves when handling the BD MAX UVE Specimen Collection Kit components and specimens. If gloves come in contact with the specimen, immediately change them to prevent contamination of other specimens. For specimens not yet transferred into the BD MAX UVE Sample Buffer Tube, prepare the samples for testing following the instructions below. Transfer of Urine Specimen to the BD MAX UVE Sample Buffer Tube: NOTE: Urine should be transferred from the collection cup to the BD MAX UVE Sample Buffer Tube within 4 hours of collection when kept at 2 30 C or within 24 hours of collection when stored at 2 8 C. 1. Uncap the BD MAX UVE Sample Buffer Tube. Use a graduated transfer pipette to mix the urine specimen gently in the collection cup and transfer approximately 1 ml into the BD MAX UVE Sample Buffer Tube. NOTE: Use the graduations on the transfer pipette as a guide. Do not overfill or underfill the tube. 2. Discard the transfer pipette in a biohazard waste container. NOTE: The transfer pipette is intended for use with a single specimen. 3. Tighten the cap securely on the BD MAX UVE Sample Buffer Tube. 4. Invert the BD MAX UVE Sample Buffer Tube 3 4 times to ensure that the specimen and reagent are well mixed. 5. Label the BD MAX UVE Sample Buffer Tube with the patient identification and date/time collected. NOTE: Be careful not to obscure the barcodes on the tube. 6. Proceed with BD Pre-warm Heater Operation. Transfer of Endocervical or Vaginal Swab Specimens to the BD MAX UVE Sample Buffer Tube: NOTE: Swabs must be transferred from the swab sheath to the BD MAX UVE Sample Buffer Tube immediately (preferred) or within 2 hours of collection when kept at 2 30 C. NOTE: Refer to Figure 1 for a summary of the swab specimen transfer workflow. 1. Uncap the BD MAX UVE Sample Buffer Tube and fully insert the swab into the tube so that the tip is at the bottom. 2. Grasping the swab by the cap, carefully break the swab shaft at the score mark. Use caution to avoid splashing or contamination of the tube contents. 3. Tighten the cap securely on the BD MAX UVE Sample Buffer Tube. 4. Label the BD MAX UVE Sample Buffer Tube with patient information and date/time collected. NOTE: Be careful not to obscure the barcodes on the tube. 5. Proceed with BD Pre-warm Heater Operation. 4

10 Figure 1: Transfer of Swab Specimens to the BD MAX UVE Sample Buffer Tube 1. Fully insert the swab into the tube so that the tip is at the bottom. 2. Carefully break the shaft at the score mark. 3. Tightly re-cap the tube. 4. Label tube with patient information. BD Pre-warm Heater Operation (Refer to the BD Pre-warm Heater Manual 7 for operating instructions) 1. Select the <BD MAX CT GC 59> option from the Run worklist screen (Run > Worklist). 2. Enter the barcode from each BD MAX UVE Sample Buffer Tube in the Sample Tube field using the barcode scanner along with the patient accession ID. 3. Enter the kit lot number from the Run > Kit Inventory screen for the BD MAX CT/GC (for lot traceability) by scanning the barcode with the scanner. NOTE: Ensure Lot Number tracking is enabled in Configuration > System 4. The pending worklist now will be updated and display a check box for the Pre-warm step to be scheduled. 5. Schedule the sample by checking the box in the pending worklist. 6. Use the viewing window on the BD MAX UVE Sample Buffer Tube label to ensure the urine or swab specimen was added to the tube. 7. Vortex briefly to mix the sample prior to loading on the BD Pre-warm Heater. 8. Place the BD MAX UVE Sample Buffer Tube (containing the specimen) on the BD Pre-warm Heater. The station accommodates up to 24 Sample Buffer Tubes. 9. Close the lid on the BD Pre-warm Heater and select Pre-warm on the Run > Worklist Panel. NOTE: Confirm tubes were physically placed in the BD Pre-warm rack and that the rack was loaded in the Pre-warm Heater, then select OK to the Start Pre-warm message. A specific BD MAX CT/GC heating and cooling profile is started. 10. The completion time of the Pre-warm run will display on the status screen. 11. In the Pending worklist screen, the selected sample/test now will be displayed as Pre-warm Complete. 12. After successful completion of the Pre-warm step, remove the BD MAX UVE Sample Buffer Tube from the BD Pre-warm Heater and prepare the following: 5

11 NOTE: Wear clean gloves when handling BD MAX UVE Sample Buffer Tubes. Swab Samples: NOTE: If the swab is not captured in the cap, carefully remove the swab using sterile methods prior to recapping with a pierceable blue septum cap. a) Uncap the BD MAX UVE Sample Buffer Tube and gently press the swab against the side of the tube to remove excess fluid. b) Withdraw the swab/cap combination from the BD MAX UVE Sample Buffer Tube and discard. c) Recap the tube with a pierceable blue septum cap. Urine Samples: a) Remove the hard cap from the BD MAX UVE Sample Buffer Tube and discard. b) Recap the tube with a pierceable blue septum cap. 13. Proceed to the BD MAX System Operation to set up the BD MAX System Rack. NOTE: In the event of an unsuccessful Pre-warm step, the BD MAX System Timer Status will display Failed / Cooling. It is necessary to repeat the Pre-warm step prior to testing on the BD MAX System. NOTE: The BD MAX CT/GC assay can only be performed after successful completion of the Pre-warm step above. Samples that have completed the Pre-warm cycle successfully do not need to be reheated in the event retesting is necessary. NOTE: For laboratories with more than one BD MAX System and BD Pre-warm Heater, samples must be tested and/or retested on the same BD MAX System on which the pre-warm step was performed. NOTE: Refer to Table 3 for sample stability after successful completion of the pre-warm step and before testing on the BD MAX System. Equilibrate stored samples to ambient temperature and mix by vortexing briefly prior to testing on the BD MAX System. If samples are tested immediately after the pre-warm step, vortexing is not required prior to testing on the BD MAX System. BD MAX System Operation NOTE: Refer to the BD MAX System User s Manual 6 for detailed instructions (Operation section). NOTE: One (1) Master Mix (B1), one (1) Extraction Tube (B2) and one (1) Unitized Reagent Strip are required for each specimen. If External Controls are to be tested, one (1) BD MAX UVE Sample Buffer Tube and one (1) Septum Cap is required for each control (e.g. one for the external positive control and one for the negative control). Set aside the required number of BD MAX materials from their protective pouches or boxes. To store opened Master Mix or Extraction Tube pouches, remove excess air and close using the zip seal, ensuring that the desiccant pack is present in the pouch. 1. Power on the BD MAX System (if not already done) and log in by entering <user name> and <password>. 2. Gloves must be changed before manipulating reagents and cartridges. 3. Remove the required number of Unitized Reagent Strips from the BD MAX CT/GC kit. Gently tap each Unitized Reagent Strip onto a hard surface to ensure that all the liquids are at the bottom of the tubes. 4. Remove the required number of Extraction Tube(s) and Master Mix Tube(s) from their protective pouches. Remove excess air, and close pouches with the zip seal. 5. For each sample to be tested, place one (1) Unitized Reagent Strip on the BD MAX System Rack, starting with Position 1 of Rack A. 6. Snap one (1) Extraction Tube (white foil) into each Unitized Reagent Strip in Position 1 as shown in Figure Snap one (1) Master Mix Tube (green foil) into each Unitized Reagent Strip in Position 2 as shown in Figure 2. Figure 2: Snap BD MAX CT/GC Master Mix and Extraction Tubes into Unitized Reagent Strips 6

12 8. Place the BD MAX UVE Sample Buffer Tube(s) in the BD MAX System Rack(s) corresponding to the Unitized Reagent Strips assembled in steps 5 to Place the required number of BD MAX PCR Cartridge(s) into the BD MAX System (refer to Figure 3). Each cartridge accommodates up to 24 samples. The BD MAX System will automatically select the position and row on the BD MAX PCR Cartridge for each run. BD MAX PCR Cartridges may be used multiple times until all lanes have been utilized. To maximize use of BD MAX PCR Cartridges, using 2000 Sample Mode, select Run Wizard under the Worklist tab for lane assignments. Consult the BD MAX System User s Manual 6 for more details. Figure 3: Load PCR Cartridges 10. Load rack(s) into the BD MAX System (refer to Figure 4). Side A Side B Figure 4: Load Rack(s) into the BD MAX System 11. Close the BD MAX System lid and click <Start > to begin processing. 12. At the end of the run, check results immediately or store the BD MAX UVE Sample Buffer Tubes according to the temperature and time represented in Table 3 until the results are checked. NOTE: If a septum cap was damaged during the run, replace it with a new one before storing the sample. NOTE: Prior to storage, remove septum cap and replace with a hard cap. NOTE: Refer to Table 3 for sample stability of the prepared BD MAX UVE Sample Buffer Tubes post-pre-warm. When an Indeterminate (IND), Unresolved (UNR), or Incomplete (INC) result is obtained, or when an External Control failure occurs, a repeat test from the same BD MAX UVE Sample Buffer Tube must be performed within this timeframe (refer to the Repeat Test Procedure section). 7

13 QUALITY CONTROL Quality control procedures monitor the performance of the assay. Laboratories must establish the number, type and frequency of testing of control materials according to guidelines or requirements of local, provincial, state and federal and/or country regulations or accreditation organizations in order to monitor the effectiveness of the entire analytical process. For general Quality Control guidance, the user may wish to refer to CLSI MM3 8 and EP External Control materials are not provided by BD. External Positive and Negative Controls are not used by the BD MAX System software for the purpose of sample test result interpretation. External Controls are treated as if they were patient samples. (Refer to the table in the Results Interpretation section for the interpretation of External Control assay results.) 2. It is recommended that one (1) External Positive Control and one (1) External Negative Control be run at least daily until adequate process validation is achieved on the BD MAX System in each laboratory setting. Reduced frequency of control testing should be in accordance with applicable regulations. 3. The External Positive Control is intended to monitor for substantial reagent failure. The External Negative Control is intended to detect reagent or environmental contamination (or carry-over) by target nucleic acids. 4. Various types of External Controls are recommended to allow the user to select the most appropriate for their laboratory quality control program. a. External Negative Control: BD MAX UVE Sample Buffer Tube without the addition of organism or a previously characterized sample known to be negative. BD recommends that the External Negative Control be prepared prior to the External Positive Control in order to reduce the potential for contamination as a result of control preparation. b. External Positive Control: Commercially available control material [e.g., Chlamydia trachomatis serovar H (ATCC VR-879), Neisseria gonorrhoeae (ATCC 19424)] or a previously characterized sample known to be positive. For the preparation of External Control suspensions, it is recommended that cell stocks be obtained from ATCC and diluted in phosphate buffered saline to a final 10-6 dilution of the parental cell stock for Chlamydia trachomatis serovar H and Neisseria gonorrhoeae. Neisseria gonorrhoeae ATCC cell stocks are lyophilized and must be rehydrated with 1 ml phosphate buffer saline prior to dilution. Subsequently dilute the solution by transferring 150 µl into a BD MAX UVE Sample Buffer Tube for a final concentration of 10-7 for Chlamydia trachomatis and Neisseria gonorrhoeae. 5. All External Controls should yield the expected results (positive for External Positive Control, negative for External Negative Control) and no failed Sample Processing Controls (Unresolved or Indeterminate results). 6. An External Negative Control that yields a positive result is indicative of sample handling and/or contamination. An External Positive Control that yields a negative result is indicative of a specimen handling/preparation problem. Review the specimen handling/preparation technique. 7. An External Control that yields an Unresolved, Indeterminate or Incomplete test result is indicative of a reagent or a BD MAX System failure. Check the BD MAX System monitor for any error messages. Refer to the System Error Summary section of the BD MAX System User s Manual 6 for interpretation of warning and error codes. If the problem persists, use reagents from an unopened pouch or use a new assay kit. 8. Each Extraction Tube contains a Sample Processing Control which is a plasmid containing a synthetic target DNA sequence. The Sample Processing Control monitors the efficiency of DNA capture, washing and elution during the sample processing steps, as well as the efficiency of DNA amplification and detection during PCR analysis. If the Sample Processing Control result fails to meet the acceptance criteria, the result of the specimen will be reported as Unresolved; however, any positive (POS) assay results will be reported and no targets will be called NEG. An Unresolved result is indicative of specimen-associated inhibition or reagent failure. Repeat any specimen reported as Unresolved according to the Repeat Test Procedure section below. RESULTS INTERPRETATION Results are available on the Results tab in the Results window on the BD MAX System Monitor. The BD MAX System automatically interprets test results. A test result may be called NEG (negative), POS (positive), or UNR (unresolved) based on the amplification status of the target and the Sample Processing Control. IND (indeterminate) or INC (incomplete) results are due to a BD MAX System failure. Results are based on the following decision algorithm: Table 5: BD MAX CT/GC Result Interpretation Assay Result Reported CT POS CT NEG CT UNR GC POS GC NEG GC UNR IND INC Interpretation of Result Chlamydia trachomatis DNA Detected No Chlamydia trachomatis DNA Detected Unresolved inhibitory sample or reagent failure; no target or Sample Processing Control amplification Neisseria gonorrhoeae DNA Detected No Neisseria gonorrhoeae DNA Detected Unresolved inhibitory sample or reagent failure; no target or Sample Processing Control amplification Indeterminate result due to BD MAX System failure (with Warning or Error Codes) a Incomplete Run (with Warning or Error Codes) a a Refer to the Troubleshooting section of the BD MAX System User s Manual 10 for interpretation of warning and error codes. 8

14 REPEAT TEST PROCEDURE NOTE: Sufficient volume is available for one repeat test from the BD MAX UVE Sample Buffer Tube on the BD MAX System. Repeat testing must be performed within the timeframes represented in Table 3. Equilibrate stored samples to ambient temperature and mix by vortexing prior to testing on the BD MAX System. Retest samples beginning at the BD MAX System Operation section. NOTE: New samples may be tested in the same run with repeat samples. UNRESOLVED RESULT Unresolved results may be obtained in the event that specimen-associated inhibition or reagent failure prevents proper target or Sample Processing Control amplification. If the Sample Processing Control does not amplify, the sample will be reported as UNR; however, any positive (POS) assay results will be reported and no targets will be called NEG. The BD MAX System reports results for each target individually and a UNR result may be obtained for one or more BD MAX CT/GC targets. In the case of a complete UNR, where all targets have a UNR result, it is necessary to repeat the test. In the case of a partial UNR, when one or more targets have a POS result and all other targets have a UNR result, it is recommended that the test be repeated as described below. In rare cases, discrepant results may be observed when a repeat test is run for those targets that were initially reported as POS. Follow appropriate procedures in accordance with current laboratory procedures. Sample(s) can be repeated from their corresponding BD MAX UVE Sample Buffer Tube(s) within the timeframes defined above. Restart following the BD MAX System Operation section. INDETERMINATE RESULT Indeterminate results may be obtained in the event that a System failure occurs. Sample(s) can be repeated from their corresponding BD MAX UVE Sample Buffer Tube(s) within the timeframes defined above. Restart following the BD MAX System Operation section. For the interpretation of warning or error code messages, refer to the BD MAX System User s Manual 6 (Troubleshooting section). INCOMPLETE RESULT Incomplete results may be obtained in the event that Specimen Preparation or the PCR failed to complete. Sample(s) can be repeated from their corresponding BD MAX UVE Sample Buffer Tube(s) within the timeframes defined above. Restart following BD MAX System Operation section. For the interpretation of warning or error code messages, refer to the BD MAX System User s Manual 6 (Troubleshooting section). EXTERNAL CONTROL FAILURE External Controls should yield the expected results when tested. If samples have to be repeated due to an incorrect External Control result, they should be repeated from their BD MAX UVE Sample Buffer Tubes along with freshly prepared External Controls within the timeframes defined above. Restart following the BD MAX System Operation section. LIMITATIONS OF THE PROCEDURE The BD MAX CT/GC assay can only be used on the BD MAX System by trained personnel. Collection and testing of urine and patient-collected vaginal swab specimens with the BD MAX CT/GC assay is not intended to replace cervical exam and endocervical sampling for diagnosis of urogenital infection. Cervicitis, urethritis, urinary tract infections and vaginal infections may result from other causes or concurrent infections may occur. The BD MAX CT/GC assay for male and female urine testing should be performed on first catch random urine specimens. During the clinical evaluation, urine volumes from 20 ml to 60 ml were included in the performance estimates. Dilutional effects of larger urine volumes may result in reduced assay sensitivity. The effects of other variables such as mid-stream collection have not been determined. The BD MAX CT/GC assay has not been validated for vaginal swab specimens collection by patients at home. Interference with the BD MAX CT/GC assay was observed for vaginal swab matrix in the presence of VCF* Contraceptive Foam/Conceptrol* Contraceptive Gel/Acyclovir ( 25 µl/ml), Vaginal Anti-Itch Cream/Metronidazole ( 2.5 µl/ml) and whole blood ( 0.66 µl/ml). Interference with the BD MAX CT/GC assay was observed for urine matrix in the presence of whole blood (>0.04% v/v). The effects of other potential variables such as vaginal discharge, use of tampons and specimen collection variables have not been determined. As with many diagnostic tests, results from the BD MAX CT/GC assay should be interpreted in conjunction with other laboratory and clinical data available to the physician. Erroneous results may occur from improper specimen collection, handling or storage, technical error, sample mix-up, or because the number of organisms in the specimen is below the analytical sensitivity of the test. If the BD MAX CT/GC assay result is IND, INC, or UNR (for one or more targets) then the test should be repeated. A BD MAX CT/GC assay result does not necessarily indicate the presence of viable organisms. A positive result is indicative of the presence of Chlamydia trachomatis and/or Neisseria gonorrhoeae DNA. The BD MAX CT/GC assay cannot be used to assess therapeutic success or failure since nucleic acids from Chlamydia trachomatis and Neisseria gonorrhoeae may persist following antimicrobial therapy. False negative results may occur due to loss of nucleic acid from inadequate collection, transport, or storage of specimens, or due to inadequate bacterial cell lysis. The Sample Processing Control has been added to the test to aid in the identification of samples that contain inhibitors to PCR amplification. The Sample Processing Control does not indicate if nucleic acid has been lost due to inadequate collection, transport, or storage of specimens, or if bacterial cells have been adequately lysed. 9

15 The BD MAX CT/GC assay should not be used for the evaluation of suspected sexual abuse or for other medico-legal indications. Additional testing is recommended in any circumstance when false positive or false negative results could lead to adverse medical, social, or psychological consequences. As with all in vitro diagnostic tests, positive and negative predictive values are highly dependent on prevalence. BD MAX CT/GC performance may vary depending on the prevalence and population tested. The BD MAX CT/GC requires the use of three (3) optical channels from the BD MAX System; FAM channel (475/520 nm), ROX channel (585/630 nm) and VIC channel (530/565 nm). Performance of the remaining optical channel has not been established with this assay. As with all PCR-based in vitro diagnostic tests, extremely low levels of target below the Limit of Detection or LoD of the assay may be detected, but results may not be reproducible. This test is a qualitative test and does not provide quantitative values nor indicate the quantity of organisms present. EXPECTED VALUES Prevalence The prevalence of specimens that are positive for Chlamydia trachomatis and Neisseria gonorrhoeae depends upon the patient population. Factors include the type of clinic, patient age, risk factors, gender, and test method. In the BD MAX CT/GC clinical study (July 2013 May 2014) a total of 1,990 female subjects for Chlamydia trachomatis and Neisseria gonorrhoeae were compliant at the subject and Patient Infected Status (PIS) levels. For male subjects, a total of 873 for Chlamydia trachomatis and 876 for Neisseria gonorrhoeae were compliant at the subject and PIS levels. These subjects were obtained from 8 geographically diverse sites. Two sites enrolled only female subjects. Table 6: BD MAX CT/GC Clinical Study Prevalence Gender Symptom Status Site Chlamydia trachomatis Neisseria gonorrhoeae Female Male Asymptomatic Symptomatic Asymptomatic Symptomatic % (5/27) 7.4% (2/27) 2 8.5% (5/59) 0.0% (0/59) 3 6.0% (13/216) 0.9% (2/216) 4 1.8% (2/113) 1.8% (2/113) 5 1.2% (1/81) 0.0% (0/81) 6 6.5% (2/31) 0.0% (0/31) 7 9.1% (23/254) 5.1% (13/254) 8 3.7% (3/82) 3.7% (3/82) All 6.3% (54/863) 2.5% (22/863) % (8/61) 3.3% (2/61) 2 9.4% (10/106) 2.8% (3/106) 3 7.0% (14/199) 1.0% (2/199) 4 4.3% (2/47) 0.0% (0/47) 5 5.4% (11/202) 1.0% (2/202) 6 2.9% (2/70) 1.4% (1/70) % (42/352) 5.7% (20/352) % (9/90) 0.0% (0/90) All 8.7% (98/1,127) 2.7% (30/1,127) Total 7.6% (152/1,990) 2.6% (52/1,990) % (2/18) 0.0% (0/18) % (19/130) 0.8% (1/132) 4 8.8% (3/34) 0.0% (0/34) 6 9.4% (6/64) 1.6% (1/64) % (42/231) 1.3% (3/231) All 15.1% (72/477) 1.0% (5/479) % (34/91) 35.2% (32/91) % (37/153) 22.1% (34/154) % (4/8) 25.0% (2/8) % (8/35) 14.3% (5/35) % (30/109) 29.4% (32/109) All 28.5% (113/396) 26.4% (105/397) Total 21.2% (185/873) 12.6% (110/876) 10

16 Positive and Negative Predictive Value Hypothetical Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated and are represented in Tables 7 8 for Chlamydia trachomatis and Neisseria gonorrhoeae. These calculations are based on the hypothetical prevalence and overall sensitivity and specificity compared to the Patient Infected Status. Table 7: Hypothetical Positive and Negative Predictive Values for Chlamydia trachomatis Compared to Patient Infected Status Prevalence Sensitivity Specificity PPV NPV 1% 53.6% 2% 70.0% 99.9% 5% 85.8% 99.8% 10% 92.7% 99.5% 95.7% (576/602) 99.2% (5,696/5,744) 20% 96.6% 98.9% 30% 98.0% 98.2% 40% 98.7% 97.2% 50% 99.1% 95.8% Table 8: Hypothetical Positive and Negative Predictive Values for Neisseria gonorrhoeae Compared to Patient Infected Status Prevalence Sensitivity Specificity PPV NPV 1% 86.9% 100.0% 2% 93.1% 99.9% 5% 97.2% 99.8% 10% 98.7% 99.7% 97.1% (235/242) 99.9% (6,098/6,107) 20% 99.4% 99.3% 30% 99.6% 98.8% 40% 99.8% 98.1% 50% 99.8% 97.2% PERFORMANCE CHARACTERISTICS Eight geographically diverse clinical sites in North America participated in the clinical trial to evaluate the BD MAX CT/GC assay. Two thousand one hundred sixty-six (2,166) female subjects and 908 male subjects from OB/GYN, sexually transmitted disease (STD) and family planning clinics were enrolled in the study. Pregnant women were not excluded from the clinical study. Subjects were classified as symptomatic if they reported symptoms such as dysuria, urethral discharge, itching, odor, coital pain/difficulty/ bleeding, testicular or scrotum pain/swelling, abnormal vaginal discharge, or pelvic/uterine/adnexal pain. Subjects were classified as asymptomatic if they did not report these symptoms. The final data analysis included 2,114 evaluable female subjects for Chlamydia trachomatis and Neisseria gonorrhoeae. For males, 892 were evaluable subjects for Chlamydia trachomatis and Neisseria gonorrhoeae analyses. From these compliant subjects, Chlamydia trachomatis performance was calculated from 1,836 patient-collected vaginal swab, 1,831 endocervical swab, 1,849 female urine and 830 male urine specimens. Neisseria gonorrhoeae evaluable specimens included 1,836 patient-collected vaginal swab, 1,824 endocervical swab, 1,849 female urine and 840 male urine specimens. Exclusions included but are not limited to: enrollment issues, missing specimens, transport errors, collection errors, shipping errors, processing errors, and/or BD MAX System operating errors. Five specimens were collected from each eligible female subject. Urine was collected and aliquoted into the BD MAX UVE Sample Buffer Tube for testing on the BD MAX CT/GC assay, and the two reference urine specimen collection devices/tests. One patientcollected vaginal swab specimen was transferred into the BD MAX UVE Sample Buffer Tube for testing on the BD MAX CT/GC assay. Three randomized endocervical swab specimens were collected for the BD MAX System and transferred to the BD MAX UVE Sample Buffer Tube for testing on the BD MAX CT/GC assay and the two reference specimen collection devices/tests. Two specimens were collected from each of the eligible male subjects. Urine was aliquoted into the BD MAX UVE Sample Buffer Tube for testing on the BD MAX CT/GC assay, and the two reference specimen collection devices/tests. One urethral swab specimen was collected and tested using a reference method. The performance of the BD MAX CT/GC was calculated compared to PIS (refer to Tables 9-10). Comparative reference methods included two different commercially available NAATs (Nucleic Acid Amplification Test) for females and three NAATs for males from at least 2 different specimen types for Chlamydia trachomatis and Neisseria gonorrhoeae. The subject was designated infected with Chlamydia trachomatis and/or Neisseria gonorrhoeae if at least two different reference NAATs were positive for urine and endocervical swabs. Endocervical infections occurred when the endocervical results were positive for both NAATs and the urine results were negative. 11

17 A total of 6,346 Chlamydia trachomatis and 6,349 Neisseria gonorrhoeae evaluable test results using the BD MAX CT/GC assay were used to calculate performance of the BD MAX CT/GC assay compared to the PIS. Sensitivity and specificity by specimen type and symptomatic status are presented in Tables 9 and 10. Tables 11 and 12 summarize the number of results from symptomatic and asymptomatic female subjects designated as infected or non-infected with CT or GC, respectively, according to the PIS algorithms. Tables 13 and 14 summarize the number of results from symptomatic and asymptomatic male subjects designated as infected or non-infected with CT or GC, respectively, according to the PIS algorithms. Gender Spec Symp Female Male Vaginal Swab Endocervical Swab Urine Urine Table 9: Overall Performance Compared to Patient Infected Status A S ALL A S ALL A S ALL A S ALL Chlamydia trachomatis Neisseria gonorrhoeae Sens Spec Sens Spec 98.7% 94.1% 99.9% (51/51) (734/744) (16/17) (777/778) % 98.6% 96.3% 99.8% (89/90) (938/951) (26/27) (1,012/1,014) % 98.6% 95.5% 99.8% (140/141) (1,672/1,695) (42/44) (1,789/1,792) % 99.1% (48/49) (739/746) (16/16) (778/778) % 99.4% 96.3% 99.9% (84/85) (945/951) (26/27) (1,002/1,003) % 99.2% 97.7% 99.9% (132/134) (1,684/1,697) (42/43) (1,780/1,781) % 99.7% 88.9% 99.5% (48/52) (747/749) (16/18) (779/783) % 99.4% 99.9% (82/90) (952/958) (28/28) (1,019/1,020) % a 99.5% 95.7% b 99.7% (130/142) (1,699/1,707) (44/46) (1,798/1,803) % 99.5% 80.0% (69/70) (378/380) (4/5) (447/447) % 99.3% (105/111) (267/269) (103/103) (285/285) % 99.4% 99.1% (174/181) (645/649) (107/108) (732/732) a Six of 12 CT false negative urine specimens were also negative by NAAT1 and NAAT 2 urine reference methods. b One of 2 GC false negative urine specimens were also negative by NAAT1 and NAAT 2 urine reference methods. 12