2.2 Brief Description of the Technology, and Technical and Clinical Specifications

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1 Detection of S. Pneumoniae, N. Meningitidis, S. Agalactiae, L. Monocytogenes and H. Influenzae Type B Using NAAT of Cerebrospinal Fluid (Reference ) Notice of Assessment December 2013 DISCLAIMER: This document was originally drafted in French by the Institut national d'ecellence en santé et en services sociau (INESSS), and that version can be consulted at iae_nmeningitidis_sagalactiae_lmonocytogenes_hinfluenzae_typeb_taan.pdf. It was translated into English by the Canadian Agency for Drugs and Technologies in Health (CADTH) with INESSS s permission. INESSS assumes no responsibility with regard to the quality or accuracy of the translation. While CADTH has taken care in the translation of the document to ensure it accurately represents the content of the original document, CADTH does not make any guarantee to that effect. CADTH is not responsible for any errors or omissions or injury, loss, or damage arising from or relating to the use (or misuse) of any information, statements, or conclusions contained in or implied by the information in this document, the original document, or in any of the source documentation.

2 1 GENERAL INFORMATION 1.1 Requestor: CHU de Québec-CHUL 1.2 Application Sent to MSSS: June 18, Application Received by INESSS: July 1, Notice Issued: October 31, 2013 Note: This notice is based on the scientific and commercial information (submitted by the requestor[s]) and on a complementary review of the literature according to the data available at the time that this test was assessed by INESSS. 2 TECHNOLOGY, COMPANY, AND LICENCE(S) 2.1 Name of the Technology Detection of a panel of bacteria in the CSF using multiple NAAT. 2.2 Brief Description of the Technology, and Technical and Clinical Specifications This is a nucleic acid amplification test (NAAT) for the detection of agents causing bacterial meningitis, such as Streptococcus pneumoniae, Neisseria meningitidis, Streptococcus agalactiae (a Group B streptococcus), Listeria monocytogenes, and Haemophilus influenza type B. The technology used is polymerase chain reaction on a sample of cerebrospinal fluid (CSF 14 ). PCR performed with the three components from the Seeple Meningitis ACE Detection multiple kit by Seegene allows the 5 bacteria as well as the 7 viruses causing meningitis to be detected within 6 hours. More precisely, the Seeple Meningitis-B ACE Detection component, which detects the five bacteria, consists of three major steps: nucleic acid isolation of bacteria; amplification of target bacterial DNA using DPO 15 primers; and qualitative detection using an automated system or agarose gel electrophoresis of the different amplification products [Seegene 2010]. According to Shin et al. [2012], the target genes are: gyrb in S. pneumoniae, CtrA in N. meningitidis, cfb in S. agalactiae, hly in L. monocytogenes and P6 in H. influenzae type B Company or Developer Seegene Inc., Seoul (South Korea), manufactures the Seeple Meningitis ACE Detection kit, which consists of three components: Seeple Meningitis-B ACE Detection (5 bacteria), Seeple Meningitis- V1 ACE Detection (6 viruses), and Seeple Meningitis-V2 ACE Detection (1 virus). 2.4 Licence: Not applicable. 2.5 Patent, If Any: Not applicable. 14.CSF: liquid that surrounds the brain and spinal cord [Gray and Fedorko, 1992]. 15.DPO : dual priming oligonucleotide. This technology by Seegene Inc. maimizes PCR specificity and sensitivity. 16. gyrb: DNA gyrase, subunit B; CtrA: capsule polysaccharide eport outer membrane protein CtrA; cfb: camp-factor (cfb); hly: pore-forming cytolysin listeriolysin; P6: outer membrane protein (OMP) P6. 1

3 2.6 Approval Status (Health Canada, FDA) According to the information provided in the application, no kit for the purpose in question has been approved for the Canadian market. The Seeple Meningitis ACE Detection kit by Seegene has been approved for diagnosis in the European Union, but it is limited to research in other countries such as Canada [Seegene, 2010]. 2.7 Weighted Value: based on the information provided in the application. 3 CLINICAL INDICATIONS, PRACTICE SETTINGS, AND TESTING PROCEDURES 3.1 Targeted Patient Group According to the information provided in the application, the test will be prescribed for patients with clinical meningitis and pleocytosis, 17 and performed if the CSF culture is negative after more than 48 hours of incubation. 3.2 Targeted Disease(s) Meningitis is an inflammation of the tissues surrounding the brain and spinal cord [Tunkel, 2012a]. Clinical features of bacterial meningitis vary and are nonspecific (fever, nausea, vomiting, headaches, confusion, etc.) [Curtis et al., 2010]. The disease can progress over a few days or it can develop rapidly, in a matter of a few hours [PHE, 2012]. The mortality rate for meningitis, if untreated, approaches 100%. Even with optimal therapy, bacterial meningitis may cause neurological or other types of sequelae or bring on patient death. Most of the damage is attributable to the action of the cytokines 18 released into the CSF when the body initiates a response against the bacteria [Tunkel, 2012a]. The main causes of community-acquired (as opposed to nosocomial) bacterial meningitis in adults in industrialized countries are S. pneumoniae, N. meningitidis, and especially L. monocytogenes in patients aged 50 years to 60 years or patients with cellular immunodeficiency [Tunkel, 2012b]. Vaccination against N. meningitidis and H. influenzae has slowed the spread of the disease [Favaro et al., 2012]. The incidence of bacterial meningitis ranges from 0.56 to per 100,000 population, depending on the bacteria and the age group, in the case of children [Kaplan, 2012]. Based on the information provided in the application, this contagious disease may also occur in outbreaks. 3.3 Number of Patients Targeted Based on the information provided by the requestor, the annual volume over the net three years is epected to be approimately 30 PCR tests for pediatric patients of the CHUL. 3.4 Medical Specialties Involved (and Other Professions, If Any) Microbiology, infectious disease, emergency medicine, intensive care medicine, neurology. 3.5 Testing Procedure According to the requestor, the Seeple Meningitis-B ACE Detection component should be ordered on an individual basis, on the basis of clinical presentation, as should the other two components of the 17.Pleocytosis: abnormal increase in white blood cell count in the cerebrospinal fluid [website of the Académie de Créteil. Available from: Low-molecular-weight proteins that stimulate or inhibit the differentiation, proliferation and function of immune cells [Delves et al., 2011]. 2

4 Seeple Meningitis ACE Detection kit by Seegene. Based on the information provided in the application, this rapid test will be offered and performed seven days a week. It must be carried out on a sample of CSF obtained from a lumbar puncture. To ensure samples of the highest quality, they must be transported for analysis with the greatest care and as quickly as possible, within 4 hours at 19 C to 25 C or within 3 days at 2 C to 8 C [Seegene, 2010]. The CSF sample must be centrifuged and the precipitate used to etract the DNA from the bacteria found within it. 4 TECHNOLOGY BACKGROUND 4.1 Nature of the Diagnostic Technology This test would replace bacterial antigen 19 testing of cerebrospinal fluid (CSF) (code 40163) and complement cerebrospinal fluid (CSF) cultures (code 40164). If it yields a positive result, it would be followed by a genotyping test performed at the Laboratoire de santé publique du Québec or at the National Microbiology Laboratory (Manitoba). 4.2 Brief Description of the Current Technological Contet A lumbar puncture is performed, unless contraindicated (e.g., for an unstable patient, a skin infection at the punction site, etc.), to obtain a CSF sample for testing. Antibiotic therapy should be initiated as soon as possible [Kaplan, 2012]. Bacterial culture of the CSF is considered the gold standard for diagnosing bacterial meningitis and assessing the susceptibility of bacteria to antibiotics [Favaro et al., 2012]. However, this test requires days of incubation, which is why initial decisions must, to a great etent, rely on the prompt eamination of the CSF (which includes Gram staining 20 ) [Bonadio, 1992; Gray and Fedorko, 1992]. An agglutination test of sensitized late particles 21 may also be used. However, the sensitivity and specificity of CSF cultures and eaminations via these tests are limited [Shin et al., 2012]. In the requestor's view, the only current option in molecular biological testing is to conduct five simple (distinct) PCRs in Montreal or Winnipeg (depending on the pathogen), which would result in delays too lengthy to yield any clinical utility for patients or for follow-up of close contacts. 4.3 Brief Description of the Advantages Cited for the New Technology The Seeple Meningitis ACE Detection kit may be useful to rapidly identify any of the 12 most common pathogens (including 5 bacteria) that cause meningitis [Shin et al., 2012]. According to the requestor, the Seeple Meningitis-B ACE Detection component of this kit can be used to detect bacteria in cultures diminished by antibiotic therapy and in cultures with an otherwise negative result 19. Based on information obtained from the Ministère de la Santé et des Services sociau (MSSS), bacterial antigen testing of cerebrospinal fluid (CSF), under code 40163, was performed using an agglutination test with a kit that is no longer commercially available. This test enabled the detection of S. pneumoniae, N. meningitidis and H. influenzae type B antigens, and the classical indication was meningitis partially treated by oral antibiotics. However it lacked sensitivity; for this reason, learned societies recommended it no longer be made available. Some replace this test with an enzyme immunoessay or enzyme-linked immunosorbent assay (ELISA) to detect S. pneumoniae antigens in a urine or CSF sample. 20. Gram staining: technique commonly used to differentiate bacteria of a clinical specimen according to the properties of their cell walls that have been affied to a slide and will be observed under a microscope. The gram-positive bacteria stain violet, as their cell walls contain a thick layer of peptidoglycan that retains the gentian violet stain after decoloration. However, gram-negative bacteria stain red, as their thin layer of peptidoglycan does not retain the gentian violet, but only the safranin [website of the Science Education Resource Center at Carleton College, Minnesota. Available from: This technique allows the morphology of the coloured bacteria to be eamined under a microscope. 21. Agglutination test of sensitized late particles: technique that consists of miing a clinical specimen with late particles coated with antibodies that recognize specific antigens. If the bacteria in the specimen contain these antigens, they will attach themselves to the antibodies on the late beads, which in turn will form visible clumps. 3

5 due to the low number of bacteria at the onset of the disease or due to bacterial lysis. Based on the information provided in the application, the ability to identify bacteria with this test even after empiric antibiotic therapy has been initiated would help improve patient care, positively affect the management of notifiable diseases 22 by the public health system, and speed up patient discharge. 4.4 Cost of Technology and Options: Not assessed. 5 EVIDENCE 5.1 Clinical Relevance Other Tests Replaced The test would replace bacterial antigen testing of cerebrospinal fluid (CSF) (code 40163) (See Section 4.1) Diagnostic or Prognostic Value As mentioned in Section 4.3, the Seeple Meningitis ACE Detection kit may be useful for the rapid identification of any of the 12 most common pathogens (including 5 bacteria) that cause meningitis [Shin et al., 2012]. Moreover, the ability to identify the targeted bacteria even after empiric antibiotic therapy has been initiated would help improve patient care, positively affect the management of notifiable diseases by the public health system, and speed up patient discharge Therapeutic Value: No data available. 5.2 Clinical Validity: No data available. 5.3 Analytical (or Technical) Validity PARAMETER PRESENCE ABSENCE NOT APPLICABLE Repeatability Reproducibility Analytical sensitivity Analytical specificity Matri effect Concordance Correlation between test and comparator Others, depending on type of test Tests were performed at five different times, over a two-week period, by three different researchers, and yielded the same results, confirming the reproducibility of the kit [Seegene, 2010]. Based on the results of an unpublished validation carried out by the requestor of the Seeple Meningitis-B ACE Detection component from the Seeple Meningitis ACE Detection kit by Seegene, only one sample (weakly positive) was divergent out of the 18 samples analyzed in duplicate, repeated over different days, and performed by two independent researchers. 22. Invasive infections by S. pneumoniae, N. meningitidis, H. influenzae and listeriosis (L. monocytogenes) but not invasive group B streptococcal infections are notifiable diseases in Quebec [MSSS, 2012]. 4

6 The analytical sensitivity of the kit is good, given that the detection limit for S. pneumoniae, N. meningitidis, S. agalactiae, L. monocytogenes, and H. influenzae was 19, 13, 5, 51 and 57 genomes/ml respectively [Shin et al., 2012]. Based on the unpublished results of the aforementioned validation, the sensitivity of the Seeple Meningitis-B ACE Detection component of the Seeple Meningitis ACE Detection kit by Seegene was 100%, at a detection limit of 600 colony-forming units (CFU)/reaction or 3,000 CFU/mL, and the concordance with the CSF culture was ecellent. The analytical specificity was good, given that different pathogens were tested, and there was no amplification of nucleic acids other than of those targeted by the kit [Shin et al., 2012; Seegene, 2010]. Based on the unpublished results of the aforementioned validation, there was no cross-reaction between the strains of bacteria or with the fluids indicating hemorrhage or anthochromia Recommendations for Listing in Other Jurisdictions No information available. 6 POSSIBLE OUTCOMES OF INTRODUCING THE TEST 6.1 Impact on Material and Human Resources: Not assessed. 6.2 Economic Consequences of Introducing the Test Into Quebec's Health Care and Social Services System: Not assessed. 6.3 Main Organizational, Ethical, and Other (Social, Legal, Political) Issues: Not assessed. 7 IN BRIEF 7.1 Clinical Relevance The test allows the rapid identification of any of the 12 most common pathogens (including 5 bacteria) that cause meningitis, even once empiric antibiotic therapy has been initiated. Therefore, it helps improve patient care, positively affects the management of notifiable diseases by the public health system, and speeds up patient discharge. 7.2 Clinical Validity: No data available. 7.3 Analytical Validity Although data on the Seeple Meningitis ACE Detection kit by Seegene are scarce, they indicate that it is reproducible, that its analytical sensitivity and specificity are good, and that its results agree with those from CSF cultures. 7.4 Recommendations for Listing in Other Jurisdictions: No information available. 23. Xanthochromia: the yellow colouring of the CSF or skin [website of the Académie de Créteil. Available at: 5

7 8 INESSS NOTICE IN BRIEF Detection of S. pneumoniae, N. meningitidis, S. agalactiae, L. monocytogenes and H. influenzae Type B Using NAAT of Cerebrospinal Fluid Status of the Diagnostic Technology Established Innovative Eperimental (for research purposes only) Replacement for technology:, which becomes obsolete INESSS Recommendation Add test to the Inde This test is essential in Quebec and would shorten response time. At present, CSF samples are sent to the LSPQ, which then sends them to Winnipeg for the identification of three bacteria. Do not add test to the Inde Reassess test Additional Recommendation Draw connection with listing of drugs, if companion test Production of an optimal use guide Introduction conditional upon determination of clinical utility (number of tests, number of diagnosed cases of meningitis, change in therapy following result, clinical outcome, costs including that of additional tests required for N. meningitidis typing at the National Microbiology Laboratory (NML) in Winnipeg). NOTE Although this test will not replace cultures, it could replace test

8 REFERENCES Bonadio WA. The cerebrospinal fluid: physiologic aspects and alterations associated with bacterial meningitis. Pediatr Infect Dis J 1992;11(6): Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics 2010;126(5): Delves PJ, Martin SJ, Burton DR, Roitt IM. Roitt s essential immunology.12e éd.chichester, Royaume- Uni Wiley-Blackwell; Favaro M, Savini V, Favalli C, Fontana C.A multi-target real-time PCR assay for rapid identification of meningitis-associated microorganisms. Mol Biotechnol 2013;53(1):74-9. Gray LD and Fedorko DP. Laboratory diagnosis of bacterial meningitis. Clin Microbiol Rev 1992;5(2): Kaplan SL. Clinical features and diagnosis of acute bacterial meningitis in children older than one month of age.waltham, MA Wolters Kluwer Health; Available from Ministère de la santé et des services sociau (MSSS). Surveillance des maladies à déclaration obligatoire au Québec - Définitions nosologiques - Maladies d'origine infectieuse.9e éd. Québec, Qc MSSS; Available from Public Health England (PHE). UK Standards for microbiolgy investigations. Investigation of cerebrospinal from PHE; Available fluid Bacteriology B27/5-1.Londres, Angleterre from Seegene; Available Seegene.Seeple Meningitis ACE Detection.Corée Shin SY, Kwon KC, Park JW, Kim JM, Koo SH. Evaluation of the Seeple(R) meningitis ACE detection kit for the detection of 12 common bacterial and viral pathogens of acute meningitis. Ann Lab Med 2012;32(1):44-9. Tunkel AR. Pathogenesis and pathophysiology of bacterial meningitis Waltham, MA Wolters Kluwer Health; Available from Tunkel AR. Clinical features and diagnostic of acute bacterial meningitis in adults Waltham, MA Wolters Kluwer Health; Available from 7