New Diagnostic Methods for Hepatitis C

Transcription

1 New Diagnostic Methods for Hepatitis C Stéphane Chevaliez French National Reference Center for Viral Hepatitis B, C and delta Department of Virology & INSERM U955 Henri Mondor Hospital University of Paris-Est Créteil, France

2 Outline Introduction New virological tools Impact of HCV testing in healthcare accessibility

3 Outline Introduction New virological tools Impact of HCV testing in healthcare accessibility

4 The Global Burden of HCV Infection Unsafe invasive procedures in healthcare facilities and unsterile equipment to inject drugs are responsible for 1.75 million of new infections worldwide (2015) Approximately 71 million people are chronically infected with HCV WHO., Global hepatitis report, 2017; Polaris Observatory HCV Collaborators., Lancet Gastroenterol Hepatol 2017;2(3):

5 Prevalence of HCV Chronic Infection ~ 71 million people (1%) Prevalence (HCV RNA) No data 0.0%-0.6% 0.6%-0.8% 0.8%-1.3% 1.3%-2.9% 2.9%-6.7% Polaris Observatory HCV Collaborators., Lancet Gastroenterol Hepatol 2017;2(3):

6 The Global Burden of HCV Infection Unsafe invasive procedures in healthcare facilities and unsterile equipment to inject drugs are responsible for 1.75 million of new infections worldwide Approximately 71 million people are chronically infected with HCV HCV is responsible for about 700,000 deaths a year worldwide WHO., Global hepatitis report, 2017; Polaris Observatory HCV Collaborators., Lancet Gastroenterol Hepatol 2017;2(3): ; GBD 2013., Lancet 2015;385:

7 Cascade of Care for Hepatitis C % % 10 0 Infected with HCV WHO Global Hepatitis Report, Diagnosed 7% 6% Receiving DAA treatment in 2015 Cured (SVR)

8 What are the WHO Objectives in 2030? 80 90% infected diagnosed Difference 70% 30 90% diagnosed treated Difference 73% 10 0 Infected with HCV WHO Global Hepatitis Report, Diagnosed Receiving DAA treatment in 2015 Cured (SVR)

9 Key Interventions for Scale up Potent and well-tolerated IFN-free DAA regimens are now available Promotion of prevention Improvement of large-scale screening Expanding of access to treatment WHO Global Hepatitis Report, 2017.

10 Outline Introduction New virological tools Impact of HCV testing in healthcare accessibility

11 Virological Tools Classical tools HCV core antigen (cag) Alternative tests (POCT) Rapid diagnostic tests (RDT) Molecular POCT Dried blood spot (DSB) for blood collection

12 Interest of HCV Core Ag Quantification A surrogate marker of HCV replication Chevaliez et al., Antivir Ther 2016 Apr 26 doi: /IMP3042; Lamoury et al., J Clin Virol 2017;92:32-38.

13 HCV Core Antigen: A Marker of HCV Replication Chevaliez et al., J Clin Virol 2014;61(1):145-8.

14 Interest of HCV Core Ag Quantification A surrogate marker of HCV replication Many advantages over molecular methods 30-50% less expensive than molecular method Stability at RT for 96 hours Short time to result New tool for the monitoring of virologic responses during IFN-free DAA-based regimens Discrimination between patients with or without SVR Chevaliez et al., Antivir Ther 2018;23(3): ; Lamoury et al., J Clin Virol 2017;92:32-38.

15 Baseline and Ontreatment HCV cag versus HCV RNA Lamoury et al., J Clin Virol 2017;92:32-38.

16 POCT: Benefits to Patients Reduced waiting times Fewer or no follow-up visits Immediate discussion of results and Rx Improved healthcare accessibility

17 Point-of-care Diagnostics: Towards to a Single Visit Grebely et al., Expert Rev Mol Diagn 2017;17(12):

18 Screening HCV infection RAPID DIAGNOSTIC TEST

19 Rapid Diagnostic Test (RDTs) Can be used at the site of patient care Physician office Emergency room, ICU Outpatient clinics, rural areas, eventually patients home Can use original specimen matrices in addition to serum or plasma Fingerstick whole blood Oral fluid

20 Interest of Oral fluid as an Alternative Matrix Simple, safe, painless, cheap to collect Contains lower amount of immunoglobulins (and viral markers) than whole blood Specimen IgG (mg/l) IgM (mg/l) IgA (mg/l) Whole saliva Parotid saliva Crevicular fluid Plasma McKie et al., Lancet Infect Dis 2002;2(1):18-24.

21 Detection of HCV Ab in Oral Fluid Chevaliez et al,. Clin Microbiol Infect 2016;22(5):459.e1-6.

22 Available RDTs for HCV Ab Detection (CE-marked, FDA-approved or Eligible for Procurement by WHO) Manufacturer Specimen type Volume needed (µl) Time required (min) Oraquick HCV rapid Ab test Toyo antihcv test 2.0 Signal HCV Ver 2.0 Multisure HCV SD Bioline HCV Orasure Technologies USA Turklab Turkey Span Divergent India MP Biomedicals Singapore Standard Diagnostics Korea Oral fluid, whole blood, serum, plasma Whole blood, serum, plasma Serum, plasma Whole blood, serum, plasma Whole blood, serum, plasma 40 (OF) (S,P)

23 Available RDTs for HCV Ab Detection (CE-marked, FDA-approved or Eligible for Procurement by WHO) First Response HCV Card Test Manufacturer Specimen type Volume needed (µl) Time required (min) Premier Medical Corporation Ltd India Advanced Quality Rapid AntiHCV Test InTec Products Inc. China Labmen HCV test First Response HCV Card Test Turklab Turkey Premier Medical Corporation Ltd India Whole blood, serum, plasma Whole blood, serum, plasma Whole blood, serum, plasma Whole blood, serum, plasma *Compatible with automatic reader ICA-R Turklab

24 Performance of RDTs for HCV Ab Detection from Fingerstick Whole Blood 318 patients with chronic HCV infection, 25 patients with resolved HCV infection and 170 HCV-seronegative subjects (N=513) Tests Specificity Sensitivity OraQuick HCV Rapid Ab Test 100% 99.4% TOYO anti-hcv test 98.8% 95.8% Labmen HCV test 100% 63.1% Chevaliez et al., Clin Microbiol Infect 2016;22(5):459.e1-6.

25 Performance of RDT for HCV Ab Detection from Oral Fluid 318 patients with chronic HCV infection, 25 patients with resolved HCV infection and 170 HCV-seronegative subjects (N=513) Tests OraQuick HCV Rapid Ab Test Chevaliez et al., Clin Microbiol Infect 2016;22(5):459.e1-6. Specificity Sensitivity 100% 97.6%

26 MOLECULAR POCTS

27 Available Kits for HCV RNA Detection and Quantification RealTime HCV (Abbott) CAP/CTM HCV 2.0 (Roche) Xpert HCV (Cepheid) Xpert HCV VL FS (Cepheid) Aptima HCV Quant Dx (Hologic) Real-time PCR Real-time PCR Real-time PCR Real-time PCR Real-time TMA Volume required (µl) , Biological matrix Plasma/serum Plasma/serum Plasma/serum Whole blood Plasma/serum Extraction procedure Automated Automated Automated Automated Automated Linear range (IU/mL) LOD (IU/mL) (plasma/serum/wb) 10.5/ / / /3.9 Time to have results (min) 276* 345* 105 <60 150* No No Yes Yes Yes Principle LLOQ (IU/mL) Random access

28 Principle of Cepheid POC RNA Testing* *CE IVD; not available in the US 1 Collect 100 µl capillary blood by finger-prick into a Minivette 2 Load blood directly into the Xpert cartridge 3 Results in 60 minutes

29 HCV RNA Quantification (Xpert HCV VL Fingerstick, Cepheid) 0.03 Grebely et al., Lancet Gastroenterol Hepatol 2017;2(7):

30 HCV RNA Quantification and Detection (Xpert HCV VL Fingerstick, Cepheid) Abbott RealTime HCV No. of quantifiable No. of unquantifiable No. of total No. of quantifiable No. of unquantifiable No. of total Xpert HCV VL FS Lamoury et al., J Infect Dis 2018;217(12):

31 HCV RNA Quantification and Detection (Xpert HCV VL Fingerstick, Cepheid) Abbott RealTime HCV No. of quantifiable No. of unquantifiable No. of total No. of quantifiable No. of unquantifiable No. of total Xpert HCV VL FS Abbott RealTime HCV No. of detectable No. of undetectable No. of total No. of detectable No. of undetectable No. of total Xpert HCV VL FS Lamoury et al., J Infect Dis 2018;217(12):

32 DRIED BLOOD SPOTS

33 DBS: a New Tool for Blood Collection? Clean site with alcohol prep Puncture the finger using a sterile lancet Apply blood to the filter paper in order to fill in circles Air dry to at least 1-3 hours Place dried DBS into bag with desiccant and mail at RT Cut out spots Ag, Abs, acid nucleic extraction with appropriate buffer Serology NAT Patient Adapted from Hirtz and Lehman., Ann Biol Clin (Paris) 2015;73(1):25-37.

34 Detection of HCV Ab in Whole Blood from DBS by 3rd-generation EIA Sensitivity = 99.1% Specificity = 98.2% Soulier et al., J Infect Dis 2016;213(7):

35 HCV RNA Quantification (Abbott RealTime HCV; CAP/CTM HCV 2.0) 306 HCV-chronically infected patients with genotype 1 to 6 Reference matrix: serum Soulier et al., J Infect Dis 2016;213(7):

36 HCV RNA Quantification (Xpert HCV VL, Cepheid) 50 HCV-chronically infected patients with genotype 1 to 6 Reference matrix: serum Pre-extraction reagent: Guanidinium Thiocyanate Unpublished data. Pre-extraction reagent: 20 mm TRis ph 8.6

37 Outline Introduction New virological tools Impact of HCV testing in healthcare accessibility

38 Clinical Benefits of Alternative Tests Improvement of healthcare accessibility in specific clinical features (blood exposure/delivery) Large-scale screening of HCV infection Improvement of cascade of care Improvement of linkage to care Reducing HCV transmission in high-risk populations

39 Test and Treat Program In egypt: Impact of RDT 4,215 individuals were screened for HCV antibodies in Al-Othmanya village by means of Advanced Quality Rapid Anti-HCV Test (Intec) 530 were anti-hcv positive (12.6%) 312 seropositive were HCV RNA positive (7.4%) 300 eligible patients were treated with SOF + RBV for 24 weeks. SVR was achieved in 293 patients (98%) Shiha et al., Lancet Gastroenterol Hepatol 2018;in press.

40 HCV RNA Screening in HIV-Infected MSM in Switzerland * *Abbott RealTime HCV assay Braun et al., Clin Infect Dis 2018;in press.

41 HCV RNA Point-of-Care Screening in Emergency Department in UK Approach was technically feasible Among the 814 subjects who accepted to complete a questionnaire, 324 (39.8%) were tested for the presence of HCV RNA using Xpert HCV VL FS assay 1 subject was detected HCV RNA positive (prevalence of 0.31%) 1 test gave an invalid result

42 HCV RNA FS Testing: Improvement of Screening in Hard to Reach Populations Area in France Investigators Objectives Target populations Paris Stéphanie Dominguez Stéphane Chevaliez Françoise Roudot-Thoraval Christophe Hézode Jean-Michel Pawlotsky Test and Cure PWID Test and Cure PWID Prisoners General population Perpignan André-Jean Remy Bordeaux Victor de Ledinghen Pascale Trimoulet Jean-Michel Delile Juliette Foucher Brigitte Reiller Toulouse Christophe Bureau Sophie Métivier Laurent Schmidt Jacque Izopet Strasbourg Michel Doffoël Frédéric Chaffraix Fiorant Di Nino Flavie Oster Samira Kremer Michel Girard Lisa Dietrich Test and Cure Test and Cure Test and Cure PWID PWID Migrants PWID General population

43 HCV RNA FS Testing: PARCOURS Program Mean age (years) Sex, male Fibrosis stage distribution F0-F1 F2 F3 F4 Not done N= ± (90%) 11 HCV- infected PWID 19 (47.5%) 4 (10%) 2 (5%) 4 (10%) 11 (27.5%) 10 µl 20 µl 30 µl 40 µl 50 µl Sensitivity = 88.9% Specificity = 100%

44 Improvement of HCV Screening in Scotland Introduction of DBS testing in drug service McLeod et al., J Epidemiol Community Health 2014;68(12):

45 Conclusions New and rapid virological tools are now available HCV core antigen assays Alternative tests for HCV antibody detection and HCV RNA detection and quantification DBS for whole blood collection Further studies are warranted to assess their clinical impact on screening, diagnosing and monitoring HCV infection

46 Thank you for your attention!