Can new diagnostics make a difference?

Transcription

1 Can new diagnostics make a difference? Lesley Scott Department of Molecular Medicine and Haematology, School of Pathology, Faulty of Health Sciences, University of the Witwatersrand, National Priority Program, Johannesburg, South Africa

2 Overview Global health security The role of the laboratory The current footprint of NHLS for HIV and TB molecular testing GeneXpert technology The need for innovation across the laboratory value chain The patient, specimen, laboratory, result return, connectivity Focus on diagnostics How have diagnostics contributed to reducing TB burden What s new in diagnostics What else can we do with a molecular connected result What about EPTB What about children

3 Healthcare in Africa Projected populations of Africa by 2050: 2.5 billion: 1:4 African Shifting expectations 2015 Move towards Universal health Coverage Increase expectations of care Greater Emphasis on quality Massive changes in disease patterns MDG s (2015): AIDS, TB, Malaria Heterogeneity in Africa: responsible for failure of certain goals Shifting disease burden 2030 Beyond the communicable diseases: CVS, Diabetes and Cancer will cause greater numbers of deaths? 3.3. End TB,AIDS, Malaria 3.4. Reduction in premature MR by1/3 Big ask will be the two together?

4 Global epidemiology of TB Desired decline in global TB incidence rates to reach the 2035 targets tb/en/

5 South Africa (high TB, HIV and MDR burden) 2016 WHO report Total population~56 million ~ new cases ~ TB deaths Mortality (HIV + TB) = Incidence (HIV+TB) = 834/ ~ TB patients are HIV+ ~ HIV+ on TB preventive therapy Cases tested for MDR = Patients starting treatment = Total number of new smear positive patients = Urgent interventions are needed, one of which has been the need for rapid diagnosis of MTB technology.

6 Priority Diseases Priority Diseases HIV Tuberculosis Malaria Fevers, emerging infections Sexually Transmitted Infections Antimicrobial Resistance Non Communicable Diseases Approach Integration (programs, platform) People centred Lab moving from transactional to integrative WHO report,2017 Cross cutting themes across the laboratory value chain Patient Specimen Transport Central laboratory Connectivity Quality Processes Models (access, implementation, costing)

7 Role of Laboratories in Universal Health Coverage Targets such as the UNAIDS 90:90:90 for HIV and the END TB strategies need delivery at scale The laboratory is central to screen, diagnose and monitor safe treatment and patient care Population diversity, resources and geography, a single solution is not feasible Recent advances in information technology, can facilitate affordable, accessible diagnostics Dramatic improvements in technologies at both spectrums (POC to high end central automation) can facilitate integrative testing Data collection and analytics is critical to improve patient linkage to care Innovative ideas need to target improved healthcare delivery

8 Need for Innovation across the laboratory value chain SPECIMEN Better quality Less invasive Single specimen/multiple testing Specimen tracking Specimen storage and biorepository TRANSPORT Increases efficiency Tracking and accountability Improved specimen integrity Minimize reliance on result return Tracking and cost sharing Uber Mapping transport routes SYSTEM WIDE CONNECTIVITY Embrace digital health transformation Linkage to care Continuous quality monitoring Mapping national and global disease trends Training needs PATIENT ACCESS Optimize linkage to care = Unique ID Increase access to self testing Access through medical wallet Improved HCW engagement Reduce waiting times in clinics Increase access to POCT Reduce unnecessary testing LABORATORY/TESTING Optimize testing across the tiered framework (Hybrid model: highly centralized to POCT) Systems approach Multiplatform and automated platforms Improve test performance (sensitivity, accuracy) Improve use case of a test (adults and paediatrics) Increase number of test results returned Improve turn around time Optimize LIS and increase access to dashboards Big data (surveillance, program M&E, outbreaks) Reduce test costs, improve forecast Quality testing and services Reduce testing errors

9 Working with the NPP Unmet clinical need Infrastructure & test options R&D and Validation Implementation, operations & Scale up Monitoring & evaluation Linkage to Care 49 CD4 laboratories 16 Viral Load laboratories 206 GeneXpert laboratories Programme improvements & impact

10 Across the National Priority Program HIV Viral Load 80% population, networked, instruments interfaced 1 LIS HIV PCR Volumes /12 12/13 13/14 14/15 15/16 16/17 17/18 _Volumes Volumes Increase 23.69% 26.95% 16.11% 25.30% 19.21% 11.97% Total Volumes to date: 22,660,095 Financial Year Volumes /12 12/13 13/14 14/15 15/16 16/17 17/18 _Volumes Volumes Increase 6.74% 5.48% 6.80% 35.12% 11.95% 3.23% Total Volumes to date: 3,054,907 Financial Year 52 CD4 labs Volumes ( ) 11/12 CD4 Count 12/13 13/14 14/15 15/16 16/17 17/18 _Volumes Volumes Increase 1.94% 2.00% 0.27% 10.44% 3.08% 9.77% Total Volumes to date: 25,517,914 Financial Year Volumes /12 12/13 13/14 14/15 15/16 16/17 17/18 _Volumes Volumes Increase % % 20.26% 5.26% 6.99% 9.26% Total Volumes todate: 12,838,921 GENEXPERT Financial Year 16 VL labs 207 GeneXpert labs

11 TB Diagnostic dilemma Earlier and improved TB case detection Including smearnegative disease often associated with: HIV TB Young age Enhanced capacity to diagnose multi drug resistant (MDR) TB Liquid culture = 2 6 weeks (longer with DST); smear = 2 days but poor sensitivity especially in HIV+

12 LS1 Traditional Screening tools for TB Symptoms of TB: Cough Hemoptysis Fever Night sweats Weight loss SYMPTOM SCREENING Strengths Helps people seek healthcare Allows the diagnostic process to start Inexpensive Limitations Inconclusive Occurs when disease has already progressed Not useful for extra pulmonary TB Potential to increase number of false positives CHEST X-ray Chest radiography is another option for screening, it can be used together with symptom screening to best determine who should continue on with diagnostic testing Strengths Quick High sensitivity Inexpensive Widely used Limitations Low specificity Requires additional testing Cannot be used for extra pulmonary TB Active TB doesn't always look the same

13 Slide 12 LS1 Reference Lesley Scott, 2018/08/14

14 SPUTUM SMEAR MICROSCOPY Inexpensive method to identify acid-fast bacilli on a stained smear on a slide viewed under a microscope The WHO recommends the following strategies to improve microscopy: Use fluorescence staining Use light-emitting diode (LED) microscope Inexpensive, battery-operated light source can be used These additions make bacteria easier to detect: offering about 10% increase in sensitivity making smear 25% faster compared to conventional microscopy BUT even still, smear is less not sensitive, especially in HIV+/TB co-infected individuals gives no information on drug resistance Strengths: Same-day results Low technology required Inexpensive Widely available Can be used for treatment monitoring Limitations Lacks desired sensitivity Only useful for pulmonary TB Not accurate for children and HIV positive people Unavailable info on drug susceptibility Multi-step, complicated procedure Inability to discriminate mycobacterial species Intrinsic limitations of performing microscopy

15 CULTURE The gold standard technique for TB diagnosis Two types: Solid culture (Löwenstein-Jensen (LJ)) Liquid culture (MGIT, MODS, BacT/ALERT 3D) Strengths: High sensitivity High specificity Ability to perform drug susceptibility testing Can be used to assess treatment progress Limitations: Requires highly skilled lab technicians Automated liquid culture is expensive Long waiting time due to slow mycobacteria growth Leads to diagnostic delays Requires BSL3 infrastructures Prone to high rates of contamination with bactera Cultural characteristics of M. tuberculosis: Solid culture Liquid culture

16 NUCLEIC ACID AMPLIFICATION TESTS: GeneXpert Lab in a cartridge (biosafe to decentralise and for near POC) Modular Random access and multi purpose (14 tests available) Interfaced to a laboratory information system Molecular (semi quantitative & identifies genetic mutation regions) Web based dashboard C360 Assay and module verification & EQA monitored globally. Cycle threshold (Ct)

17 Xpert: single to high throughput Closed platform for extraction, amplification and detection of Mycobacterium tuberculosis (Mtb) complex and Rif resistance Direct from unprocessed sputum (0.5 4ml) Time to result: minutes 2. Shake then stand 10 minutes 4. Transfer 2ml to cartridge 1. Add 2:1 Sample Buffer to sample 3. Shake then stand further 5 minutes Begin Test

18 Lawn, Nicol. Future Microbiol 2001; 6(9):

19 GeneXpert: OVERVIEW Strengths: The WHO recommends GeneXpert as the initial test for all adults and children in need of TB evaluation Ultra detects additional cases of MTB, compared to Xpert Ultra verified as fit for purpose for EPTB specimen testing One step process automated Quick (results in <2 hrs) Requires fewer biosafety measures than culture/lpa, so can be used in lower-level laboratories High sensitivity High specificity Can detect rifampicin resistance Same machine can also be used for HIV, hepatitis C diagnoses/viral load monitoring Can work on many extrapulmonary TB samples Lab-in-a cartridge (biosafe to decentralise and for near POC) Reduces time to treatment Limitations: Reliant on electricity Expensive Cannot be used to track treatment progress Requires annual calibration Ongoing error rate monitoring (SA): Verification: 7 of 265 (2.64%) Xpert and 10 of 265 (3.77%) Ultra; small numbers. Error rates stable at <2%, nationally (pre and post Ultra implementation). GeneXpert XVI (Image source: Cepheid)

20 National Xpert TB Diagnostic Programme Xpert is the initial diagnostic test of choice for suspected TB (respiratory specimens): Introduced in March 2011 with full national implementation by September Xpert also effective at identifying EPTB (off label): Cochrane systematic review and meta analysis of 18 studies: o Pooled sensitivity: >80% in lymph node biopsies/fna & CSF; 46.4% in pleural fluid o Pooled specificity: Ranging from 93.6% (lymph node specimens) to 99.1% (pleural fluid). Denkinger CM, et al. Eur Respir J 2014 Two separate SA studies: o Similar findings for pleural fluid, sensitivity for FNA 93.3%. Van Rie A, et al. Eur J Clin Microbiol Infect Dis 2013 Scott LE, et al. J Clin Microbiol : Xpert endorsed by WHO for certain extrapulmonary specimens. 2014: SA s National TB Management Guidelines recommended use of Xpert for suspected EPTB.

21 National Xpert TB Diagnostic Programme EXTRA PULMONARY * Volume Processing Fluids ): Pus, aspirates, purulent pleural <1.5ml Xpert: SR buffer: specimen (2:1) 1.5ml Split specimen: Xpert/TB Culture 3ml Digestion & Decontamination: Pellet split for Xpert/TB Culture CSF 1 3ml Xpert: SR buffer: specimen (2:1) <1ml Xpert: SR buffer: specimen (3:1) FNA 1ml 0.7ml FNA + 1.7ml SR buffer Lymph nodes and tissue biopsies Cut, grind/homogenise in 2ml PBS 0.5ml homogenate + 1.5ml SR sensitivity 91% for pus, 80% for lymph node aspirates, and 51% for fluids (ascitic, 59%; pleural, 47%). Difference in sensitivities for specimens with thick (87%) versus clear/watery (48%) appearance. This was unchanged with traces of blood (52%) or pre centrifugation (57%) among clear specimens. Scott LE, et al. J Clin Microbiol 2014 * Xpert not for urine, stool, or blood

22 Tested EPTB Specimens by Positivity and Resistance, March 2011 December 2016: Analysis of National Xpert EPTB Data Limitations in specimen type categorisation by clinicians and at specimen registration. Overall EPTB positivity: 10.4%. Pus/abscess 42% > FNA 36% > aspirates, 35% > swabs 34%. Lowest: CSF 3%. 9% of positive results rifampicin resistant. Observed variability in resistance likely driven by sample size.

23 Utilisation by Specimen Type & Age Group, March 2011 December 2016: Analysis of National Xpert EPTB Data 93% 1% 6%

24 Xpert Performance for PTB and EPTB Specimens/HIV Co infected Limitations of the Xpert cartridge: Imperfect sensitivity for paucibacillary disease (HIV, early disease, children etc.) Imperfect specificity of RIF in patients with paucibacillary disease EPTB Pleural Fluid EPTB CSF with centrifugation (TBM) EPTB Urine Adult Overall PTB Adult Smear Positive PTB 98 Adult Smear Negative PTB Adult Overall BAL >12million tests, 10.3% MTBC, 6.3% Rif R EPTB CSF (TBM) Children Overall PTB (sputum) 44 EPTB Lymph Node Tissue/Aspirate Children Smear Positive PTB Pooled HIV+ EPTB Overall Children Smear Negative PTB Children Overall Gastric Lavage Scott LE, et al. Current Opin HIV AIDS 2017,12

25 Childhood TB: Xpert is better than smear but not good enough using sputum! Sensitivity and specificity for pediatric TB detection Nicol et al, Lancet ID 2011 Rachow et al, CID 2012* Sensitivity in C+ (95 CI) 76% [64 87] 75% [55 89] Zar et al, CID, % [53 77] Specificity in C (95 CI) 99% [98 100] 100% [99 100] 99% [98 100] Baseline characteristics Specimens Induced Induced and spontaneous Nasopharyngeal aspirate Volumes (ml) Volumes of specimens recieved 36% 5% 59% Paediatrics: stool prototype under development # of specimens Bar chart showing results for specimen volumes received. The vertical axis shows the specimen volumes and horizontal axis depicts number of specimens received.

26 Xpert MTB/RIF Xpert MTB/RIF vs Xpert Ultra LOD cfu/ml spiked sputum (131 bacilli/ml sputum) within 2hrs Target: rpob with 5 probes to detect mutations, 25ul DNA for PCR Sensitivity only 60 80% smear negative TB. Semi quantification with Cycle Threshold (Ct) Very low, low, medium, high Smear replacement strategy Alland D. et al, CROI 2015, abstract 91 Xpert Ultra NUCLEIC ACID AMPLIFICATION TESTS: GENEXPERT LOD 5 25cfu/ml spiked sputum (16 bacilli/ml sputum within 70 minutes New sample processing cartridge (50ul DNA for PCR) Target: IS16110, IS1081 and rpob with 4 probes to detect mutations. Cartridge fluidics and PCR cycling optimized (melt technology) Semi quantification with Cycle Threshold (Ct) Trace, very low, low, medium, high Melting temperature (may identify codons) Smear negative: 94% sensitivity against 1 liquid Culture replacement strategy to be considered culture and improved Rif R specificity (n=21 NTM)

27 Incorporation of Xpert Ultra in the National TB Diagnostic Programme FIND Non inferiority: Ultra versus Xpert, Multicenter 10 sites in 8 countries Pooled Smearnegative WHO/HTM/TB/ Sensitivity (95%CI) HIV HIV+ The current WHO recommendations for the use of Xpert MTB/RIF also apply to the use of Ultra as the initial for all adults and children with signs and symptoms of TB and in the testing of selected extrapulmonary specimens (CSF, lymph nodes and tissue specimens) TB * meningitis Children* Specificity (95%CI) Xpert 82.9% 44.5% 89.3% 75.5% 45% 47% 98% Ultra 87.8% 61.3% 90.6% 87.8% 95% 71% 94.8% *These studies were conducted outside of the CDRC/FIND study: SA, Tanzania and Uganda Diagnostic accuracy of Ultra for tuberculous meningitis in HIVinfected adults: a prospective cohort study. Sensitivity: 70% (probable/definitive TBM); 95% (composite reference standard). Bahr, NC, et al. Lancet Infect Dis 2018;18. Ultra Implementation: MTB/RIF MTB/RIF ULTRA

28 Improved sensitivity and efficiency of testing South Africa s national TB incidence is declining The background disease prevalence is not stable Xpert has detected more positive case since introduction 2011 Xpert MTB/RIF doubled the detection rate over smear when used as the initial diagnostic tool The total number of tests shows a reducing trend The Ultra has an increased sensitivity over G4 (~5% overall) NPP TB positivity rate on tests increased ~2 % over 4 months Ultra is more efficient at finding positive cases (11.8 G4 tests to 9.5 Ultra tests to find 1 positive case): ~19% efficiency Gx4 versus Ultra across 4 months in 2017/ total tests in 4 months total positive Ppredicted Gx in 2018

29 KF3 Compliance and understanding of a TRACE result remains poor 100% 113 PATIENT TRACE FOLLOW UP % 45 80% % % Culture Only 50% Culture and Smear 40% Smear Only No follow up 30% % 10% 0% OCT DEC 2017 MANUAL GAUTENG OCT DEC 2017 JAN FEB 2018

30 Slide 28 KF3 These charts show the breakdowns from the previoius slides Kyle Fyvie, 2018/06/11

31 NUCLEIC ACID AMPLIFICATION TESTS: LINE PROBE ASSAY Genotype MTBDrPlus (Hain lifescience): Line probe assay for detection of first line drug resistance (MDR TB) rifampicin resistance rpob gene high level isoniazid resistance katg gene low level isoniazid resistance promoter region of inha gene Version1 sm+ (LOD 10000bact/ml) Version2 sm+ and sm (160bact/ml)3 RIF resistance INH resistance Strengths: Can perform multiple tests at once Quick (results in under 48 hrs) Accurate Only rapid test to give information about isoniazid resistance Necessary for guiding treatment decisions Limitations: Cannot fully replace other methods, like conventional cultures Not as fast as Xpert Expensive Requires well trained staff in a professional laboratory Has high biosafety requirements (can only be used in certain labs) Genotype MTBDRplus ver2.0 Instructions for use Hain LifeScience GmbH, Germany. Blakemore et al JCM no

32 THE LAM TEST The lateral flow urine lipoarabinomannan (LAM) assay for use only in some people living with HIV In 2015, WHO recommended TB LAM for people with HIV with CD4<100/mm 3 or who are seriously ill Only test demonstrated to reduce TB deaths Best introduced in hospitals in settings with high burdens of TB/HIV Photo from Alere Strengths Point-of-care test Simple, very low-tech Fast takes approximately 25 minutes Inexpensive Easy to collect and store urine Detection in population that cannot use other diagnostic techniques Does not require electricity or labs Saves lives by allowing earlier treatment start* Limitations Test must be followed up with other diagnostics Low sensitivity No info on drug resistance Used in limited patient population Cannot distinguish MTB from other non-tb mycobacteria *Peter, J. G. et al. (March 01, 2016). Effect on mortality of point-of-care, urine-based lipoarabinomannan testing to guide tuberculosis treatment initiation in HIV-positive hospital inpatients: a pragmatic, parallel-group, multicountry, open-label, randomised controlled trial. The Lancet, 387, 10024,

33 Diagnostic Algorithm for TB Suspects, including EPTB: 2017/2018 screening Specimen collection is not feasible DIAGNOSIS: Urine LAM Urine LAM POC: Integration of results into the current data platforms/lis Specimen collection is feasible DIAGNOSIS: GeneXpert MTB/RIF ULTRA + Urine LAM MTB Detected Trace MTB Detected MTB Not Detected Unsuccessful PTB: Indeterminate Culture EPTB RIF S RIF R RIF Unsuccessful Drug sensitive anti TB regimen Baseline smear microscopy Drug sensitive anti TB regimen Drug resistant anti TB (Shortened MDR) regimen Drug Resistant TB Reflex Testing: LPA first line LPA second line ±DST Drug resistant anti TB regimen Smear microscopy, culture, LPA±DST Clinical correlation Chest XR Response to Ab HIV status ±Culture Culture

34 Diagnostic algorithm revised based on new evidence

35 What s new in the TB diagnostic pipeline Advances in Tuberculosis Diagnostics Scientific Figure on ResearchGate.

36 New TB Diagnostics The current WHO endorsed technology for TB in SA as initial diagnostic test as a replacement for smear Technology Early Development 1 Digital chest X rays 2 ImmiPrint 3 TB Breathalyser 4 TBDx system 5 Hydra 1 K microarray 6 LoopAmp MTBC 7 VereMTB 8 TruDx 9 Roche COBAS 6800/8800 MTB 10 GeneDrive MTB/RIF 11 Abbott RealTime MTB 12 GeneChip 13 BD MTB 14 Hain Fluorotype MTBDR 15 Seegene Anyplex 16 MeltPro DR TB MDS 17 Alere Determine LAM assay 18 IRISA TB 19 TB LAMP MTBC Assay 20 GeneDrive MTBC 21 GeneXpert MTB/RIF Ultra Unitaid TB Diagnostics Technology Landscape.pdf Late or completed Development Point of Care Centralized

37 New Screening tools for TB DIGITAL CHEST X-RAYS (DCXR) The use of DCXR is an area of increasing interest for clinicians and TB programmes. There is potential of portable DCXR as a tool for TB screening in low-resource settings Strengths Offers rapid and low-cost screening Offers greater flexibility Leads to rapid diagnosis May be used as a triage tool and for patients with abnormalities Increases throughput of patient testing Limitations Requires computer-based algorithms Requires skilled radiographer Only useful for patients with active TB VOLATILE ORGANIC COMPOUNDS (VOCS) A number of companies are developing instrumented VOC products via a range of methods, including: gas chromatography (Menssana Research Inc., USA) metal-oxide sensors (Nanosynth Materials and Sensors, USA) The enose Company, Netherlands metabolite detection by chemical reaction (Metabolomx, USA). Strengths Rapid and non-invasive screening of PTB disease Screening devices takes 10 minutes to run a single test Portable devices Limitations Products are at varying stages in the development pipeline. Only useful for patients with active TB

38 New TB Diagnostics Setting Test Type Detection 50% Digital chest x rays, Alere Determine Lam assay, IRISA TB, Immiprint, TB Breathalyzer, TB LAMP MTBC Assay, GeneDrive MTBC, GeneXpert MTB/RIF Ultra. VereMTB, TruDx, Hydra 1 K microarray, Roche cobas 6800/8800 MTB, Abbott RT MTB, GeneChip, BD MAX MTBDR, Hain Fluorotype MTBDR, Seegene Anyplex, MeltPro DR TB MDS 40% 20% 10% Alere Determine LAM Assay, IRISA TB, Immiprint, TB Breathalyser 70% TB LAMP MTBC Assay, GeneDrive MTBC, GeneXpert MTB/RIF Ultra, Loop Amp MTB, VereMTB, TruDx, Hydra 1 K microarray, Roche cobas 6800/8800 MTB, Abbott RT MTB, GeneChip, BD MAX MTBDR, Hain Fluorotype MTBDR, Seegene Anyplex, MeltPro DR TB MDS 45% Alere Determine LAM assay, IRISA TB, Immiprint, TB Breathalyser, Digital chest X rays, TBDx system, Loop Amp MTBC, VereMTB, TruDx, Hydra 1 K microarray, MeltPro DR TB MDS GeneDrive MTBC, GeneXpert MTB/RIF Ultra, Roche cobas 6800/8800 MTB, Abbott RT MTB, GeneChip, BD MAX MTBDR, Hain Fluorotype MTBDR, Seegene Anyplex, MeltPro DR TB MDS 55% 10% POC Centralised laboratory Microscopy Centre NAAT Immunology/Serology Other MTBC MTBC & DST Compiled from: 2017 UNITAD TB

39 GeneXpert technology: national implementation March 2011

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41 In Summary Molecular technology has changed the landscape significantly Digital connectivity has transformed quality, M&E, surveillance capability Real time connectivity Operation and program M&E Mapping tools down to molecular granularity Geographic heterogeneity Temporal and spatial Xpert Ultra likely to be important in settings with high TB prevalence, high HIV prevalence Xpert Ultra likely to contribute to finding the missing cases Clinical algorithm challenges, adherence, linkage to care remain constant Agreed reflexed resistance algorithm has assisted with delivery of shortened MDR regimens and improved XDR Laboratory can assist in finding missing TB cases in several ways Making diagnostics more sensitive, more accessible Simplification of algorithms & constant algorithm review Evaluation of novel assays Data reporting: assistance with improving quality reporting Linkage to care Unique identifier will make this much easier

42 Acknowledgements Wendy Stevens, Pedro da Silva, Anura Davids, Trish Kahamba South Africa s Honorable Minister of Health: Dr Motsoaledi National Department of Health (HIV and TB cluster) Department of Molecular Medicine and Haematology, Wits University NHLS, National Priority Program, TB Expert working group Centre for Tuberculosis Dr N. Ismail Funders (specifically CDC, Bill and Melinda Gates foundation, NIH/ACTG, USAID) Clinical partners Right to care, Aurum, TB/HIV care, WRHI, PHRU Centre for TB excellence FIND Commercial collaborators (Cepheid, Abbott, Roche, Hain, BD)

43 Innovation: Laboratory Engineered Accelerated Diagnostics Impact across the clinic/lab interface towards patient centered care and community engagement Pillars of experience across diverse African regions and across the lab value chain Scaled implementation International partnerships Centres of excellence in public health care MOH engagement Laboratory platform Clinical collaboration Research and development HE, mapping and big data Academic affiliations Underpinned by strong ethics # AccessThroughInnovation

44 Additional slides: summary of UNITAID 2017 diagnostics landscape

45 OTHER POINT OF CARE DIAGNOSTICS Technology TB LAMP Mycobacterium tuberculosis complex (MTBC) assay Principle of test An assay used as a replacement test for SSM for the diagnosis of PTB in adults with signs and symptoms consistent with TB. Also used as a follow on test to smear microscopy in adults with signs and symptoms consistent with PTB, especially when further testing of sputum smear negative specimens is necessary ImmiPrint Complex immuno array technology to detect soluble cellular differentiators (scds), produced by macrophages in response to an infection. Can be used to screen samples to identify scd biomarker profiles to discriminate active TB infection from other infectious diseases TB Breathalyzer Used to detect TB antigens from a breath specimen. The system uses aerosol collection (fine liquid droplets in a gas, in this case a cough), combined with an immunoassay system, with fluorescence detection of an evanescent wave. GeneXpert Omni This is a single stand alone system that is capable of processing Xpert cartridges in more austere settings than the current Xpert instruments, which are not designed for extreme conditions such as elevated temperatures and humidity above 30 C. This system runs both the current Xpert MTB/RIF assay and Xpert Ultra MTB/RIF, in addition to Xpert HIV 1 Qual, Xpert HIV 1 Viral Load and Xpert HCV Viral Load assays. Unitaid TB Diagnostics Technology Landscape.pdf

46 Technology TBDx system CENTRALIZED (LABORATORY) DIAGNOSTICS Principle of test An automated digital microscopy platform that consists of a high quality microscope and imaging system that in conjunction with a slide holding carousel that can read up to 200 prepared smears using fluorescent microscopy in a single run IRISA TB An ELISA designed for use in a laboratory to specifically diagnose extra pulmonary TB. It can detect the presence of extra pulmonary TB from samples, including pleural, pericardial, ascetic and cerebrospinal fluid. Genedrive MTBC assay Used in detection of MTBC directly from sputum samples, it simultaneously identifies mutations involved in conferring RIF resistance. The system uses a simple paper based extraction method coupled with an asymmetric PCR and proprietary hybridization probe technology (Highlighter Probes) that provides genotypic information. The assay targets specific sequences in the MTBC genomes and has a broad detection profile covering clinically relevant strains and subtypes; these include M. tuberculosis, Mycobacterium bovis, and Mycobacterium africanum, as all three species are clinically significant human pathogen Abbott Real Time MTB The assay offers an automated DNA extraction platform (m2000sp) performed by the m2000rt real time PCR platform to detect MTB from sputum, bronchial alveolar lavage or sediments derived from either specimen type. BD FluoroType MTBDR A multiplexed real time PCR assay, fully intergrated single platform for the detection of MTB and RIF and INH resistance. The platform has a 5 colour detection real time PCR platform to expand its capacity to multiplex different PCR assays in the same reaction with short TAT (8hrs). Used to detect TB in addition to genotyping for RIF and INH resistance alleles. It uses novel amplification and probe technologies, Late After The Exponential (LATE) PCR coupled with lights on/lights off probes that tile side by side on the target region. COBAS 6800/8800 Systems The technology offers real time PCR assays for MTB and Mycobacterium avium infection. It is fully automated from end to end, designed for very high throughput (processes 960 samples in 8hrs) Unitaid TB Diagnostics Technology Landscape.pdf

47 Technology Seegene Anyplex MeltPro Drug Resistant TB Molecular Diagnostics System CENTRALIZED (LABORATORY) DIAGNOSTICS Principle of test Offers several highly multiplexed NAAT assay kits that use real time PCR for MTBC, RIF/INH as well as NTM detection. *Sample preparation is not supplied by the company thus a different product must be used to first prepare MTB DNA for real time PCR analysis. The assays use real time PCR and multicolour melting curve analysis to indicate allelic variations associated with drug resistance (RIF, INH, EMB, streptomycin [STR], FLQ and SLID resistance) GeneChip Assay offers two microarray products directly related to TB: the Mycobacterial Species Identification Array Kit; and the M. tuberculosis Drug Resistance Detection Array Kit. The first product speciates MTB and other NTMs from a specimen, while the second genotypes for resistance to RIF via rpob and INH via katg and the inha promoter region TruDx This assay is designed to be used with DNA from sputum that is prepared via the TruTip extraction tool, a pipette tip that contains a nucleic acid binding matrix with volume transfer and reagent mixing/washing mixing being performed via a hand held battery powered automatic pipettor that hosts the TruTip VerePLEXTM Biosystem Hydra 1K microarray Loopamp MTBC Detection This platform can host several disease specific microarrays, including the VereMTB Detection chip which is designed to identify MTB as well as speciate common NTMs. The time to result is around 2 hours and the assay may be used with culture or SSM positive samples. This technology employs complementary metal oxide semiconductor (CMOS) technology for lens free digital imaging and uses heating within 1024 individual spots on the array to enable on chip PCR of the specific MTB target amplicons This is the first NAAT product specifically designed for use in microscopy level facilities to receive WHO endorsement.the assay is well suited to resource limited settings as the equipment is relatively simple and several user steps are added to reduce instrumentation complexity, including sample preparation and the interpretation of test results Genedrive MTB/RIF Used to screen for three individual components: an MTBC assay; a genotyping assay targeting rpob to indicate RIF resistance; and a control assay to indicate inhibitory compounds in the sample Unitaid TB Diagnostics Technology Landscape.pdf