Today s presentation Lyme Disease Diagnostics What can we use now What do we need for the future? Anja Garritsen, Innatoss Laboratories, NL Innatoss Diagnostics for Lyme Disease The present Diagnostic Concepts Available Tools Use of diagnostic tests in different stages of disease The future? Precision Diagnostics for Lyme Disease 1 2 Focus of Innatoss Location in the middle of Q fever epidemic 3 Q fever Lyme disease 4 Many ticks in the Netherlands Mission Innatoss Catch it early! And significantly reduce healthcare issues associated with infectious diseases such as Q fever and Lyme Disease Tick bites 1,5 million EM 30,000 EM persistent 2500 GP visits for erythema migrans in the Netherlands 1994-2014 (source: RIVM) 5 6 LDA Conference 2017 - Anja Garritsen 1
Impact Lyme in Time (the simple view) Early diagnosis of Lyme Borreliosis results in more effective treatment GP 0,2 % Specialist No treatment options? No tests? Public Health Prevention, Awareness 7 8 How do we diagnose? Different Faces of Lyme Disease Clinical signs & symptoms Indirect Detection Memory T cell Innate Memory Cells Direct Detection Culture PCR Mass Spectrometry Antigen detection Arthritis Synovial Fluid Early disseminated Neurological CSF Acute Skin Erythema migrans Fatigue Q fever? Late disseminated 9 10 Even the simple signs are not easy Different tests are needed The ideal test is 95 % sensitive Is 98% specific The ideal test gives a yes-no answer covers all stages of the disease The ideal test costs 15 or less 11 12 LDA Conference 2017 - Anja Garritsen 2
Serology One principle Clinical signs & symptoms Indirect Detection Memory T cell Innate Memory Cells Direct Detection Culture PCR Mass Spectrometry Antigen detection ELISA Indirect Immune Fluorescence Assay Western Blot (whole cell lysates) Immunoblot (recombinant) Protein Arrays Antibody tests work, sometimes... Antigen is coated to solid support in serum bind to antigen Can be used with Blood Liquor Synovial fluid 13 14 Lyme over time What if antibodies are not generated? GP Localized disease When in doubt, test! Antibody generation Takes time No antibodies? Signs & symptoms? Clinical signs & symptoms Indirect detection Memory T cell Innate memory cells Direct detection Culture PCR Mann Spectrometry Antigen detection 15 16 Marketed CMI tests CMI the other side of the immune system Mantoux test (skin prick test) Quantiferon TB (Qiagen) T-Spot-TB (Oxford Immunotec) Quantiferon - CMV T-Spot CMV Q fever skin prick test Q-detect (Innatoss) Humoral immunity tests B-cells Cellular immunity Biomarker tests T-cells 17 Memory T cell Innate immunity 17 18 Will a cell-based assay detect more infections and/or detect them sooner LDA Conference 2017 - Anja Garritsen 3
Available CMI tests for Lyme Ixodes trial (2015-2017) AID LTT (IMD) Invitalab Armin BCA Qiagen Spirofind (MELISA) revised PBMC Cells PBMC PBMC PBMC PBMC PBMC Whole blood Ixodes Whole blood Tick bite 24 h Prediction possible? Antigens B31 Osp-mix = AID = AID Flagellin plus LFA1 p66 DbpB OspC B. afzelii B. garinii B. burg Early antigens Material lysate peptides lysate peptides many = AID = AID peptides lysates Recomb proteins Read-out ELISpot Cell Cell Elispot Elispot IFN Elispot IFN + IFN proliferation proliferation IFN IFN /IL2 IL-1β others Intended use Exposure Lyme Lyme Lyme Lyme Early Early Early Prior infection? Markers Markers Regulatory CE LDT LDT Pre-market Pre-market Developme nt 19 20 Ixodes study - challenges Media attention Getting access to people with tick bites Logistics 21 22 Ixodes study results to date Addressing logistics: ID-LYME Recruitment 610 participants recruited 500 with tick bite, uninfected 30 with tick bite, infected subjects 80 without tick bite This project has received funding from the European Union s Horizon 2020 research and innovation programme under grant agreement No 720480 Biomarkers Strong responders in the healthy control group Likely due to some of the antigens used Working on a solution Repeating part of the study 23 24 LDA Conference 2017 - Anja Garritsen 4
Spin-off from Ixodes study improved serological test strategy Case 1 Observation There are patients with Lyme-like symptoms who test negative in ELISA but are positive in an immunoblot Question Is this true positive or cross-reactivity No Erythema Migrans or other symptoms 160 140 120 100 80 Opportunity Ixodes study provided well-defined cases 60 40 20 0 IgG IgM C6x10 25 26 Case 1 Case 1 IgM after 3 months No Erythema Migrans or other symptoms 160 140 120 100 80 60 40 20 160 140 120 100 80 60 40 20 4 Aug 31 Aug 2015 27 Oct 11 May 1 June 2016 27 July 0 IgG IgM C6x10 0 IgG IgM C6x10 27 28 Case 1 IgM after 9 months Case 1 - IgG after 3 months 29 30 LDA Conference 2017 - Anja Garritsen 5
Case 1 IgG after 9 months Case 2: Value of Immunoblot for reinfections IgG ELISA negative VlsE garinii, flagellin and BmpA antibodies remaining Regular pattern for prior infections C6 0,8 IgG 40 IgM 8 31 32 Case 2: Value of immunoblot for reinfections Recommendation Use available diagnostic tools as well as you can C6 1,9 IgG 43 IgM 11 3 ELISAs that are really different (C6 and Euroimmun IgG/IgM) 2-3 Immunoblots that have unique features (Mikrogen, Euroimmun) Combine them Will not solve the problem of people that make not antibodies 33 34 Serological lessons Lyme Testing Strategy over Time Use diverse antigens, do not rely on one test Use immunoblots as well as ELISAs (one tier) Quantify ELISA and immunoblot Repeat measurements Baseline measurement is useful to detect infection Anyone can do this, can be implemented around the world At least 50% more cases identified Monitor 98 % 0.2 % Active infection Immune suppression Immune activation Cross reactivity Side effects treatment Prevention, Awareness t=0 measurement Local disease Doubt, test When in doubt, test When in doubt, test 35 36 LDA Conference 2017 - Anja Garritsen 6
Direct Detection of Borrelia Nanotrap 37 38 Mechanims Can we discriminate groups in late stage disease? Active infection 0.2 % Immune suppression Monitor 98 % Immune activation Cross reactivity Side effects treatment Prevention, Awareness t=0 measurement Local disease Doubt, test When in doubt, test What is this? 39 40 Precision Medicine for Lyme Disease Precision Medicine FAILS for Lyme 41 42 LDA Conference 2017 - Anja Garritsen 7
Precision Medicine for Lyme Lyme Testing Strategy (the complicated view) Your knowledge is required 0.2 % Active infection Immune suppression Which groups exist What treatments are effective How can we distinguish these groups Right intervention for the right people Monitor 98 % Immune activation Cross reactivity Side effects treatment 43 Prevention, Awareness t=0 measurement ELISA 44 (immunoblot?) Local disease ELISA, CMI CMI, Direct Detection Immunoblot for re-infections Precision Diagnostics What is needed to make this happen COLLABORATION FUNDING 45 LDA Conference 2017 - Anja Garritsen 8