Reliable screening for early diagnosis

Elecsys TORCH panel Reliable screening for early diagnosis Toxoplasmosis Rubella HSV CMV

Toxoplasmosis The safe and sure approach to Toxo screening Ultrasensitive Toxo IgM optimized to detect all potential acute infections Toxo IgG with high sensitivity to past infections Toxo IgG avidity to confirm exclusion of an acute infection Suggested Toxoplasma gondii serologic diagnostic algorithm in immunocompetent individuals Pregnancy toxoplasma serology Back to overview

Suggested Toxoplasma gondii serologic diagnostic algorithm in immunocompetent individuals Start Perform Toxo IgG/IgM tests IgG neg. IgM neg. IgG pos. IgM neg. IgG neg. IgM pos. IgG pos. IgM pos. Intermediate low Toxo IgG avidity high No immunity Acquired immunity Beginning infection Unspecific IgM Repeat IgG test ~3 weeks later Infection > 4 months ago Avoid primary infection Past infection likely Toxo IgG titer stable Increasing (2 4 fold increase) Repeat testing during pregnancy Repeat testing ~3 weeks later Infection > 2 months before 1st sample Recent infection < 2 months before 1st sample Start Stop Start Further action may be required Remington, J.S., McLeod, R., Desmonts, G. (2001). Toxoplasmosis, 205-346. in J.S. Remington & J.O. Klein (ed.), Infectious Diseases of the Fetus and Newborn Infant, 5th ed., W.B. Saunders, Philadelphia, Pa. Meek, B., van Gool, T., Gilis, H., Peek, R. (2001). Dissecting the IgM antibody response during the acute and latent phase of toxoplasmosis. Diagn Microbiol Infect Dis 41: 131-7.

Pregnancy toxoplasma serology Toxo IgG Toxo IgM N/A LOW HIGH Toxo IgG avidity!!! Relative concentration Toxo lgg persistent Toxo lgm No infection or immunological Rare: may indicate acute infection (or false positive IgM result) Exclusion of acute infection impossible Latent infection, acquired immunity Toxo lgg avidity Toxo lgm Recommendation Infection Days Weeks Months Years Educate patient on risk factors Repeat screening >4 weeks later Repeat testing >14 days later and/or PCR for toxoplasma DNA on amniotic fluid; avidity testing within 3 4 months after conception source: adapted from Montoya and Liesenfeld, Lancet. 2004 Aug 14-20;364(9434):579 No future testing required when avidity testing within 3 4 months after conception No future testing required Pregnancy toxoplasma ser 1 / 5

Pregnancy toxoplasma serology Toxo IgG Toxo IgM N/A LOW HIGH Toxo IgG avidity!!! Relative concentration Toxo lgg persistent Toxo lgm No infection or immunological Rare: may indicate acute infection (or false positive IgM result) Exclusion of acute infection impossible Latent infection, acquired immunity Toxo lgg avidity Toxo lgm Recommendation Infection Days Weeks Months Years Educate patient on risk factors Repeat screening >4 weeks later Repeat testing >14 days later and/or PCR for toxoplasma DNA on amniotic fluid; avidity testing within 3 4 months after conception source: adapted from Montoya and Liesenfeld, Lancet. 2004 Aug 14-20;364(9434):579 No future testing required when avidity testing within 3 4 months after conception No future testing required Pregnancy to 2 / 5

Pregnancy toxoplasma serology Toxo IgG Toxo IgM N/A LOW HIGH Toxo IgG avidity!!! Relative concentration Toxo lgg Toxo lgg avidity persistent Toxo lgm Toxo lgm No infection or immunological Rare: may indicate acute infection (or false positive IgM result) Exclusion of acute infection impossible Latent infection, acquired immunity Recommendation ology Infection Days Weeks Months Years Educate patient on risk factors Repeat screening >4 weeks later Repeat testing >14 days later and/or PCR for toxoplasma DNA on amniotic fluid; avidity testing within 3 4 months after conception source: adapted from Montoya and Liesenfeld, Lancet. 2004 Aug 14-20;364(9434):579 No future testing required when avidity testing within 3 4 months after conception No future testing required 3 / 5

Pregnancy toxoplasma serology Toxo IgG Toxo IgM N/A LOW HIGH Toxo IgG avidity!!! Relative concentration Toxo lgg Toxo lgg avidity persistent Toxo lgm Toxo lgm No infection or immunological Rare: may indicate acute infection (or false positive IgM result) Exclusion of acute infection impossible Latent infection, acquired immunity Recommendation Infection Days Weeks Months Years Educate patient on risk factors toxoplasma serology Repeat screening >4 weeks later Repeat testing >14 days later and/or PCR for toxoplasma DNA on amniotic fluid; avidity testing within 3 4 months after conception source: adapted from Montoya and Liesenfeld, Lancet. 2004 Aug 14-20;364(9434):579 No future testing required when avidity testing within 3 4 months after conception No future testing required 4 / 5

Pregnancy toxoplasma serology Toxo IgG Toxo IgM N/A LOW HIGH Toxo IgG avidity!!! Relative concentration Toxo lgg Toxo lgg avidity persistent Toxo lgm Toxo lgm No infection or immunological Rare: may indicate acute infection (or false positive IgM result) Exclusion of acute infection impossible Latent infection, acquired immunity Recommendation Infection Days Weeks Months Years Educate patient on risk factors Repeat screening >4 weeks later Pregnancy toxoplasma serology Repeat testing >14 days later and/or PCR for toxoplasma DNA on amniotic fluid; avidity testing within 3 4 months after conception source: adapted from Montoya and Liesenfeld, Lancet. 2004 Aug 14-20;364(9434):579 No future testing required when avidity testing within 3 4 months after conception No future testing required 5 / 5

Rubella Clear discrimination between acute and past infections Superior sensitivity where it matters most IgM very sensitive to early acute infection IgM less sensitive to persistent IgM IgG test ultra sensitive to remote infections and vaccination Diagnosis of rubella infections Pregnancy rubella serology Back to overview

Diagnosis of rubella infections Start Perform IgG and IgM test IgG Negative IgM Negative IgG Positive IgM Negative IgG Negative IgM Positive IgG Positive IgM Positive Patient susceptible to infection. Repeat tests in 2 3 weeks and monitoring or immunization if required Patient immune to Rubella infection Early stage infection. Repeat test required after 2 3 weeks Recent acute Rubella infection or reinfection Confirm positive finding IgG, IgM serology, avidity and PCR in amniotic fluid and/or blood Negative IgM negative, High avidity, PCR negative Acute infection can not be confirmed Positive Where acute Rubella infection confirmed, discuss pregnancy outcomes with patient Stop Postnatal follow-up and care Mendelson at al. (2006) Reprod Toxicol. 21(4), 350-82. Manual for the Surveillance of Vaccine-Preventable Diseases: Available at: www.cdc.gov/vaccines/pubs/surv-manual/index.html.

Pregnancy rubella serology* Rubella IgG Rubella IgM Recommendation Relative concentration Infection Days!!! Weeks Months/years Educate patient on risk factors Repeat testing in a few weeks Rubella IgM IgG avidity test can refine the findings Rubella IgG No future testing required No infection or immunologic Very early stages of infection or unspecific IgM Acute infection Significant IgG titer: latent infection, acquired immunity or immunization *In the case of pre-conception screening, patients identified as non-immune should be immunized; patients suspected of being in the early stages of infection or with acute infection should be counselled to delay becoming pregnant until the infection has resolved. Source: adapted from Thomas, L. (2009). Laboratory and Diagnosis. T.H. Books, Frankfurt, Germany. COBAS and LIFE NEEDS ANSWERS are trademarks of Roche. 2013, Roche Diagnostics International Ltd, CH-6343 Rotkreuz, Switzerland Pregnancy rubella serol 1 / 4

Pregnancy rubella serology* Rubella IgG Rubella IgM Recommendation Relative concentration Infection Days Weeks!!! Months/years Educate patient on risk factors Repeat testing in a few weeks Rubella IgM IgG avidity test can refine the findings Rubella IgG No future testing required No infection or immunologic Very early stages of infection or unspecific IgM Acute infection Significant IgG titer: latent infection, acquired immunity or immunization *In the case of pre-conception screening, patients identified as non-immune should be immunized; patients suspected of being in the early stages of infection or with acute infection should be counselled to delay becoming pregnant until the infection has resolved. Source: adapted from Thomas, L. (2009). Laboratory and Diagnosis. T.H. Books, Frankfurt, Germany. COBAS and LIFE NEEDS ANSWERS are trademarks of Roche. 2013, Roche Diagnostics International Ltd, CH-6343 Rotkreuz, Switzerland Pregnancy rub 2 / 4

Pregnancy rubella serology* Rubella IgG Rubella IgM Recommendation Relative concentration Infection Days Weeks Months/years!!! Educate patient on risk factors Repeat testing in a few weeks Rubella IgM IgG avidity test can refine the findings Rubella IgG No future testing required No infection or immunologic Very early stages of infection or unspecific IgM Acute infection Significant IgG titer: latent infection, acquired immunity or immunization *In the case of pre-conception screening, patients identified as non-immune should be immunized; patients suspected of being in the early stages of infection or with acute infection should be counselled to delay becoming pregnant until the infection has resolved. Source: adapted from Thomas, L. (2009). Laboratory and Diagnosis. T.H. Books, Frankfurt, Germany. COBAS and LIFE NEEDS ANSWERS are trademarks of Roche. 2013, Roche Diagnostics International Ltd, CH-6343 Rotkreuz, Switzerland 3 / 4

Pregnancy rubella serology* Rubella IgG Rubella IgM Recommendation Relative concentration Infection Days Weeks Months/years Educate patient on risk factors Repeat testing in a few weeks Rubella IgM IgG avidity test can refine the findings Rubella IgG No future testing required No infection or immunologic Very early stages of infection or unspecific IgM Acute infection Significant IgG titer: latent infection, acquired immunity or immunization!!! *In the case of pre-conception screening, patients identified as non-immune should be immunized; patients suspected of being in the early stages of infection or with acute infection should be counselled to delay becoming pregnant until the infection has resolved. Source: adapted from Thomas, L. (2009). Laboratory and Diagnosis. T.H. Books, Frankfurt, Germany. COBAS and LIFE NEEDS ANSWERS are trademarks of Roche. 2013, Roche Diagnostics International Ltd, CH-6343 Rotkreuz, Switzerland egnancy rubella serology* 4 / 4

CMV High precision diagnosis of acute CMV infections The anti-interference CMV assay Detects the IgM associated with an acute infection by using a novel blocking agent to persistent IgM Anti-interference recombinant protein prevents cross reactivity with other herpes viruses IgG avidity helps to discriminate between acute and past infections Suggested CMV serologic diagnostic algorithm in immunocompetent individuals Pregnancy cytomegalovirus serology Back to overview

Suggested CMV serologic diagnostic algorithm in immunocompetent individuals Start Perform CMV IgG/IgM tests IgG pos. IgM pos. IgG neg. IgM neg. IgG neg. IgM pos. IgG pos. IgM neg. high IgG avidity low to borderline 20 w Gestational age > 20 w High risk of transmission low to borderline IgG avidity high No immunity Beginning infection Acquired immunity Possibly additional testing IgG neg. IgM neg. Refer to 1st trimester samples Avoid primary infection Repeat testing during pregnancy Start Repeat testing ~3 weeks later Past infection likely Recidivation possible Stop Maternal viremia Virus isolation Blood PCR Fetal well-being Ultrasound MRI Invasive testing Amniocentesis Cordocentesis IgG pos. / IgM pos. Low avidity IgG neg. IgM pos. IgG pos. / IgM pos. High avidity IgG pos. IgM neg. Non-primary infection low risk of transmission Stop Munro, S.C., Hall, B., Whybin, L.R., et al. (2005). J Clin Microbiol 43(9): 4713-8. Lazzarotto, T., Gabrielli, L., Lanari, M., et al. (2004). Hum Immunol 65: 410-415. Guerra, B., Simonazzi, G., Banfi, A., et al. (2007). Am J Obstet Gynecol 196: 221-223. Duff, P. (2007). A thoughtful algorithm for the accurate diagnosis of primary CMV infection in pregnancy. Am J Obstet Gynecol 196: 196-197.

Pregnancy cytomegalovirus serology CMV IgG CMV IgM N/A LOW HIGH CMV avidity!!! Relative concentration Recommendation Infection Days Weeks Months Years Educate patient on risk factors; control at later stage of pregnancy Repeat testing in >10 days Anti-CMV IgG s ource: adapted from Revello and Gerna, J Clin Virol. 2004 Feb;29(2):71-83 CMV lgg avidity Anti-CMV IgM Any suspected infection during pregnancy: Testing of amniotic fluid for CMV-DNA (PCR), fetal blood for early CMV antigen (PCR) and CMV IgM 05465753001 No infection or immunological Suspected acute infection Acute infection or reactivation; high risk for transmission Aquired immunity; low risk for transmission Latent infection; low risk for transmission Pregnancy cytomegalovirus ser 1 / 5

Pregnancy cytomegalovirus serology CMV IgG CMV IgM N/A LOW HIGH CMV avidity!!! Relative concentration Recommendation Infection Days Weeks Months Years Educate patient on risk factors; control at later stage of pregnancy Repeat testing in >10 days Anti-CMV IgG s ource: adapted from Revello and Gerna, J Clin Virol. 2004 Feb;29(2):71-83 CMV lgg avidity Anti-CMV IgM Any suspected infection during pregnancy: Testing of amniotic fluid for CMV-DNA (PCR), fetal blood for early CMV antigen (PCR) and CMV IgM 05465753001 No infection or immunological Suspected acute infection Acute infection or reactivation; high risk for transmission Aquired immunity; low risk for transmission Latent infection; low risk for transmission Pregnancy cytom 2 / 5

Pregnancy cytomegalovirus serology CMV IgG CMV IgM N/A LOW HIGH!!! CMV avidity Relative concentration Recommendation ology s ource: Infection Days Weeks Months Years Educate patient on risk factors; control at later stage of pregnancy Repeat testing in >10 days Anti-CMV IgG adapted from Revello and Gerna, J Clin Virol. 2004 Feb;29(2):71-83 CMV lgg avidity Anti-CMV IgM Any suspected infection during pregnancy: Testing of amniotic fluid for CMV-DNA (PCR), fetal blood for early CMV antigen (PCR) and CMV IgM 05465753001 No infection or immunological Suspected acute infection Acute infection or reactivation; high risk for transmission Aquired immunity; low risk for transmission Latent infection; low risk for transmission Pre 3 / 5

Pregnancy cytomegalovirus serology CMV IgG CMV IgM N/A LOW HIGH CMV avidity!!! Relative concentration Recommendation Infection Days Weeks Months Years Educate patient on risk factors; control at later stage of pregnancy egalovirus serology Repeat testing in >10 days s ource: adapted from Revello and Gerna, Anti-CMV IgG J Clin Virol. 2004 Feb;29(2):71-83 CMV lgg avidity Anti-CMV IgM Any suspected infection during pregnancy: Testing of amniotic fluid for CMV-DNA (PCR), fetal blood for early CMV antigen (PCR) and CMV IgM 05465753001 No infection or immunological Suspected acute infection Acute infection or reactivation; high risk for transmission Aquired immunity; low risk for transmission Latent infection; low risk for transmission 4 / 5

Pregnancy cytomegalovirus serology CMV IgG CMV IgM N/A LOW HIGH CMV avidity!!! Relative concentration Recommendation Infection Days Weeks Months Years Educate patient on risk factors; control at later stage of pregnancy Repeat testing in >10 days egnancy cytomegalovirus serology Anti-CMV IgG s ource: adapted from Revello and Gerna, J Clin Virol. 2004 Feb;29(2):71-83 CMV lgg avidity Anti-CMV IgM Any suspected infection during pregnancy: Testing of amniotic fluid for CMV-DNA (PCR), fetal blood for early CMV antigen (PCR) and CMV IgM 05465753001 No infection or immunological Suspected acute infection Acute infection or reactivation; high risk for transmission Aquired immunity; low risk for transmission Latent infection; low risk for transmission 5 / 5

HSV The new generation of HSV testing The right menu The relevant tests to assess congenital risk The anti-interference approach Prevents cross reactivity with other herpes viruses Prevents cross reaction between HSV 1 and HSV 2 Diagnosis of HSV infections Assessing the risk of congenital HSV transmission The Power of synergy (Serology & PCR) Back to overview

The new generation of HSV testing For informed pregnancy management Test woman for HSV 1 & HSV 2 type specific IgG test HSV 1 and HSV-2 Negative Pregnant women is HSV-1 IgG Positive HSV-2 IgG Positive Partner is HSV Check the immune status of the partner Partner is HSV-2 Educate the woman and her partner Antiviral treatment Consider avoiding vaginal delivery Educate the couple explaining: the potential risks of HSV-2 infections and protection Educate the women and her partner: To avoid genital contact Use of condoms Antiviral treatment Adapted from Brown et al. Obstet Gynecol 2005; 106:845-856 and Bulletin of the World Health Organization 2008; 86: 737-816.

Assessing the risk of congenital HSV transmission HSV type 1 & 2 specific IgG IgM testing is not reliable Cross-reaction with other Herpesviridea group viruses IgM serology cannot distinguish acute infection from the recurrent disease HSV-IgM antibodies may persist many months or years Production of IgG and IgM start at similar time Titer Primary HSV infection after infection IgM tests do not allow proper differentiation between primary and persistent infection. Cowan et al. (2000 Apr) J Antimicrob Chemother. 45 Suppl T3, 9-13. Song et al. (2004 Apr) Sex Transm Infect. 80(2), 113-7. Page et al. (2003 Aug) Sex Transm Infect. 79(4), 276-9. 1 / 2

Elecsys HSV-1 IgG & HSV-2 IgG HSV IgM tests are not useful in adults Expert opinions: IgM blood tests do not accurately distinguish between the types of herpes virus and cannot accurately tell a new infection from an old one. Unfortunately, many clinicians still order them. In fact, it is probably the biggest mistake clinicians make when doing herpes testing. IgM tests for herpes simplex may also mistakenly pick up other herpes viruses like chicken pox or mono. IgM tests for herpes diagnosis in adults should be avoided completely. T. Warren; Herpes: evrything you need to know; p. 54; 2009. Bottom lines: Sometimes a new HSV infection in an adult indeed will be positive by IgM before IgG. But this is pretty infrequent, and it outweighed by the downsides: high risk of false positive result; and even when truly positive, there is no distinction between HSV-1 and HSV-2, which is pretty important to most patients and providers. T. H. Hunter Handsfield, M.D.; http://www.medhelp.org/posts/stds/confusiion-over-other-igm-herpes-posts/ show/248394)as ; 2006. 2 / 2

Herpes HSV-1 and HSV-2 serology and PCR assays from Roche The power of synergy: Differentiation of primary from recurrent infection Asymtomatic testing (Serology) Elecsys HSV-1 and HSV-2 assays run on cobas 4000, 6000 or 8000 analyzer series Symtomatic testing (PCR) cobas HSV 1 and 2 Test in cobas 4800 system Differentiation of primary from recurrent HSV infections + PCR Serology New HSV infection + PCR + Serology Recurrent HSV infection