Diagnostic testing for tuberculosis

3 - 9 months

The slow road to microscopy diagnosis of TB
Implement molecular test with sensitivity similar to culture

AFB/ml

Abbreviating delay through better sensitivity or better access

Implement dipstick with sensitivity equal to microscopy
10,000,000 AFB/ml

Implement molecular test with sensitivity similar to culture

AFB/ml

Where delay contributes greatest to morbidity, mortality, transmission

Where is the point of care for TB and how do you get to it?

Reference center

District hospital

Microscopy center

Health post

Referral for 3.8b people in 22 HBC 325

1500 Reference center

District hospital 27,000 Microscopy center 270,000 Health post 1,52m?

Strength of health system

Major Markets

Rest of World

‡Simple one-step testing in 15 minutes ‡Accurate, quantitative readout ‡Simultaneous results from multiple markers ‡Portable, low maintenance instrument ‡Built-in quality control

‡Complex, slow tasks ‡Inaccurate, qualitative readout ‡Single marker, single disease ‡Heavy, high maintenance instruments ‡Absent quality control

FIND: a public engine for diagnostic development
Upstream FIND¶s focus Downstream

Discovery and research

Development

Evaluation

Demonstratio n

Market access and distribution

Liaise with funders, pharmaceutical and biotech companies, research institutions, academia

Create network of public and private partners to create effective tests and demonstrate their success

Liaise with funders, multi-lateral agencies, NGOs,health ministries, and agencies like GDF and GFATM

Development
Proof of principle Facilitate, co-fund, co-develop Product in box

Evaluation
Regulatoryquality lab & field trials Efficacy Data

Demonstration
Large-scale projects Effectiveness measuring Data feasibility and impact on disease control programs

Policy

Making US standard accessible in DEC

‡Price negotiations on MGIT ‡Licensing agreement for MPT64 ‡Development for lower cost version ‡Large demonstration projects (>100,000 pts) ‡Customer support plan

Steps in Hain test for molecular MDR screening with PCR and line probe hybridization
Process specimen, extract DNA, amplify DNA targets with PCR Hybridize amplified DNA to oligonucleotide probes on strips

Geneva, Switzerland - 2007

17 y.o. male AFB microscopy positive: admitted to hospital patient placed in isolation with cough and fever pending drug susceptibility testing

18th birthday passed in isolation

Conventional DST results: fully susceptible

weeks 0 1 2 3 4 5 6 7 8 9 10 11 12

Evolution of TB diagnostics in the public sector

Fundamental diagnostic: 1882

Fundamental diagnostic: 2009

Integrated NAAT for TB/Rif

Automated sample preparation Amplification and detection
<2h

Xpert TM MTB/Rif

Workflow ‡ fully automated, with 1-step external sample prep. ‡ time-to-result < 2 h (walk away test) ‡ throughput: up to 1-48 tests / run ‡ no bio-safety cabinet ‡ closed system (no contamination risk)

A technology platform for  TB & Rif resistance  TB Quinolone resistance  Potential for HIV viral load

Xpert MTB/Rif: FIND Evaluation studies
Rigorous performance evaluation at 5 sites (>1500 TB suspects) Included 2 sites with high HIV prevalence (80%) & 2 with high MDR prevalence (>30%)
UPCH HIV TB (C+) MDR TB 2% 61% 7% HIV TB (C+) MDR TB STI 5% 42% 31%

Hinduja HIV UCT HIV TB (C+) MDR TB 77% 39% 10% SAMRC 72% 13% 9% TB (C+) MDR TB 5% 60% 67%

Xpert MTB/Rif: FIND evaluation studies

Sensitivity for in S+/C+ = 100%, in S-/C+ = 91%

High accuracy for Rif detection Sequencing data for discrepant results suggest Xpert correct

Simple, manual NAAT

‡Closed system ‡Isothermal ‡Rapid ‡Multiprimer ‡Visible readout 

Single instrument

TB LAMP Procedure
85 , 5 min 

From 32 to 7 steps  From 15 to 3 plastics

Mixing

Sputum

One drop

Dried reagent

Calcein fluorescence

LAMP reation 67 40 min

Spiked sputum samples

Decentralization of molecular diagnostics

1st generation MDR

2nd generation automated MDR 1st generation manual detection

2nd generation manual detection

LPA 2008

Xpert 2010

LAMP 2011

POC test 2015
24

Serodiagnosis of TB

Sensitivity of selected antigens at >95% specificity level compared to healthy controls
Antigen TB9.7 CFP10:ESAT6* TB10.2 TB15.3 TB16.3 TB 51 TB51.7 aCry:MPT83 38 kDa Europe, HIV± (n=71) 35% 25% 21% 41% 55% 31% 57% 26% 19% Africa, HIV± (n=79) 79 % 64% 45% 75% 81% 76% 83% 83% 29% Africa, HIV+ (n=77) 91% 49% 48% 65% 88 % 48% 78% 58% 15%

Whole proteome screening of M. tuberculosis for diagnostic antigens

Mtb Antigen Detection
Another needle in the haystack?
Collaborations
‡ Existing Assays: Chemogen, Inverness, Biomed, J Mitra, Lionex, SMI / TBDiaDirect, Standard, ANDA Biomarkers: Forsythe, Harvard / Beth Israel, SSI, Proteome Systems, TAUNS, Cellzome, St. Georges Hospital, Genovac, Cornell, NYU, MPI / GC-6, KIT, Scensive, EMBO Technology: SBRI, CibiTest, Nanogen, LRE Medical Inverness, DKFZ, Singulex, Chimera, deTect, Roche, Luminex, ProteomeBinders, BD, Biomerieux,

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