Final version - EN UPDATE - OraQuick HCV Rapid antibody test (OraSure) MSF Laboratory working group; March 12,

2014 The OraQuick HCV Rapid antibody test, Orasure (ref 1001- 0270 25 tests) [DDGTHCTE25T] was introduced in MSF programmes in July 2013. Early in fall 2013 we got reports from field sites that the positive control of the OraQuick HCV Rapid Antibody Test Kit Controls showed either no reactive or even more often only very faint reactive lines. We investigated the problem over the last months and the manufacturer has confirmed that the controls were designed to be only weakly reactive. In addition, a recent publication by Cha et al. (2013) illustrates that the reactivity of the control solution provided by OraSure is very/too weak for visual detection. To find a better solution and re-gain confident in the test, we took the following interim measures together with the quality assurance team in MSF: Placement of 2 batches in quarantine in November 2013 which was lifted again in December, 2013. Evaluation of one batch evaluated at the reference laboratory of the Paul-Ehrlich Institute in Germany in January/February 2014. Stop the use of the commercial positive control from Orasure (decision in November 2013).

The latest news: 1. Evaluation of the OraQuick HCV Rapid antibody test (Orasure) by the Paul Ehrlich Institute, Germany with 3 panels of known 248 positive and 78 negative samples. The Oraquick HCV RDT detected 246 of 248 positives samples and 78 of 78 negative samples, resulting in a sensitivity of 99.2 % (CI 95%: 97.1-99.9) and a specificity of 100% (CI 95%: 95.4-100) These results confirm the very good performance of the test and are coherent with the systematic review and meta-analysis which was carried out in 2012 (Shivkumaret al.). Therefore, we propose to continue to use the Oraquick HCV RDT in MSF programs.

2. Due to the fact that the positive control OraQuick HCV Rapid antibody test (Orasure) is calibrated extremely weak, which results in hardly visible lines, the lab working group propose to the Medical Directors to stop using the commercial control solution (positive and negative) for the Oraquick HCV test (March 5, 2014). The rationale for this decision is based on the fear that training staff in reading these extremely weak lines, may result in reading artifacts (false positive lines) when using the HCV test itself and for other RDTs.

Instead of the commercial control kit, the LWG recommended that known positive (and negative samples) are tested at least once per week and with every new batch that is being used by each facility as we currently recommend for other RDTs which do not have commercial controls available. The decision to stop using both positive and negative controls has been endorsed by the medical directors on the 11/3/14.

Important remarks for field use of the OraQuick HCV rapid antibody in MSF:
1. All batches of the OraQuick HCV rapid antibody test can be used to screen patients and potential blood donors for HCV infection. Reminder: This is regardless of the warning on the package insert, saying that the test is not intended for screening of donated blood, plasma or tissue donors. This statement is intended for western settings where ELISA fourth generation tests and PCR are systematically used to screen potential blood donors for HCV infection. As it is not the case in MSF field projects, the OraQuick HCV Rapid antibody test can be used for screening potential blood donors; besides screening patients for HCV infection. 2. Reminder: MSF validated the OraQuick HCV Rapid antibody test on whole blood, plasma or serum but NOT on oral fluid as the sensitivity is lower than on blood specimens (Lee et al, 2010 and 2011, Smith et al, 2011-2; Drobnik et all, 2011; Larrat et al, 2012; Cha et al, 2013). 3. Please test a known positive and negative sample once per week and on every new batch that is opened as a measure of internal quality control and record the results.

In case of questions or problems regarding the use of the test, please contact the laboratory advisor of your operational centre.

The MSF Laboratory working group March 12, 2013

References Cha YJ, Park Q, Kang E, Yoo BC, Park KU, Kim J, Hwang Y, Kim M (2013) Performance evaluation of the OraQuick Hepatitis C Virus Rapid Antibody Test. Ann Lab Med 33; 184-189. Drobnik A, Judd C, Banach D, Egger J, Konty K, Rude E (2011) Public health implications of rapid hepatitis C screening with an oral swab for communitybased organizations serving high-risk populations. Am J Public Health. 101: 2151-5. Larrat S, Bourdon C, Baccard M, Garnaud C, Mathieu S, Quesada JL, Signori-Schmuck A et al (2012) Performance of an antigen-antibody combined assay for hepatitis C virus testing without venipuncture. J Clin Virol 55 (3) 220225. Lee SR, Yearwood GD, Guillon GB, Kurtz LA, Fischl M, Friel T, et al (2010) Evaluation of a rapid, point-of-care test device for the diagnosis of hepatitis Cinfection. J Clin Virol. 2010;48:15-7. Lee SR, Kardos KW, Schiff E, Berne CA, Mounzer K, Banks AT, et al (2011) Evaluation of a new, rapid test for detecting HCV infection, suitable for use with blood or oral fluid. J Virol Methods. 2011;172:27-31 OConnell RJ, Gates RG, Bautista CT, Imbach M, Eggleston JC, Beardsley SG, et al (2013) Laboratory evaluation of rapid test kits to detect hepatitis C antibody for use in predonation screening in emergency settings. Transfusion 53: 505-517. Smith BD, Drobeniuc J, Jewett A, Branson BM, Garfein RS, Teshale E, et al (2011) Evaluation of three rapid screening assays for detection of antibodies to hepatitis C virus. J Infect Dis. 204:825-31. (1) Smith BD, Teshale E, Jewett A, Weinbaum CM, Neaigus A, Hagan H, et al. (2011) Performance of premarket rapid hepatitis C virus antibody assays in 4 national human immunodeficiency virus behavioral surveillance system sites.Clin Infect Dis.53:780-6. (2)