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 •Complex, slow tasks

•Accurate, quantitative readout •Inaccurate, qualitative readout
•Simultaneous results from multiple markers •Single marker, single disease
•Portable, low maintenance instrument •Heavy, high maintenance instruments
•Built-in quality control •Absent quality control
FIND: a public engine for diagnostic development

Upstream FIND’s focus Downstream

Discovery Market access

Development Evaluation Demonstration
and research and distribution

Liaise with funders, pharmaceutical Liaise with funders, multi-lateral

and biotech companies, research Create network of public and private partners agencies, NGOs,health ministries,
institutions, academia to create effective tests and demonstrate their and agencies like GDF and
success
GFATM

Development Evaluation Demonstration

Large-scale
Facilitate, Regulatory- projects
Proof of Product Efficacy Effectiveness
principle
co-fund,
co-develop in box
quality
lab & field Data
measuring
Data Policy
feasibility and
trials impact on
disease control
programs
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 Hybridize amplified DNA

DNA, amplify DNA targets to oligonucleotide probes
with PCR on strips
 Geneva, Switzerland - 2007

17 y.o. male AFB microscopy positive:

18th birthday Conventional
admitted to hospital patient placed in isolation
passed in DST results:
with cough and fever pending drug
isolation fully susceptible
susceptibility testing

weeks

0 1 2 3 4 5 6 7 8 9 10 11 12
 Evolution of
TB
diagnostics in
the public
sector

Fundamental Fundamental
diagnostic: 1882 diagnostic: 2009
Integrated NAAT for TB/Rif

Automated sample preparation

Amplification and detection Xpert TM MTB/Rif
<2h

Workflow
• fully automated, with 1-step external sample prep. A technology platform for
• time-to-result < 2 h (walk away test)  TB & Rif resistance
• throughput: up to 1-48 tests / run  TB Quinolone resistance
• no bio-safety cabinet
 Potential for HIV viral load
• closed system (no contamination risk)
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 2%
TB (C+) 61%
MDR TB 7% STI
HIV 5%
TB (C+) 42%
MDR TB 31%

Hinduja
HIV 5%
UCT SAMRC TB (C+) 60%
HIV 77% 72% MDR TB 67%
TB (C+) 39% 13%
MDR TB 10% 9%
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  From 32 to 7 steps

 From 15 to 3 plastics

85℃, 5 min
Mixing

Sputum

One
drop

Dried
reagent

Calcein fluorescence LAMP reation

67℃ 　 40 min
Spiked sputum samples
Decentralization of molecular diagnostics
Le
ss
1st generation co
MDR mp
lex
ity
, mo
2nd generation re
automated MDR rob
us
1st generation tne
manual detection
ss

2nd generation
manual detection

LPA Xpert LAMP POC test

2008 2010 2011 2015

24
Serodiagnosis of TB
 Sensitivity of selected antigens at >95%
specificity level compared to healthy controls

Antigen Europe, HIV– Africa, HIV– Africa, HIV+

(n=71) (n=79) (n=77)
TB9.7 35% 79 % 91%
CFP10:ESAT6* 25% 64% 49%
TB10.2 21% 45% 48%
TB15.3 41% 75% 65%
TB16.3 55% 81% 88 %
TB 51 31% 76% 48%
TB51.7 57% 83% 78%
aCry:MPT83 26% 83% 58%
38 kDa 19% 29% 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,