Diagnostics: Bench to Bedside Pathway

Rosanna W Peeling Professor and Chair, Diagnostic Research Director, International Diagnostics Centre

London School of Hygiene & Tropical

Medicine

www.idx-dx.org

The Ideal Diagnostic Test

A = Affordable

S = Sensitive

S = Specific

U = User-friendly

R = Rapid and robust

E = Equipment-free

D = Deliverable

Accurate

Fast/Simple

Cheap

Pick 2 of 3!

Ease of detection

Confidence

DIRECT METHODS: Pathogen Detection

INDIRECT METHODS: Host Biomarkers

Culture Genome

detection Antigen

detection

Serology

IgM Serology

IgG

Adapted with permission from J. Cardosa

Diagnostics Methods: Ease of Detection vs Confidence in diagnosis

Time to Result:

Minutes Days/Hours

Microscopy

Diagnostics: Access vs Accuracy vs Affordability

Urban

Semi urban

Rural

Urban

Semi urban

Rural

Urban

Semi urban

Rural

Accurate ✓✓✓

Cheap×

Fast/simple×

Accurate ✓✓

Cheap ✓

Fast/simple✓

Accurate ✓

Cheap ✓✓

Fast/simple✓✓

FDA approves Oral HIV Tests

for home use, July, 2012

Source: time.com

Oct 22, 2013: European Parliament votes favourably for home use of IVDs

Performance of the oral HIV Test

Performance Measure*

Professional Use OraQuick Test Performance (2-sided 95% CI**)

Over-the-Counter OraQuick Test Performance (2-sided 95% CI**)

Minimum FDA Recommended Performance

Evaluation Results

Minimum FDA Recommended Performance

Evaluation Results

Sensitivity 98% (lower bound of the 2-sided 95% CI)

99.3% (98.4 - 99.7%)

95% (lower bound of the 2-sided 95% CI)

92.98% (86.64 – 96.92%)

Specificity 98% (lower bound of the 2-sided 95% CI)

99. 8% (99.6 – 99.9%)

95% (lower bound of the 2-sided 95% CI)

99.98% (99.90 – 100%)

* Compared to a blood based HIV test **95%CI = 95% Confidence Interval

Connectivity Solutions for Rapid Point-of-care Tests

Abbott Architect Ag/Ab Combo

Bio-Rad Ag/Ab Combo

Antibody Antigen Control

Determine Combo Ag/Ab Rapid Test

4th Generation HIV Tests

2011

2013

2010

Detect HIV-1 p24 antigen and IgM and IgG antibodies against either HIV-1 or HIV-2

Insufficient data for rapid Ag/Ab test to recommend it as 1st test in algorithm

2015 2013 2014 2016

Alere Q

Alere

LYNX Viral Load Platform

NWGHF

SAMBA VL

DDU/Cambridge

Liat™ Analyser

IQuum

EOSCAPE HIV™ Rapid RNA Assay System

Wave 80 Biosciences

Gene Xpert

Cepheid Cavidi AMP

Viral Load Assay with

BART Lumora

Truelab PCR

Molbio/bigTec Gene-RADAR

Nanobiosym

RT CPA HIV-1 Viral Load

Ustar

http://www.unitaid.eu/images/marketdynamics/publications/UNITAID-HIV_Diagnostic_Landscape-3rd_edition

Sample in-answer out

HIV Viral Load Product Pipeline

5 20 80 500-1000 Samples per shift

Sample In, Answer Out: A Multi-disease Random Access Real-time PCR Platform MTB/RIF

MRSA CT/Ng HIV Viral Load …..

Roche LIAT Analyser

IQuum (Boston) currently has FDA-approved Flu H1N1, A and B detection assays. The Liat Analyser has an internal optical system that provides 6 independent optical detection channels for real-time detection and quantification of multiple targets in each test. It can be powered by AC mains or by battery, allowing mobile use.

Roche: Liat Molecular Platform

Molecular point-of-care tests for Influenza

• ONLY molecular platform that is FDA approved as a POCT • Nucleic acid amplification system that uses a fluorescence-

based molecular signal to detect influenza A and B. • Time to result: 15min (only 2 min of “hands on” time) • Adapted to be used by non-laboratory staff • Results from a multicentre clinical evaluation (Bell et al

2014) indicate:

- 99.3% sensitivity and 98.1% specificity for Influenza A - 97.6 sensitivity and 100% specificity for Influenza B

- Sensitivities of 73.2% and 82.3% have ben reported in other studies

Alere i Influenza A&B (Alere, San Diego, CA, USA)

Alere i Influenza A&B test:

STI Multiplex Molecular BioChip Array

• Chlamydia trachomatis

• Neisseria gonorrhoea

• Herpes simplex I

• Herpes simplex II

• Treponema pallidum

• Trichomonas vaginalis

• Mycoplasma hominis

• Mycoplasma genitalium

• Ureaplasma urealyticum

• Haemophilus ducreyi

25 ul sample, 22 assays per biochip, 45 samples and 4 calibrators per run

Nanotechnologies

Nanowire technology: From a finger-pricked sample of blood, this device can detect in 20 min: - malaria parasites - distinguish malaria species - malaria drug resistance

Nanodot technology:

Diagnostic Targets

Product Prototype

Lab & field evaluation

Test adoption

Policy and guidelines for use

Proof of Principle

Technology platform

Diagnostics: Bench to Bedside Pathway

Regulatory Approval: 2-5 years

Valley of Death:

Target Product Profile

Policy & Uptake 5-7 years

R & D: 2-10 years; $ 10-100 million

Diagnostic Targets

Product Prototype

Lab & field evaluation

Test adoption

Policy and guidelines for use

Proof of Principle

Technology platform

Overcoming Challenges along the Diagnostics Bench to Bedside Pathway

Regulatory science to keep up with technological innovation;

Harmonized Regulation

Target Product Profile

Define product standards/ target product profiles

Standardise/ publish evaluation protocols

Set up networks of evaluation sites pre-approved for standardised protocols

Share resources: Biobank Targets Reagents

Accelerate policy development through modelling health impact and cost-effectiveness

Product profile of HIV/Syphilis Dual Tests

Purpose/use setting

Screen for HIV and Syphilis in clinics Screen for HIV and Syphilis in clinics

Screen for HIV and Syphilis in clinics

Specimen Serum/Plasma/Whole Blood

(10-20uL) S/P/WB

(1 drop, approx.30-40uL) S/P/WB

(1 drop, approx.30-40uL)

Test time 15-20min. >20min

+ sample preparation 15-20min

+ sample preparation

#Operator steps

3 3 4

Performance HIV: 100%/100%

SYP : 100%/99.1%

99.8%/99.7% 94.4%/100%

99.1-100%/99.6-100% 95.7-100%/98.2-100%

Price($)

$1.50

$3.50

$2.50 - 3.00

Standard Diagnostics, Inc.

BIOLINE HIV/Syphilis Duo

MedMira Multiplo TP/HIV Antibody Test

Chembio DPP® HIV-Syphilis Assay