Malaria or not? Challenges in diagnosis · RDTs have played an increasing role in malaria...
Transcript of Malaria or not? Challenges in diagnosis · RDTs have played an increasing role in malaria...
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Malaria or not? Challenges in diagnosis
Dylan R. Pillai MD, PhD, FRCP(C)
Associate Professor
Pathology & Laboratory Medicine, Medicine, and MIID
Cummings School of Medicine
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Disclosures (diagnostic studies)
• Funding Becton Dickinson
• Funding Meridian Biosciences
• Funding Somagen Diagnostics
• Funding Phoenix Airmid
• Funding R-Biopharm
• Funding Promega
• Funding Luminex
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Malaria is rapidly fatal (even in Canada)
Maclean’s Aug 11 2015
“On June 25,
she died from
complications
of malaria.
She was 42.”
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Malaria is a multi-organ disease
Miller et al, Nature Medicine, 2013
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Microscopy is a visual art
Name this species?
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Malaysia – epidemic of mis-diagnosed P. knowlesi
• Human infection with P. knowlesi was commonly misidentified as the more benign P. malariae
• Natural host is the long-tailed macaque
• Widely distributed across Malaysian Borneo and extend to Peninsular Malaysia
• Rapid diagnosis and prompt effective treatment are essential
• Patients who reside in or have traveled to Southeast Asia receive intensive management as
appropriate for severe falciparum malaria Clin Infect Dis. 2008 Jan 15;46(2):165-71
Dambulla, Sri Lanka
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Case: Imported P. knowlesi to Munich, Germany
Laboratory testing
Parameter Creatinine GFR Pro-
calcitonin CRP LDH Bilirubin
Day 1 1.7 40 32.4 300.2 415 1.4
Day 2 3.1 19 38.7 342.6 586 2.2
Day 5 5.1 (HD for
5 wks) 11 8.2 149 924 1.5
Day 30 1.9 32 0,1 5.8 391 0.8
Seilmaier et al, Mal J, 2014
73 year old M Myanmar Thailand “rain forest excursions” presented to ED
GCS 7-8, BP 70/50 mmHg, pulse 115/min respiratory frequency 18-20/min, temperature 39.4°C,
SP02 74%
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Quality assurance in the laboratory is paramount – Case A
AHRI, Addis Ababa
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Quality assurance in the laboratory is paramount – Case B
Kola Diba Health Centre, Ethiopia
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Leapfrog technology RDTs have played an increasing role in malaria diagnostics
Ann Trop Med Parasitol. 2001 Oct;95(7):671-7
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Over 100 manufacturers of RDTs worldwide
hrp2
LDH/
aldoase
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Limitations of malaria RDTs
• Insensitive for non-falciparum malaria especially
P. ovale (LDH antigen is not stable)
• False positivity in treated patients or gametocytemia
• Spill over bands confounds interpretation of mixed infections
• False positives with rheumatoid factor, co-infections
• Hrp 2 deletions observed in South America and parts of Africa
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The problem… how low can you go?
>100,000 parasites per uL (2.5%)
500 parasites per uL (0.0125%)
1 parasites per uL (0.000025%)
0.01 parasites per uL
MICROSCOPY
& RDT
MOLECULAR
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Clinical and public health impact of Diagnostics
Severe and most symptomatic cases
Asymptomatic cases
Pregnancy
Liver-stage only
Resistant parasites
ERADICATION
>100,000 parasites per uL (2.5%)
500 parasites per uL (0.0125%)
1 parasites per uL (0.000025%)
0.01 parasites per uL
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What about molecular (NAAT) diagnostics?
• Why do we need it?
• Asymptomatic or sub-clinical malaria, pregnancy, surveillance, eradication
• Cheaper gold standard for training/QC purposes
• Clinical trials for accurate monitoring (MIC studies)
• What formats are feasible?
• “Lab on a chip”
• “LAMP”
• Microfluidics
• Aptamer technology
• Nanopore sequencing
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Real-time PCR for the detection of malaria:
• RDT: “P. falciparum antigen”
• Microscopy: “Plasmodium species”
P. falciparum
P. malariae
11 year old Congolese refugee in Calgary
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Nucleic acid-based testing for malaria
• PCR, nested PCR, and real time PCR formats have all been used effectively
• Greater limit of detection than RDT and microscopy especially with multi-copy RNA targets
• High capital and reagent cost, not field-friendly
• Require preventive maintenance of equipment and access to reagents with limited shelf life
• Need to train technologists in molecular diagnostics
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LAMP – loop mediated isothermal amplification
• An example of isothermal amplification (others exist such as helicase dependent amplification, strand displacement amplification)
• Relies on a strand-displacing enzyme Bst polymerase
• Relatively resistant to inhibitors in clinical samples permitting crude extraction
• End products are detectable to the naked eye
• RNA can also be used as a target with RT-LAMP and SNP genotyping possible with primer design
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Leapfrog technology LAMP allows molecular amplification detectable by naked eye
www.cdc.gov
LOD is 1 parasite per uL
Can detect RNA or repetitive elements to improve LOD
Acta Trop. 2014 Jun;134:52-7
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SNP-LAMP POCT to guide chemotherapy
C580Y
WT
Triple therapy (eg. Co-ART + MQ)
Extended therapy (eg. 7 days)
Regular 3 day ACT or SERCA
Unpublished data
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Theranostics and Genotyping: critical to drug development
• Theranostics refers to specific diagnostic tests that are required prior to treatment choices
• Treatment of P. vivax and gametocidal drugs are restricted to primaquine and derivatives which require G6PD screening
• Genotyping of parasites is essential to distinguish recrudescence from re-infection
• Both theranostics and genotyping methods are not clinically validated and require research and development support
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LAMP training
U Gondar, Ethiopia
Dr. Abebe Bayih Meslo Sema, MSc student
Malaria Journal 2015 14:44
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Active detection of asymptomatic malaria by LAMP in Northwest Ethiopia
• A community based cross-sectional study was conducted in North Gondar, Ethiopia
• A total of 802 study participants were enrolled
• The overall prevalence of asymptomatic malaria using giemsa microscopy was 3.75% compared to LAMP at 5%
Sisay Getie, University of Gondar
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Case detection of malaria in pregnancy by LAMP in Northwest Ethiopia
• Study conducted in maternity clinics at rural health centres in NW Ethiopia
• A total of 93 pregnant women suspected of having malaria based on clinical symptoms were enrolled
• The overall prevalence of asymptomatic malaria using giemsa microscopy was 10.8% compared to LAMP at 14%
Banchamlak Tegegne, University of Gondar
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LAMP study in returning travelers (n=140)
Test Nested PCR
Sensitivity (%)(95% CI) Specificity (%)(95% CI)
LAMP Overall 100 (93.6-100) 98.6 (91.1-99.9)
P. falciparum 97.6 (85.9-99.9) 100 (95.3-100)
non-falciparum 100 (86.3-100) 99.1 (94.3-100)
RDT Overall 85.9 (75.2-92.7) 98.6 (91.1-99.9)
P. falciparum 90.5 (76.5-96.9) 100 (95.3-100)
non-falciparum 71.0 (51.8-85.1) 99.1 (94.3-100)
Mohon AN et al, DMID, 2015
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Leapfrog technology
New Metagenomic Sequencing Protocol for the Nanopore
(Greninger, et al., 2015, Genome Medicine 7:99)
MinION (Oxford Nanopore Technologies)
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Undifferentiated fever in sub-Saharan Africa:
Precision “omics” diagnostics
Collaboration with Charles Chiu, UCSF
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Clinical and public health impact of Diagnostics
Severe and most symptomatic cases
Asymptomatic cases
Pregnancy
Liver-stage only
Resistant parasites
ERADICATION
>100,000 parasites per uL (2.5%)
500 parasites per uL (0.0125%)
1 parasites per uL (0.000025%)
0.01 parasites per uL
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Acknowledgments
• Colleagues at Calgary Laboratory Services and U Calgary
• R&D staff: • Dr. Asongna Folefoc • AN Mohon – PhD student • Dr. Abebe Bayih – former postdoc • Lydia Lee, Clara Lee, Tamiso Rego • MSc students at U Gondar (Meslo Sema, Benchamlak Tegegne, Lubaba Seid)
• Collaborators: • Abebe Alemu, Sisay Getie (UG) • Dr. Shafiul Alam (ICDDRB) • Prof. Lashitew Gedamu (Bio Sci) • Dr. Robert Burton, PATH • Dr. Iveth Gonzalez, FIND diagnostics • Dr. Tim Wells, CSO, MMV • Dr. Charles Chiu, UCSF • Dr. Ingrid Felger, STI