Diagnosing Tuberculosis Old and new tools

Anne Detjen, The Union

Over 100 years ago.

Microscopy
Acid-fast bacilli (AFB) Ziehl andNeelsen (1892)

Tuberculin-Skin Test
Robert Koch 1890 (Tuberculin) Mendel (1909), Mantoux (1910)

Diagnosis of active TB

Diagnosis of M. tuberculosis infection (LTBI)

Today
Microscopy remains the frontline tool for diagnosing active TB But New and exciting developments

Sputum smear microscopy

Microscopy
o Certain amount of bacilli needed for visibility Diagnostic delay Morbidity

Transmission

Microscopy
Advantages o Can be used at district level o Simple and inexpensive o Rapid detection of infectious cases Disadvantages
o Diagnostic delay: 5000-10,000 bacilli/ml o Sensitivity 60-70% in HIVuninfected adults o Suboptimal in
o HIV-infected o Children 20% o Extrapulmonary TB (EPTB)

o Smear positivity = Basis for recording and reporting of TB cases

o Cannot distinguish
o M. tuberculosis versus NTM o Dead or live M. tuberculosis o Drug-sensitive or resistant

Measures of diagnostic accuracy

o Sensitivity = correctly identified sick people

number of true positives number of true positives plus number of false negatives

o Specificity = correctly identified healthy people

number of true negatives number of true negatives plus number of false positives

What else? Approaches to diagnose TB

o Symptoms o Chest radiography (or other imaging) o Immune response to M. tuberculosis
o Tuberculin Skin Test o Interferon-gamma Release Assays o Antibody tests

o Bacteriologic confirmation = gold standard and Drug susceptibility testing (DST)

o Smear microscopy o Culture o Nucleic acid amplicfication tests (NAATs)

Symptoms
o Non-remitting cough o Night sweats o Fever o Fatigue o Organ-specific symptoms

Symptoms
Advantages o Cheap o Can be done anywhere Disadvantages o Unspecific o No diagnosis BUT: index of suspicion

Chest radiography ~1910

o Unspecific o Certain characteristic features
o Cavities o Lymph node enlargement in children o Miliary tuberculosis

o Remains pillar in diagnosis of TB in children

Chest radiography
Advantages o Diagnosis of extent of disease and complications o o o o Disadvantages Unspecific Often difficult to access Equipment and personnel Training in interpretation

Immune-based Tests - Concept

= Indirect assays Detection of the host response to M. tuberculosis o Cannot differentiate between active TB and M. tuberculosis infection (LTBI)

Tuberculin Skin Test, 1910

o Sensitivity false negative results
o Immune-compromised (HIV) o Severely ill (TB meningitis, Miliary TB) o After vaccinations (e.g. measles) or acute viral infections

o Specificity false positive results

o BCG-vaccinated o Infection with non-tuberculous mycobacteria (NTM)

Tuberculin Skin Test

Advantages o Basic test for M. tuberculosis infection o Used for contact tracing o Risk assessment for active TB Disadvantages o Not widely available o Feasibility: Return visit necessary o Cross-reactivity

Interferon-gamma Release Assays (IGRAs)

o Developed for detection of LTBI
o Sensitized T-cells produce interferon-gamma after stimulation with TB-specific antigens o Interferon-gamma/Interferon-gamma producing cells can be measured

o Sensitivity similar to TST (70-90%)

o Increased in HIV-infected? o Children?

o Specificity superior to TST (>95%)

o No cross-reactivity with BCG or common NTM

Interferon-gamma Release Assays (IGRAs)

T SPOT TM.TB
Advantages
o HIC: Superiority over TST (?) o LMIC: Value in HIV-infected, children?

QuantiFERONTb Gold In-Tube

Disadvantages
o Cost o HR and lab requirements o No value for detection of active TB WHO 25 October 2010: Negative policy recommendation for low and middle income countries 2010

Recommended in many high income countries for detection of LTBI

Antibody Detection Tests

o Would be ideal point of care test (similar to HIV rapid test) o Current commercial versions have suboptimal accuracy (and are yet widely used e.g. India)

First negative policy recommendation WHO 2011

Bacteriologic confirmation - Culture methods

o Solid media
o Egg-based (Lwenstein-Jensen), Agar-based (Middlebrook) o Time to detection: 3-4 weeks

o Liquid media (WHO 2007)

o E.g. Bactec 460 (radiolabelled CO2) or Mycobacterial growth indicator tube (MGIT) 960 (fluorescent indicator) o Time to detection: 10-14 days o Yield +10% over solid media o More prone to contamination

o Strain specification needed (Phenotypic, Genotypic)

Drug Sensitivity Testing

o Conventional = Culture of M. tuberculosis in the presence of anti-TB drugs to detect growth (resistant) or inhibition of growth (susceptible)
o Direct DST = from specimen o indirect DST = from positive culture = gold standard

Bacteriologic confirmation
Advantages Disadvantages

o Gold standard o Increases case-finding (3050%) o Earlier detection than microscopy (10-100 bacteria/ml)

o o o o o o

Time (incl. DST) Cost Lab and HR requirements Biosafety requirements Training Maintenance of equipment

Use of current TB diagnostics

o Microscopy ~ 90 Million patient examinations/year (6% in high income countries) o 50 Million chest radiographies (2/3 in Asia) o Culture:
o 17 Million cultures, 1/3 in HIC o Of cultures performed in 22 high burden countries: 75% are done in Brazil, Russian Federation o South Africa: > 90% of cultures on African continent o 2.5% of incident TB cases in Asian and African HBC receive DST

Conclusion
o Existing diagnostic tools are suboptimal
o Accuracy (microscopy)
o HIV-infected o Children

o Time to diagnosis = Transmission o Feasibility in settings with limited resources

o Financial o Human o Infrastructure

New diagnostics are urgently needed

Pathway for the development of new diagnostics

NDWG 2009

Development of new tools What will a new test be used for?

o Case detection o Diagnosis of drug resistance o Treatment follow-up o Diagnosis of latent TB infection

Where in the health system?

Reference Laboratory Patient access Regional/Referral Laboratory Microscopy Laboratory

Sophistication of diagnostic

Health clinic

Needs assessment
o Depends on the epidemiologic setting and health system context o Add-on or replacement? Each of these indications has different needs for a test no one-fits all solution

Desirable: o High accuracy in all patient groups (smear positive, smear negative, HIV-infected, children, EPTB) o Easy to perform
o Little training, user-friendly o Biosafety o Close to the patient point of care

The diagnostic pipeline

Improved microscopy
o Fluorescent microscopy
o 10% increased yield o Recommended for intermediate level laboratories (100+ smears)

o Light-emitting diode (LED) fluorescence microscopy

o Accuracy comparable to conventional fluorescence o Less power, can run on batteries, bulbs long half life o Alternative to conventional microscopy at high- and low-volume laboratories

Point of care diagnostic within reach? Urinary LAM Antigen detection

LAM = Lipoarrabinomannan o Cell wall component of M. tuberculosis o Promising marker of active TB, found in urine o Potential for simple, non-invasive and safe point-of care test? o Commercial assay available

LAM Assays Systematic review

o Sensitivity of early non-commercial versions higher than pooled sensitivity of commercial versions

Minion, ERJ 2011

Simplified culture methods

o Microscopic Observation Drug Susceptibility (MODS) o Using liquid medium o Non-commercial, manual culture method o Detection of
o M. tuberculosis o INH and RIF resistance

o Time to detection 7-14 days

www.modsperu.org

MODS
o Simple o Less expensive o Modest training requirements o Combines detection of M. tuberculosis and DST o Not standardized o Local variations in methodology o Quality assurance o Biosafety WHO 2011: Recommended for MDR suspects as interim alternative

Nucleic Acid Amplification Tests (NAAT)

o Genotypic detection of M. tuberculosis o Allows for screening of common resistancecausing mutations o Various commercial and non-commercial NAATs have been around for >15 years
o Excellent specificity o Clinical sensitivity depends on bacterial concentration: 50-80% in smear negative

Line Probe Assays (WHO 2008)

o Manual NAAT o Detection of
o M. tuberculosis o INH and RIF resistance

o based on DNA strip technology. Three steps: DNA extraction, PCR and reverse hybridization Recommended for detection of MDR TB on smear+ samples

Line Probe Assays

Advantages o Results within hours o Fast detection of INH, RIF resistance o Excellent sensitivity and specificity compared to conventional culture Disadvantages o Biosafety level 2 or 3 o Limited use in
o HIV-infected o Children o (on positive cultures)

o Conventional culture (and DST) still needed for smear negative

Xpert MTB/RIF (WHO 2010)

o Real-time PCR assay o Fully automated: No prior specimen processing and DNA extraction needed o Detects M. tuberculosis and RIF resistance o Highly accurate in smear + (99%) and smear (>80%) as well as HIV-infected o Sensitivity for RIF resistance 95.1%, Specificity 98.4% o Results within 2 hours

Xpert MTB/RIF

Boehme et al. NEJM 2011

Xpert MTB/RIF
Potential for point of care test? Cost Electric supply WHO policy statement: Xpert MTB/RIF as initial diagnostic test in MDR suspects or HIV-infected TB suspects Follow-on test to microscopy in MDR or HIV lowburden settings, further testing of smear negative samples District, Sub-district Level

Conclusions
Exciting development in the area of new diagnostics Challenges:
Cost Adoption at country level Implementation and scale up

Still not optimal for

Vulnerable populations: Children Extrapulmonary TB

Populations at risk - children

Infants Toddlers (1-5 years)

43 % 24 %

Children 57-85%

Adolescents (11-15 years)

Adults

15 %
5-10 %

modified from Sharma SK Lancet Infect Dis 2005; Marais Int J Tuberc Lung Dis 2004

TB in children a global challenge

o Children account for approximately 15% of the annual incident cases globally
o Up to 40% of caseload in some areas

o TB in children contributes to global child morbidity and mortality

TB diagnosis in children
Diagnostic challenges: o Different disease presentation o Difficulty to produce sputum
Alternative: gastric acid

o Paucibacillary TB

Diagnosis relies on composite of exposure history, symptoms, X-ray

New diagnostics in children

Method Characteristics adults No data Very few data (2 studies) Few data No data One study published Children Fluorescence Improved sensitivity compared to light microscopy/ microscopy (5-10%) LED FM MODS NAAT LPA Xpert MTB/RIF Simple, rapid, inexpensive Multiple Commercial/In-house assays Variable performance High accuracy Recommended in smear positive Good performance in smear negative Highly variable Improved sensitivity in HIV-infected

Urine LAM
Volatile organic compounds

No data

Few data No data Sub-optimal accuracy in adults (breath)

New diagnostics from concept to public health implementation

Policy

NDWG 2009

WHO policy formulation

WHO

New diagnostics recent WHO policy recommendations

o o o o 2007: Liquid culture and DST 2008: Line probe Assay 2010: Xpert MTB/RIF 2011: o Non-commercial culture and DST (MODS) o LED microscopy o Negative recommendation commercial serodiagnostic tests o IGRAs

Challenges in developing policy guidance

Limited data on patient outcomes and impact

High accuracy positive changes in outcomes

Little information on
o Functioning of new tool in different epidemiologic settings o Functioning of new tool within diagnostic algorithms o Cost effectiveness o Impact on health system and patients o Operational issues: training, maintenance, , supply chains, storage, waste management

How does a country decide what to do?

o WHO recommendation as basis for consideration o Data from own or similar epidemiologic setting
e.g. Brazil requests in-country validation and costeffectiveness data

o Question remains: which tool or which combination of new tools o Will there be another, better tool soon?
vanKampen PLoS One 2010

Global support example Xpert

o Negotiated reduced cost (WHO & FIND) o Rapid implementation document o Interim algorithms o Close monitoring of roll-out
http://www.who.int/tb/laboratory/mtbrifrollout/en/index.ht ml

o TREAT TB: Monitoring of research

Research open questions

o Each policy document lists a number of open research questions
o Test-specific o General related to implementation and impact
o Cost effectiveness o Functioning of new test within health systems o Functioning within diagnostic algorithms (combination of steps and tools) o Impact on patients (Cost, access)

Research
o Delay policy process? o Accompanying implementation process
o Optimize implementation o Inform national and global policy

o Different risk groups and disease manifestations

o HIV-infected o Children o Extrapulmonary TB

A framework for policy-relevant research impact assessment

o Evaluation of new tools o under program conditions o as part of diagnostic strategies o The impact of new diagnostic approaches should be measured on their ability to increase case detection. o Acceptable levels of sensitivity and specificity o Affordability (to the health system and patients) o Accessibility (e.g. to all TB suspects) o Impact on the society Support decision making process for National TB Programs on which, when and how to implement new tools

Impact Assessment framework

Layer of Layer of Assessment Assessment Layer 1: Layer 1: EFFICACY EFFICACY ANALYSIS ANALYSIS Layer 2: Layer 2: ANALYSIS EQUITY EQUITY ANALYSIS Layer 3: Layer 3: SYSTEM HEALTH HEALTH SYSTEM ANALYSIS ANALYSIS Kinds of question(s) being answered How well does new test work in terms of accuracy? How many additional cases will be identified? How many additional cases will actually start treatment / achieve cure / avoid death? Who benefits from new test? (ambulant vs hospitalised, poor/less poor, men/women, adults/children) Why do these benefits accrue? (level health system in which tests are deployed, change time to issue of results, change in patient costs)

What are the human resource implications of introducing the test? (training, number and cadre of staff) What are the infrastructure implications? (equipment, lab layout, safety installations) What are the procurement implications? (reagents, consumables, documentation) What are the implications for quality assurance? (internal and external)
What are the projected impacts of going to scale with the test? eg a) cost savings to patients in relation to income b) cost savings to health providers / the health system d) Effects on transmission of improved infection control as a result of test introduction What other similar technologies are available or likely to become available? How do similar existing or emerging technologies compare in their projected performance within each of the layers above? Bertie Squire and Gillian Mann, Liverpool School of Tropical Medicine

Layer 4: Layer 4: SCALE UP SCALE UP ANALYSIS ANALYSIS Layer 5: Layer 5: POLICY ANALYSIS POLICY ANALYSIS

Conclusions
o Exciting new diagnostics have been developed o Many open questions remain as to
o how these new diagnostics work in health systems o how they influence patient outcomes

o Need for more research o Still needed:

o point of care diagnostics test o Better diagnostics for

Thank you!