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National Public Health Laboratory Drug Susceptibility Testing (DST) Reference Center for Mycobacterium tuberculosis

DST Reference Center

National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of TB Elimination

Division of TB Elimination/ Laboratory Branch U.S. Centers for Disease Control and Prevention

February 19, 2015

Drug Susceptibility Testing in United States

Public Health Laboratories (PHLs) serve as a primary provider of drug susceptibility test (DST) results

580 (100%) labs perform AFB smear microscopy

474 (81.7%) perform culture

• 60/94 (63%) are PHL • 26/94 (28%) are clinical labs

215 (37.1%) perform MTBC identification

94 (16.2%)

perform first-line

DST

APHL, National TB Services Survey Report, 2012

Volume Varies for DST

Range of 1–685 patients/year for whom DST performed by PHL supported in part by DTBE CoAg 24 PHL performed testing for <50

patients/year which is the recommended volume for maintaining technical proficiency* <1 isolate each week 458 total patients for these labs

*http://www.aphl.org/aphlprograms/infectious/tuberculosis/Documents/ID_2007Dec_TB-DST-Report.pdf

http://www.aphl.org/aphlprograms/infectious/tuberculosis/Documents/ID_2007Dec_TB-DST-Report.pdf







DST Reference Center Center primarily to support first-line DST for low volume

PHLs Access to second-line DST and rapid molecular

detection of drug resistance

Low volume PHLs electing not to use reference center for first-line DST (i.e., not formally enrolled) may use services for pyrosequencing and second-line DST on request

Services complementary to those performed by DTBE Reference Laboratory and offered free-of-charge Shipping charges responsibility of submitting PHL

Selection of Reference Center

Competitive process led by APHL California Microbial Diseases Laboratory (MDL)

selected Experienced and well-respected laboratory Pioneer in use of molecular diagnostics for

detecting drug resistant TB Joint DTBE/ APHL site visit to finalize plans and

statement of work (December 2014) Dear Colleague letter announcing MDL

selection on January 16th and APHL role in administering contract

FAQs Regarding Services at CDC and MDL

Is my PHL required to use the DST Reference Center? Participation is voluntary Current enrollment focused on low-volume PHLs (<50

DST/year)

Does the reference center impact testing for PHLs with higher DST volumes (>50 DST/year)? No, higher volume PHLs will not use services at the DST

Reference Center

FAQs Regarding Services at CDC and MDL (2)

My PHL performs DST for >50 patients/year. Can I still refer samples to CDC for second-line DST and MDDR? Yes, please continue to use current referral algorithms MDDR remains available for all U.S. TB Programs

My PHL test volume is near 50 DST/year. How will we know if we are eligible to use the DST Reference Center? If volume falls below 50 DST/year, PHL is eligible to

enroll Variations above this threshold will not impact

availability of services once enrolled

Considerations

Laboratory services are core to TB control Maintaining proficiency is essential and

standardization of methods is optimal Ensuring success of DST Reference Center is

priority for all involved Partnership with PHLs and TB Programs Open communication needed Feedback essential


Enrollment of Eligible PHLs

• Laboratories from jurisdictions with <50 TB Cases per year are eligible. All have been contacted

• Complete enrollment form and return to Will Murtaugh at [email protected]

• Deadline for initial enrollment is February 25 • Labs can continue to enroll on a rolling basis • Information on shipping and submission will be

provided to laboratories who enroll

mailto:[email protected]

National TB DST Reference Lab MDL, California

Ed Desmond Grace Lin 2/19/15

Tests Offered

• Pyrosequencing (PSQ) – Detect mutations associated with INH & RIF

resistance • INH: katG, promoters of inhA and ahpC,

– fabG (will be added later to improve sensitivity)

• RIF: rpoB (codons 507 to 533) – rpoB codon 176 (will be added later to improve sensitivity)

• Culture-based DST by MGIT 960

TB DST Ref Lab 2/19/15 12

PSQ Submission Criteria to MDL

1. Patient history suggests high risk of INH or RIF resistance: prev. treatment, contact of DRTB case, foreign born from area with high rates of MDRTB, not responding to current treatment.

2. Patients for whom drug resistance would have high public health impact (e.g. vulnerable population exposed)

3. Mixed or non-viable cultures 4. Isolates which fail to grow in DST medium 5. Other situations considered on a case by case basis 6. Specimens should be submitted to CDC, not MDL, if:

• Known RIF resistance (based on GXP or culture) CDC • Patient has adverse reaction to critical TB drug (e.g. allergy to RIF CDC)

Note: allergy to RIF is equivalent to MDR


PSQ • Specimens

– Pre-approval required. (Email the requesting form to [email protected]) – Smear-positive sediments (NAAT-pos for MTBC)

• Minimal volume: 1 ml (if possible: 1.5 ml) • If there are multiple specimens, sub a specimen with higher smear-positivity and higher

volume. – Positive cultures (MTBC-identified)

• Solid media or broth media. • Keep a sub or a portion (1ml) of broth in your lab, send the most growth to MDL.

• Turnaround time – 1-3 days. [Results are usually available on the next day of specimen receipt.]

• If both PSQ and 1st-line DST are requested – MGIT DST

• From sediment specimens – MDL will make sub from remaining specimens: 0.5 ml to inoculate MGIT, 0.1ml to LJ,

7H10. – It may take several weeks to get sufficient growth for setting up DST.

• From cultures – If growth is sufficient and young, will perform DST in the same week.

• If RIF-R is found, will also forward to CDC for MDDR.


1st-line DST (if PSQ also requested)

• If no mutations detected – Test RIPE

• If mutations are detected – Test RIPE + MACE (MOX, AMK, CAP, ETO)

• If PSQ is performed on a sediment specimens, and the cultures inoculated at MDL do not grow in 2 weeks or found contaminated, MDL will request a pure isolate. – Prefer submission of the isolate from the same specimen

sent for PSQ. OK to submit an isolate with collection date w/in 1 weeks of the collection date of PSQ specimen.


1st-line DST only requested

• MGIT 1st-line DST – Pre-approval is not required.

• Email notification of isolate submission is required. – RIPE will be performed. – Resistance to any one of the RIPE drugs will trigger testing

of 2nd-line DST. • When MGIT DST shows resistance, will first rule out presence of

contamination or presence of NTM. • INH/RIF resistance: Will use PSQ to confirm.

– If not confirmed, will repeat MGIT DST. • EMB or PZA resistance: Will repeat MGIT DST to confirm.

– If RIF-R is detected, will also forward to CDC for MDDR.


2nd-line DST only requested

• MGIT 2nd-line DST – Pre-approval is not required.

• Email notification of isolate submission is required.

– MACE will be performed. • MOX (0.25 ug/ml), AMK (1.5), CAP (3) & ETO (5)

– When resistance is detected, will first rule of presence of NTM or other bacteria.

– Resistance to MOX at 0.25 µg/ml will trigger testing of MOX at 0.5, 1, 2 & 3 ug/ml.


Example of requisition form

DST report PSQ report


Genotyping

• Isolates are shipped to MI once a week. – Likely be on Tuesdays. – MDL will send isolates for genotyping if 1st-line

DST is performed at MDL. – Similarly, if submitting labs perform 1st-line DST

themselves, they are responsible to submit isolates for genotyping.

• MDL will notify your lab when isolates are sent to Michigan.


Contact list

Name Email account Phone/Fax Functions

TB Ref lab [email protected] 510-412-3949 (phone) 510-412-3704 (Fax)

Request for PSQ approval Notification of DST submission General info inquiry

Ed Desmond [email protected]

510-412-3781 Chief Technical info Special requests

Grace Lin [email protected] 510-412-3929 Technical info Special requests

Steven Yu [email protected] 510-412-3949 General info

For primary communication, please email [email protected] or call 510-412-3949.


mailto:[email protected]

Summary TB DST Reference Center

Service Flow Chart



Resources for Enrolled Labs

• Submission and Shipping Instructions • Dedicated Pre-submission Approval Form for

pyrosequencing • Dedicated Requisition Form • Visuals on Submission/Testing Algorithms • Users Guide with details on testing services and

results interpretation • All on dedicated web-page which will be

available by March 1


Questions?

• If you have questions following the call or need the enrollment form contact Kelly Wroblewski <[email protected]>