WHO SRLs and Phenotypic Resistance

Transcription

1 WHO SRLs and Phenotypic Resistance CPTR Rapid DST 2014 Workoshop Daniela M Cirillo, MD, PhD San Raffaele Scientific Institute Milan

2 Outline SRLN EQAs Differences in data sets Delamanid testing: current status and link with SRLs Bedaquiline testing: current status and link with SRLs

3 Evolution of SRLs Network From a consortium of proficient laboratories involved in EQAs for DST GLI subgroup with demanding and ambitious terms of references and eligibility criteria

4 Categories of Laboratories in the SRLN SRLs National centre of Excellence Candidate SRLs

5 SRLs Term of References Be officially recognized by the National Health Authority or MoH in the own Country Have established of show the capacity to establish formal working relationships with NRL in other Countries through formal links including Collaboration Agreements Commit to provide the minimum SRL package including: Formal link with 2 NRLS 3 In Country TA visit in 2 years provide reports to WHO

6 SRLN-Centre of Excellence Recognises well performing labs in large middleincome Countries A designated SRLN-CE has an equivalent status as an SRL with an in-country focus for laboratory strengthening Eligible: Brazil, Russia, China, India South Africa Nominated by NTP and WHO Country Office Need to establish a collaboration agreement with existing SRL Actively implementing QMS Assessed by WHO 6

7 Candidate SRLs Candidate SRLs are National level TB Reference Laboratories which have been identified as well performing laboratories with the potential to be mentored towards being a full member of the SRLN. To be eligible, laboratories need to be nominated by their partner SRL or the WHO country office, undergo a laboratory assessment by WHO, and actively implement a quality management system towards accreditation. The mentorship period 1-3 years to helps these laboratories meet the eligibility and inclusion criteria for the SRLN Currently - Johannesburg, Benin

8 Function of the SRLN The SRLN is a structure which delivers co-ordination, identifies synergies among individual SRLs, and serves as a platform to: Assist National Reference Laboratories (NRLs) and National TB Programmes (NTPs) implement WHO policy guidance on TB diagnostics, diagnostic algorithms, and laboratory norms and standards using GLI-endorsed recording and reporting systems and other laboratory tools; Disseminate WHO guidance on biosafety requirements and quality management systems for national level TB reference laboratories and laboratory networks; Facilitate sharing of standardized technical reports from all technical assistance missions to counties with in-country partners and among the SRLs; Provide standardized quality assessment for microscopy, culture, drug susceptibility testing of M. tuberculosis, and molecular methods as needed; Co-ordinate comparative evaluations of diagnostic tests among individual SRLs and define priorities for evaluation of different tests as needed; Oversee the pathway for the development and implementation of standardized protocols to test susceptibility against new and existing anti-tuberculosis drugs; Advocate with National TB Programmes to help ensure capacities for the diagnosis and treatment of TB and drug resistant TB are aligned.

9 Critical Concentrations revised in

10 Provide standardized quality assessment for microscopy, culture, drug susceptibility testing of M. tuberculosis, and molecular methods as needed Round 20 th : Panel Composition for SRLs: 10TB in duplicate/9tb single/1ntm Major changes: Strepto dropped PZA added Speciation (NTM/TBC) Combi phenotypic genotypic Use of new critical concentrations From A.VD report 2014

11 20th round proficiency test for SRLs: lesson learned NTM correctly ID PZA : MGIT PZA was the best performing method Ethambutol poor overall agreement (for 3 strains no agreement) MGIT related errors: Isoniazid false resistance Ethambutol false susceptibility Specific drugs related errors: Ethambutol Capreomycin (isolated sensitivity with AGs res) Several transcription errors Extremely good performance of genotypic (including LPAsl,)

12 Provide standardized quality assessment for microscopy, culture, drug susceptibility testing of M. tuberculosis, and molecular methods as needed Round 20 th : Panel Composition for NRLs: 9TB in duplicate/1tb single/1ntm PROBLEMS: Custom -clearance Delay in reporting Only half tested PZA 2 nd line less than half Technical PROBLEM: PZA, Ethambutol NTM interpreted as TB (9/26)

13 EQA in 24 Regional labs Fattorini et al ERJ 2012

14 Phenotypic data set: Quality matters! EQA and retesting at SRLs as external controls Concordance NRL/SRL varies between % for R -H Pattern of resistance poorly compatible with the expected DR prevalence based on previous surveys Unusually high monoresistance to specific drugs(z) Phenotype/genotype concordance for canonical mutations rare or unexpected phenotypes

15 Very high confidence genetic markers of RIF-R Mutation n n studies MGIT R LJ R Agar R Failure/relapse Q513K 19 3/5 100,0 100,0 100,0 33,3 Q513P 9 2/5 100,0 91,7 100,0 Q513E 2 1/5 100,0 100,0 D516V 102 3/5 100,0 99,2 100,0 80,0 D516F 23 2/5 100,0 97,5 80,0 S522L 17 3/5 100,0 93,0 100,0 75,0 S522Q 20 2/5 72,7 100,0 H526D 67 3/5 86,4 100,0 100,0 47,1 H526Y 125 3/5 85,7 97,5 100,0 61,3 H526R 19 2/5 100,0 100,0 100,0 85,7 H526G 1 1/5 100,0 S531L 664 4/5 100,0 98,6 100,0 81,8 S531W 29 3/5 100,0 94,9 100,0 83,3 S531Q 5 1/5 100,0 100,0 S531F 1 1/5 100,0 509T + H526L 1 1/5 100,0 0,0 L511P + D516C 1 1/5 100,0 100,0 L511P + 512C 1 1/5 100,0 100,0 L511R + D516G 1 1/5 100,0 Q513E + D516F 2 1/5 100,0 Q513E + D516V 1 1/5 100,0 Q513K + H526D 2 1/5 100,0 M515I + D516Y 1 1/5 100,0 100,0 100,0 100,0 M515I + L533P 1 1/5 100,0 M515T + D516G 1 1/5 100,0 50,0 D516V + F514L 1 1/5 100,0 100,0 D516F + S531L 1 1/5 100,0 D516K + H526N 1 1/5 100,0 D516Y + L533P 1 1/5 100,0 H526N + I572L 1 1/5 100,0 H526R + S531E 1 1/5 100,0 100,0 L511P 41 3/5 0,0 72,9 66,0 56,8 Correlation between MGIT resistance and mutations is high for rpob codon 531 and 526D S531L mutation and specific mutations at codons 513 and 526 are conferring (highlevel) RIF-R They comprise 90% of those found among phenotypically RIF-R isolates Multiple mutations are also conferring RIF-R High association with failure/relapse Nebenzahl-Guimaraes H et al, JAC 2014; 69(2): Van Deun A et al, J Clin Microbiol 2009; 47(11) Yip CW et al, Int J Tuberc Lung Dis 2006; 10: Miotto P CabibbeA et al, ESM 2014

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17 First Evaluation after Implementation of a Quality Control System for the Second Line Drug Susceptibility Testing of Mycobacterium tuberculosis Joint Efforts in Low and High Incidence Countries * Baltic Network TBPANNET SRLs Network *Hilleman et al.plosone 2013

18 Oversee the pathway for the development and implementation of standardized protocols to test susceptibility against new antituberculosis drugs

19 Bedaquiline Sirturo It has received marketing authorization in US, EU, commercially available with prescription restrictions in different Countries 19

20 WHO provisional policy recommendation WHO recommends that bedaquiline may be added to a WHO recommended regimen in adult patients with pulmonary MDR TB when 5 conditions are met: 1. Treatment under closely monitored conditions 2. Proper patient selection 3. Patient informed consent 4. Treatment design based on WHO recommendations (DST): Z + 4 drugs considered effective FQ or SLD resistance AE s, poor tolerance, or contraindication XDR TB (with or instead of Group 5 drugs) 5. Pharmacovigilance 20

21 Janssen s responsibilities relating to bedaquiline DST Establish a DST method based on agar and broth dilution MICs Establish a QC ranges in collaboration with a selected number of laboratories (validation on going to be completed by 4 th quarter 2014) Collaborate with WHO to establish testing at SRLs level 21

22 Validation of DST Methods and QC Ranges Agar and broth dilution MIC methods: Developed using QC strains including CLSI recommended H37Rv ATCC Protocol approved by the FDA in 2013 Tested at different location worldwide including WHO SRLs, US CDC and additional labs to reach a consensus methods Each lab performs 10 replicate on 3 lots of media Establish QC ranges 22

23 Availability of BDQ Diagnostic Tools 2014: If Must Do BDQ DST Contact WHO SRLN 2015 Q1 or Q2: DST MIC Methods (7H11/7H9): EUCAST Website & Published Peer- Reviewed Journal Bedaquiline Powder: Plan To Provide Via NIH Reagents Agents Program Bedaquiline Resistant Mutants: Plan To Provide Via Institute Tropical Medicine ( 23

24 Delamanid (Deltyba) Delamanid (OPC-67683) is a new agent derived from the nitrodihydro-imidazo-oxazole class of compounds and inhibits mycolic acid synthesis. It has demonstrated potent pre-clinical in vitro and in vivo activity against both drug-susceptible and drug-resistant strains of Mycobacterium tuberculosis. It has received marketing authorization in Japan, EU and is commercially available in UK and Germany 24

25 IC and mechanism of action The inhibitory concentrations of delamanid (IC50) for methoxy- and ketomycolic-acid biosynthesis are mcg/ml and mcg/ml, respectively, lower than for isoniazid. Unlike isoniazid, delamanid does not inhibit α-mycolic acid synthesis Delamanid inhibits synthesis of key mycolic acids, specifically keto- and methoxy-mycolic acids., primarily in the MTB complex species. It is inactive against most other bacteria and eukaryotes

26 Establishment of a DST Otsuka has independently established a7h11- based DST method for testing strains This method has been used to assess sensitivity in the sponsored studies (204/208/210/213) A break point has been established based on mic performed on a collection of wt strains and resistant mutant in vitro generated The break point has been discussed with the EUCAST committee

27 Otsuka s responsibilities relating to delamanid DST Working with the following EU reference labs: Emerging Pathogens Unit, TB Supranational Reference laboratory, San Raffaele Scientific Institute, Milano, Italy Supranational Reference Laboratory Munich-Gauting Health Protection Agency National Mycobacterium Reference Laboratory, London, UK Swedish Institute for Communicable Disease Control, Solna, Sweden National Reference Center, Research Center Borstel, Germany

28 Step 1 Collaboration with 4 SRLs 1. Agree and sign MTA (2013) 2. Ship delamanid from Otsuka to the 4 EU labs 3. Consultation of DST procedures by Otsuka to assist with validation 4. Validation step 1: complete the establishment of DST procedures using H37Rv, including the performance of 20 assay runs demonstrating susceptibility to delamanid 5. Ship validation isolates to the 4 EU labs (10 clinical isolates with susceptibility to delamanid blinded) 6. Validation step 2: complete DSTs using the 10 isolates from Otsuka (requires 100% susceptibility agreement: susceptible or resistance)

29 Step 2: development of MGIT based DST in collaboration with SRLs The development of DST methodologies using liquid media Validation of the protocol Integration of delamanid DST into existing European systems for TB drug resistance surveillance

30 Acknowledgements WHO/SRLN ERLN/ ECDC Otsuka Janssen All of you!