Next Wave Molecular Meets Point of Care

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Next WaveMolecular Meets Point of Care

• Business Financial Strategies for Molecular
  Diagnostics
• 2009 Conference

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Molecular POC Defined

• Molecular Point of Care diagnostic testing is
  done outside of the traditional molecular
  laboratory
• Dispersed testing inside a hospital
• Critical care centers
• Physician labs
• Retail service centers
• Home testing
• Retains the sensitivity and precision of
  lab-based Molecular testing and moves it closer
  to the patient and physician
• Testing may include
• Infectious agents
• STDs
• Genetic conditions
• Oncology
• Encompasses sample capture and preparation,
  amplification, and detection steps

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Profile of the Future Molecular POC Solution

• Low cost lt 20 per test
• Small, portable or hand held instrument
• Time to result of lt 30 minutes
• Single use, integrated, disposable test device
• Single test or panels, where they make clinical
  sense
• Routine sample capture
• Invisible methodology i.e. sample in answer
  out
• Automated, or operationally simple handled by
  non-skilled personnel or even patients
• Clear result without need for interpretation
• LIS connectivity
• HIPPA compliant

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Challenges for Molecular Dx in POC setting

• Molecular Dx is still in the early stage of
  market development
• Though molecular methods have been around for
  decades, there are comparatively few FDA cleared
  diagnostic assays
• Limited number of laboratories do Molecular Dx
• Real Time PCR is and will likely remain the
  standard
• This requires the amplification step which is
  time consuming and complex
• Typical amplification times for diagnostic tests
  are 2 hours
• Big challenge to reduce time and complexity of
  PCR
• Molecular methods are highly complex
• Require trained/skilled technicians
• Require precision equipment significant capital
  cost
• Space and cost of operation considerations due to
  multiple steps (extraction, amplification,
  detection)
• Time to answer not rapid
• Products and technology will diverge
• Highly automated lab testing (high volume, cost
  sensitive, not time sensitive) and
• Dispersed/POC testing (lower volume, specific
  clinical action that is time sensitive or where
  convenience is important)

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Drivers of Molecular POC

• Need for high level of accuracy, specificity,
  sensitivity in testing that is provided by
  Molecular testing
• Clinical Value is at the point of testing the
  situation requires rapid analysis

Clinically Actionable Information

• Time critical treatment
• Triage
• Needed to initiate treatment or prescribe
  therapeutic regimen
• Surgical support (oncology)
• Ease of use/practicality/convenience
• Patient setting
• 24/7 availability
• Low cost, easy to use

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Examples of Molecular Diagnostics POC Applications

• Time to result essential to therapeutic approach
• Hospital acquired infections
• Sepsis
• Meningitis
• Operating Room feedback (oncology)
• Convenience
• Drug resistance or adverse drug response testing
  (PGx) ability to provide prescription at time
  of visit
• STDs getting the answer when the patient is
  tested addresses privacy issues and closes the
  loop in a patient population that may be hard to
  reach for follow up
• Examples for single tests
• Enterovirus for meningitis (but a panel may be
  more useful )
• MRSA
• Group B strep
• TB (cost is big consideration but rapid sensitive
  testing could make a difference in treatment)
• Panels make sense when there is limited patient
  sample but multiple data points are needed in
  diagnosis
• Respiratory Panel Influenza  and similar
  viruses
• STD (Chlamydia, Gonorrhea, HPV) increased
  sensitivity over current POC methods
• Sepsis
• HPV panel
• Meningitis quickly identify and differentiate
  viral from bacterial to determine treatment

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Move to Molecular POC

• Laboratory testing
• Molecular lab does sample extraction,
  preparation, RT PCR, detection on thermocycler
• Requires trained, skilled lab personnel,
  equipment, lab space
• Centralized with increasing automation

Enabling Technology
Breakthroughs Required

• Point of Care testing
• Testing done in patient setting using simple
  sample capture
• Sample transferred to POC system, attendant or
  patient runs system
• Answer to physician via LIS or wireless
  connectivity in 30 minutes

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Integration at Low Cost is the Key Technology
Consideration
Sample Acquisition
Extraction and Isolation
Amplification
Detection
Reporting and Interpretation
Simple without critical steps
Integrated and invisible to user

• Sample capture has to be easy and integrated
• Administered by patient or attendant swab,
  finger stick, etc.
• Requires innovative packaging and processing
• Limited amount of DNA in a sample means that
  there needs to be amplification or new direct
  detection technologies
• Most approaches are using some form of rapid PCR
• Some work on direct detection and non-PCR
• Accomplish this at a very low cost with
  processing time of less than 30 minutes.

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Cepheid GeneXpert

• GeneXpert is the first example of an evolutionary
  move toward Molecular POC
• Targeted for medium complexity labs
• Proven in multiple diagnostic settings
• Easier to use and portable
• Technical features
• 1 to 16 site random access instrument
• Integrated sample processing and PCR
  amplification
• Multiplexing
• Emphasis on controls
• Software based result analysis
• Results in 1 to 2.5 hours depending on
  application
• Applications
• Anthrax screening for the USPS
• MRSA
• EV
• GBS
• Drawbacks
• Technical skills still required for sample
  preparation
• High cost per test

Reagent cartridge
Expandable system
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Regulatory and Quality Considerations

• FDA sign off required on all tests
• New, more difficult CLIA waiver guidelines raise
  the hurdle
• PMAs may be required in many cases for infectious
  disease tests drives higher costs
• Clinical validation of approach in the hospital,
  POL or other testing site
• Central lab control will remain important in
  hospital settings
• Qualification of platform and test
• Process control for testing
• Correlation to laboratory testing methods
• Software validation ability to read the answer
  versus interpret the data
• Assay controls are important to make sure the
  tests have been performed properly

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Non-Molecular POC Competition

• Immunoassay POC testing is becoming routine
• Proven, easy to use formats
• Low cost approach
• Volumes drive adoption, cost, usability, etc.
• Immunoassays dont require sample extraction and
  amplification, a significant advantage over
  Molecular tests
• However, lateral flow approaches have lacked
  sensitivity and precision required for many tests
• Technological improvements in lateral flow
  devices may provide a cost effective alternative
  to some MDx POC applications
• New immunoassay technologies will be available to
  provide testing solutions not currently available
  including
• Infectious disease identification
• Influenza subtyping
• TB
• The key for patients and physicians is the
  application and the result, not the technology
• Several companies are working on combined
  MDx/Immunoassay platforms to be used in POC
  applications

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NeXus

• Multi-analyte immunoassay testing system
  utilizing a synthetic binding system
• Immunoassay cost profile
• Quantitative or qualitative answers
• Less than 20 minutes from sample to answer
• Uses a small, inexpensive reader
• Integrated sample and reagent packaging contains
  all the elements of the assay
• Highly sensitive, CVs of 5
• CLIA waiver possible depending on sample
  acquisition method

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Quidel vs. fluID vs. PCRPreclinical lot (Dev lot
4)
Decreasing viral titer
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Development Approaches
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Common Approaches
Integrated Sample Processing
Rapid PCR Amplification using miniaturized
thermocycler approaches
Scalable equipment configurations to fit specific
testing situations
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ST Micro -- In-checkTM platform Main elements
Biological Content From ST partners
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Application The concept of a panelSepsis

• Field
• Hospital
• Emergency Room
• Add Value
• Multiplexing
• Fast responses
• User friendly
• Point of care

Multiple bacteria can be diagnosed per single
test
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Application Flu-chip to prvent panedemic risk

• Field
• Point-of-needs
• Airport
• Immigration centers
• Food industry
• Add Value
• Multiplexing
• Fast responses
• User friendly
• Content
• Influenza A
• Influenza B
• Avian flu

Swab
Lysis
Nucleic Acid Extraction
Reverse Transcription
PCR
Detection of most of influenza A B Virus
Define H1-H16 and N1-N6 genotyping
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Atlas Genetics Ltd

• Novel platform for ultra-rapid Point-Of-Care
  infectious disease tests
• First products for rapidly growing STD market
  (30MM Chlamydia tests in 2007 for USA W Europe)
• Single use, single patient disposable plastic
  card with simple reader instrument
• Molecular (advanced high reimbursement) and
  immunoassay (in development medium
  reimbursement)
• Provides a single test instrument for all
  diagnostics avoids user labs/offices requiring
  multiple instruments
• Multiple tests per card (up to 1 plus controls)
  enhanced value to user
• IP protected core assay chemistry, specific
  tests, and fluidic disposable card
• Key know-how for all high value elements of the
  product
• Assay development
• Assay chemistry
• Reagent formulation and deposition
• Disposable card design

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Card functions
Card assembly
The cartridge is comprised of the following
components hard plastic cover (pneumatic lines),
TPE layer (valves bellows), hard plastic
backbone (fluidic elements), adhesive tape,
blister foil, blister seal, and the electrode on
a polymer foil.  
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Real Time PCR and Immunoassay Diagnostic Products
for the Developing WorldMeaslesMalaria
(Pan)Flaviviruses (Dengue) Rickettsia (spotted
fevers)InfluenzaTyphoid/para-typhoid
feverGoals1) 20 minutes blood to answer2)
Sensitivity similar to instruments in the
developed world
Supported by the Bill and Melinda Gates
Foundation
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PCR Implementation in the DxBox
Move sample through different containers held
at fixed temperatures above ambient for Reverse
Transcriptase PCR cycling Fluorescence
detection (before and after thermal ramp)
Moving small samples uses little power Cooling
the sample, not the instrument or card uses power
efficiently
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Rapid Inductive PCR Amplification

• Using a novel method for heating contact-less
  inductively induced heat transfer in a coil
• Low mass
• Very fast heating rates
• Electronic control with fast switching
• Rapid air cooling
• Easy coupling and insertion of cartridge

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Rapid Inductive PCR
Eddy current depth penetration
PCR Reaction mix (50 mL)
PP sample tube
Coil
AC source ( 40 kHz)
Outer Al tube
Temperature sensor
Cool Air Flow
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Rapid Inductive PCR - RIP

• Short amplification times
• Maximum heating rates (15-20 0C per s)
• 40 PCR cycles lt 10 min
• Modular
• 1 to 5 Units
• Amplification
• Contained in tube
• No loss of Taq activity

Denaturation 95 oC
Extension 72 oC
Annealing 60 oC
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Summary

• Molecular POC testing will fill an important
  healthcare need for rapid, highly sensitive
  testing
• Development will be evolutionary
• Products and technologies will follow current
  Molecular Diagnostics approaches
• Initially the biggest opportunities will be in
  infectious disease testing
• Immunoassay technologies will fill part of the
  market need but will not replace the need for
  Molecular POC testing

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THANK YOU