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The DiagnosTics
The DiagnosTicsinnovaTion
innovaTion MapMap
2010 2010
a young lady waits
to be seen at a clinic
in rural Liberia, West africa
and interpreting models to improve diagnostics in Murray, C. K., R. A. Gasser, Jr., et al. (2008). “Update
The Diagnostics Innovation Map: Medical Diagnostics
developing countries.” Nature 444 Suppl 1: 3-8. on rapid diagnostic testing for malaria.” Clin Microbiol
for the Unmet Needs of the Developing World
Rev 21(1): 97-110.
Han, Z. G., P. J. Brindley, et al. (2009). “Schistosoma
Copyright © 2010 BIO Ventures
genomics: new perspectives on schistosome biology Nicastri, E., N. Bevilacqua, et al. (2009). “Accuracy
for Global Health
and host-parasite interaction.” Annu Rev Genomics of malaria diagnosis by microscopy, rapid diagnostic
Hum Genet 10: 211-240. test, and PCR methods and evidence of antimalarial
All rights reserved
overprescription in non-severe febrile patients in two
Keeler, E., M. D. Perkins, et al. (2006). “Reducing Tanzanian hospitals.” Am J Trop Med Hyg 80(5):
This report was written by Priya Mehta and David
the global burden of tuberculosis: the contribution of 712-717.
Cook, with the support of Health Advances, LLC.
improved diagnostics.” Nature 444 Suppl 1: 49-57.
Rafael, M. E., T. Taylor, et al. (2006). “Reducing the
Authors’ note:
Kyle, J. L. and E. Harris (2008). “Global spread and burden of childhood malaria in Africa: the role of
persistence of dengue.” Annu Rev Microbiol 62: improved.” Nature 444 Suppl 1: 39-48.
We thank the Bill & Melinda Gates Foundation for
71-92.
its financial support. We are grateful to the team at
Rodriguez, B. (2009). H. Advances, Daktari.
Health Advances: Kristin Pothier, Sonia Gupta, Paula
Lim, Y. W., M. Steinhoff, et al. (2006). “Reducing the
Ness Speers, Philina Lee, Kimberly Howland, Mark
global burden of acute lower respiratory infections in Scott, J. A., W. A. Brooks, et al. (2008). “Pneumonia
Speers, and Donna Hochberg for their hard work and
children: the contribution of new diagnostics.” Nature research to reduce childhood mortality in the devel-
significant contributions to this document. We thank
444 Suppl 1: 9-18. oping world.” J Clin Invest 118(4): 1291-1300.
Christopher D. Earl for his continued contributions
and valuable feedback. We also thank our Scientific
Michael J A Reid, N. S. S. (2009). “Approaches to Yager, P., G. J. Domingo, et al. (2008). “Point-of-care
Advisory Board for their feedback and support: N.
tuberculosis screening and diagnosis in people with diagnostics for global health.” Annu Rev Biomed Eng
Leigh Anderson, Deborah Burgess, David Kelso,
HIV in resource-limited settings.” Lancet Infectious 10: 107-144.
Alan Magill, Francis Moussy, Rosanna Peeling, Mark
Diseases 9: 173-184.
Perkins, Mark Reynolds, William Rodriguez, Samuel
Sia, John J. Sninsky, Amy Wong, and Paul Yager. We
Molyneux, D. H. (2009). “Filaria control and elimina-
thank all those interviewed during the course of this
tion: diagnostic, monitoring and surveillance needs.”
project for their time and effort to ensure the accuracy
Trans R Soc Trop Med Hyg 103(4): 338-341.
of the report.
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Biomarker A biological marker of disease. In vitro diagnostics (IVD) Medical device products
including instrument and reagents that utilize a variety
CD4/CD8 Cell surface markers that are used in HIV of methods and formats to perform tests on human
viral load testing. samples in order to assess disease risk, diagnose a
condition, or monitor a patient’s health.
Central laboratory Hospital laboratory staffed by
trained lab technicians performing high volume, Isothermal reaction A chemical reaction going to
moderately complex tests on highly automated instru- completion at one temperature; not needing a change in
ments. temperature to continue reaction to completion.
Deoxyribonucleic acid (DNA) A nucleic acid that Lateral flow test A simple device intended to detect
contains the genetic instructions used in the develop- the presence (or absence) of a target analyte in sample.
ment and functioning of all known living organisms Lateral flow tests are a form of immunoassay in which
and some viruses. DNA consists of two long polymers the test sample flows along a solid substrate via capil-
of simple units called nucleotides, with backbones lary action, and are often produced in a dipstick format.
made of sugars and phosphate groups joined by ester
bonds. These two strands run in opposite directions to Light-emitting diode (LED) A semiconductor light source.
each other.
Lysis The breaking down of a cell, often by viral,
Endonucleases Enzymes that cleave the phosphodi- enzymic, or osmotic mechanisms that compromise its
ester bond within a polynucleotide chain, in contrast integrity. A fluid containing the contents of lysed cells
to exonucleases, enzymes that work by cleaving is called a “lysate.”
nucleotides one at a time from the end of a poly-
nucleotide chain. Microfluidics Deals with the behavior, precise control,
and manipulation of fluids that are geometrically
Enzyme Usually a protein, that catalyzes (i.e., increase constrained to a small, typically sub-millimeter, scale.
the rates of) chemical reactions.
Nucleic acid Macromolecule composed of chains Sample preparation Processes by which a represen-
of monomeric nucleotides. These molecules carry tative piece of material (sample) is extracted from a
genetic information or form structures within cells. larger amount and readied for analysis.
The most common nucleic acids are deoxyribonucleic
acid (DNA) and ribonucleic acid (RNA). Nucleic Sample to result automation/ processing A fully
acids are universal in living things, as they are found automated process which allows the operator to input
in all cells and viruses. a sample and walk away. The instrument returns a
result with no further intervention.
Nucleotide Molecule that, when joined together,
makes up the structural units of RNA and DNA. Thermal cycling A temperature modulation process
developed to improve the performance, strength, and
Oligonucleotide A short nucleic acid polymer, longevity of a variety of materials.
typically with twenty or fewer bases.
Transcription-mediated amplification (TMA) An
Photodetectors Sensors of light or other isothermal nucleic-acid-based method that can amplify
electromagnetic energy. RNA or DNA targets a billion-fold in less than one
hour’s time.
Point of care (POC) Testing performed at the point
of patient care. This includes physician office POC Turnaround time (TAT) The turnaround time of an
testing outside the central laboratory. assay within the context of an instrument or the labo-
ratory procedure beginning with the sample being
loaded onto the instrument and ending with the result
being recorded on the instrument. This can also be
called the time to result.
and simple enough to be used by minimally trained tests in a variety of sample types that previously
health care workers. Only then will the majority of required multiple detection technologies. In
individuals in the developing world have access to addition, many of these detection technologies
needed diagnostic tests. will simplify process steps like sample prepara-
The report aims to provide: Primary research was supported with reviews of rele-
vant clinical, technical, and global health research litera-
• A
n understanding of unmet diagnostic needs for ture as well as information provided on company Web
neglected diseases and the performance require- sites. In conducting this research, we identified similar
ments for diagnostics used in resource-poor settings published work and tried to leverage, rather than dupli-
cate, prior efforts. Our sources are referenced and anno-
• A
n overview of the value that novel diagnostics tated in the bibliography at the end of the document.
can bring to health care in resource-poor settings
To ensure the integrity of our findings, the research
• E
xamples of innovative lab-based and point-of- was periodically reviewed and refined by our Scientific
care (POC) technologies and analysis of how Advisory Board, comprised of thought leaders in diag-
these recent advances could address unmet diag- nostics development and global health. We are grateful
nostic needs in the developing world for the contributions of our advisory group:
• A
resource to aid in forging new partnerships • N
. Leigh Anderson, PhD, Founder and CEO,
to accelerate the development of diagnostics for Plasma Proteome Institute
neglected diseases
• D
eborah Burgess, Senior Program Medical
Officer, Bill & Melinda Gates Foundation
• D
avid Kelso, PhD, Professor of Biomedical
Engineering, Northwestern University
• F
rancis Moussy, PhD, Leader - Accessible
Quality-Assured Diagnostics, Special Programme
for Research and Training in Tropical Diseases
(TDR), World Health Organization
• R
osanna Peeling, PhD, Professor of Diagnostics
Research, London School of Hygiene & Tropical The Scientific Advisory Board has endorsed the objec-
Medicine, University of London tives of this report and provided critical feedback
throughout the process. However, the content of the
• M
ark Perkins, MD, Chief Scientific Officer, report—and any errors—are the responsibility of
Foundation for Innovative New BIO Ventures for Global Health and not the Scientific
Diagnostics (FIND) Advisory Board.
• M
ark Reynolds, PhD, Senior Director This report is intended to build on the existing public
of Research, Gen-Probe knowledge of unmet diagnostic needs of the devel-
oping world (see Appendix II) and to identify exam-
• W
illiam Rodriguez, MD, Co-founder, ples of promising technologies that may be able to
Daktari Diagnostics address those needs. As such, it is not intended to be
an encyclopedic accounting of all diagnostics currently
• S amuel Sia, PhD, Assistant Professor, used in the developing world nor of all novel tech-
Molecular and Microscale Bioengineering, nologies in development that may have applicability to
Columbia University the needs of the developing world. Wherever possible,
we have attempted to build on the previous work
• J ohn J. Sninsky, PhD, Vice President conducted by others in this field.
of Discovery Research, Celera Diagnostics
As a result of this report, we hope that diagnostic
• A
my Wong, PhD, Project Manager, developers will have a better understanding of how
World Health Organization their technologies might be able to apply to neglected
diseases that affect patients in resource-poor settings.
• P
aul Yager, PhD, Professor, Bioengineering, We also hope that public sector organizations looking
University of Washington to collaborate with the private sector in developing
novel diagnostics will have the information necessary
to form such partnerships and advance this cause.
The Value of Novel In Vitro Diagnostics Improved in vitro diagnostic products, coupled
for Neglected Diseases with access to therapies, can save hundreds of thou-
sands of lives per year. For example, determining
Sensitivity/
Infectious Clinical
Specificity/ Sample
Disease Decision Potential Impact
Turn-around Type
Area Point
Time (TAT)
Acute Lower Identification of Saliva
95% sensitivity
Respiratory children aged <5 Urine ≥405K adjusted lives
85% specificity
Infection years with bacte- Dried blood saved per year
<1 hr TAT
(ALRI) rial ALRI spot
Reduce prevalence of
Detection of G.
diarrheal-related stunting
lamblia, C. par- 90% sensitivity Feces
Diarrheal by 12.5%
vum and entero- 90% specificity Vapors
diseases 2.8M DALYs saved per
aggregative E. <1 hr TAT
year if the cost of treat-
coli in children <5
ment is $6
A detailed table identifying disease-specific unmet diagnostic needs is presented in Appendix II.
Yet despite these pressing unmet needs and estimates of lives that could be saved in developing countries with
improved diagnostic tests, the investment in diagnostics designed for the developing world has been meager.
1
L im, Y. W., M. Steinhoff, et al. (2006). “Reducing the global burden of acute lower respiratory infections in children: the contribution of new
diagnostics.” Nature 444 Suppl 1: 9-18.
2
Keeler, E., M. D. Perkins, et al.”Reducing the global burden of tuberculosis: the contribution of improved diagnostics.” 49-57.
3
Aledort, J. E., A. Ronald, et al. “Reducing the burden of HIV/AIDS in infants: the contribution of improved diagnostics.” 19-28.
4
Rafael, M. E., T. Taylor, et al. “Reducing the burden of childhood malaria in Africa: the role of improved.” 39-48.
5
Ricci, Karen A., et al. ”Reducing stunting among children: the potential contribution of diagnostics.” 29-38.
$1,165
$1,200 Vaccines
Drugs
Microbicides
$1,000 Basic Research
Vector Control
Diagnostics
$800
Millions of Dollars
Unspecified
$600 $542
$446
$400
$200
$0
HIV/AIDS MALARIA TB
Disease
6
Moran, M., J. Guzman, et al. (2009). G-Finder 2009. “Neglected disease research & development: new times, new trends” The George Institute for
International Health, 67.
7
Ibid, 52.
8
Ibid, 16-19.
9
(2008). The World Can’t Wait: More Funding Needed for Research on Neglected Infectious Diseases. Global Health Initiative. F. U. Foundation.
Washington, DC, Families USA.
10
Moran, M., J. Guzman, et al. (2009). G-Finder 2009. “Neglected disease research & development: new times, new trends” The George Institute for
International Health, 22.
Diagnostic tools are essential for efficiently and cost-effectively diagnosing illness, selecting appropriate treatment,
monitoring chronic diseases, and tracking the prevalence and impact of disease globally.
Selecting
Early Detection Appropriate
Treatment
Test Purpose
Monitoring
Disease
Treatment
Surveillance
Effectiveness
Detection of disease enables treatment for those in patients co-infected with HIV. TB is the main cause of
need, resulting in lower morbidity and mortality rates. suffering and death in people with HIV/AIDS, because
This can save lives and money by avoiding more costly TB progresses quickly in patients whose immune
care likely to be incurred as untreated patients become system has been destroyed by HIV/AIDS. Earlier and
sicker, as well as avoiding productivity and income more accurate diagnosis of active TB is necessary to
losses due to illness. For example, detection of TB in improve treatment outcomes for individual patients
HIV patients is a particularly pressing need. The most and reduce transmission.11 In addition, early diagnosis
commonly used method for TB detection, sputum has been shown to have benefits in disease prevention
microscopy, identifies fewer than 50% of TB cases in as well as treatment.
Michael J A Reid, N. S. S. (2009). “Approaches to tuberculosis screening and diagnosis in people with HIV in resource-limited settings.” Lancet
11
Monitoring treatment effectiveness for diseases Determining which diseases are present in various geog-
requiring lengthy therapy is an important role for raphies and whether they are increasing or decreasing
diagnostics even after a treatment regimen has been in incidence helps guide the allocation of human, finan-
selected. Monitoring therapy effectiveness in diseases cial, and medical resources. For example, the WHO
such as HIV/AIDS, where treatment is chronic, can Global Influenza Surveillance Network enables the orga-
help identify issues with treatment compliance or nization to recommend content of the influenza vaccine
declining efficacy of the prescribed regimen due to the for the subsequent season by collecting patient samples
emergence of drug resistant viral strains. This allows and submitting viruses to collaborating centers for
caregivers to either re-educate the patient on how and antigenic and genetic analyses. Updating this informa-
why to comply with his or her treatment or to change tion is necessary to select an appropriate strain for the
treatment regimens for a better outcome. following year’s vaccine content and protect individuals
against perpetually evolving viruses.14 This is a critical
Enabling surveillance programs that seek to identify role for diagnostics to play.
and track the incidence and prevalence of diseases in
various geographic areas is a vital public health role
(2009). Global tuberculosis control: a short update to the 2009 report World Health Organization. Geneva. From http://www.who.int/tb/
12
publications/global_report/2009/update/en/index.html
13
“ETEC Vaccines: The Case for Investment; A Report Prepared by BIO Ventures for Global Health, 2009”; BVGH.
(2009). “World Health Organization Global Influenza Surveillance Network.” from http://www.who.int/csr/disease/influenza/surveillance/en/index.html.
14
15
Girosi, F., S. S. Olmsted, et al. (2006). ”Developing and interpreting models to improve diagnostics in developing countries.” Nature 444 Suppl 1: 3-8.
Cohen, B. (2004). “Urban Growth in Developing Countries: A Review of Current Trends and a Caution Regarding Existing Forecasts.” World
16
Moderate/
Minimal
Region No Infrastructure Advanced
Infrastructure
Infrastructure
Africa 25% 47% 28%
Asia 13% 29% 58%
Latin America 5% 5% 90%
Nevertheless, the vast majority of patients in sub- patients living in areas with little or no access to
Saharan Africa are living in minimal or no infrastruc- laboratory equipment, trained health care workers,
ture settings. And in Asia, the 42% of the population and unreliable electricity and clean water. To reach
living in no or minimal infrastructure settings patients living in these settings, diagnostic tests must
corresponds to a staggering population upwards of be inexpensive, easy to use and interpret, robust, and
a billion and a half individuals. There are immense require few external resources.
photo: Gregory Goode
17
Girosi, F., S. S. Olmsted, et al. (2006). “Developing and interpreting models to improve diagnostics in developing countries.” Nature 444 Suppl 1: 3-8.
In the context of these constraints, it is easy to under- format if they were able to achieve the same accuracy
stand the potential value of point-of-care (POC) diag- and low price as the best assays currently run on large,
nostics. POC tests make diagnosis simple and fast by central lab-based platforms. Not surprisingly, however,
enabling accessible samples to be quickly analyzed there are typically trade-offs to make when moving
outside a laboratory. In fact, in an ideal world, one from lab-based tests and equipment to POC tests.
could imagine that all tests might benefit from a POC
Urdea, Mickey, et al. (2006) “Requirements for high impact diagnostics in the developing world.” Nature 444 Suppl 1: 73-79.
18
Pros Cons
• Increases access to diagnostics by reaching
patients who don’t have lab access
• Reduces patient loss to follow-up by enabling • Lower sensitivity/specificity than lab-based
POC test and treat in same encounter tests
Tests • Enhances clinically-based diagnosis in • Higher cost per test, on average
regions without lab access, thereby reducing • More waste from packaging and disposables
inappropriate use of antibiotics and
antimalarials
Given the diversity of settings in the developing such as malaria or TB, where a delay between diag-
world—from densely populated cities to remote rural nosis and treatment can be life threatening, coupling
villages, there is no single answer to whether POC or of POC diagnostics with delivery of therapy is critical.
lab-based tests are superior. In remote rural settings, Conversely, in situations where patient loss to follow-
POC diagnostics that can be readily administered up is not a critical concern because the result is not
by a minimally-trained healthcare worker, or even immediately actionable, or in situations where the
self-administered, are the required solution. This is patient is located near the laboratory, then a central
because point of care theoretically affords the ultimate laboratory test may be preferable, given the advantages
“test and treat” care model, reducing the likelihood of in specificity, sensitivity, and costs.
losing a patient to follow up. For clinical indications
A rapid test performed at the point of care, even if less sensitive than a lab-based
molecular test, can result in accurate diagnosis and treatment of more patients overall.
19
ift, T. L., M. S. Pate, et al. (1999). “The rapid test paradox: when fewer cases detected lead to more cases treated: a decision analysis of tests for
G
Chlamydia trachomatis.” Sex Transm Dis 26(4): 232-240.
D
20
iagnostics for the Real World (2006) presentation. Modified from: Gift, T. L., M. S. Pate, et al. (1999). “The rapid test paradox: when fewer cases
detected lead to more cases treated: a decision analysis of tests for Chlamydia trachomatis.” Sex Transm Dis 26(4): 232-240.
• M
oderate/Advanced Infrastructure
Settings: Equipment used in labs with moderate
to advanced infrastructure in the developing world
needs to be cost-effective and relatively easy to use,
as constraints on budgets and availability of trained
technicians continue to confront the urban centers.
Fortunately, companies in the developed world
are pursuing simplified diagnostic equipment for
lab-based settings in the United States to deal with
constraints on the supply of trained lab technicians.
However, these products remain unaffordable for
most of the developing world. Improving the afford-
ability of these instruments to enable their introduc-
tion into the developing world is critical to meeting
the needs of the health care systems. Reducing the
cost of service and maintenance and the costs of • N
o Infrastructure Settings: Finally, in the
training will also be critical to enabling the overall most rural and remote settings, the need for cheap,
affordability of introducing these diagnostic tests. rapid POC diagnostic tests that are easy to interpret
and require no instrumentation is critical.
• M
inimal Infrastructure Settings: In settings
where there is only minimal infrastructure avail- The understanding of the broad requirements for
able—such as village or town health clinics—the diagnostics in the developing world and how they
imperative is for a small number of affordable vary by test setting leads to the conclusion that devel-
benchtop instruments that are easy-to-use, robust, oping world markets have inherent limitations to the
and require minimal water and energy. In these number of different diagnostic instruments that can
settings, limitations on the availability of trained be adopted. Scarce funding, the lack of trained techni-
technicians, resources and budgets require creative cians, and distribution challenges limit the number of
and efficient solutions to the diagnostic unmet needs. diagnostic instruments that can be effectively intro-
duced into these markets. To increase access to diag-
nostic tools and optimize health outcomes, industry
and the global health community must work towards
developing a small number of instruments based on
photo: Gregory Goode
• Discovery of novel biomarkers: The discovery Note: A summary of these technologies and a summary
of new biomarkers—molecules that are indicative of how they rate on various key requirements of diagnos-
of disease—will have the least predictable time- tics for resource-poor settings can be found in Figure 20
frame. In the developing world, the need for new at the end of this chapter.
biomarkers falls into several classes. First are those
diseases for which a relevant biomarker has not yet Adapting Existing
been identified. For example, there is no defini- Detection Platforms
tive biomarker for demonstrating cure of Chagas
disease after therapy. Second are the diseases for Nucleic Acid Detection Technologies
which known biomarkers require difficult-to-obtain
samples. For instance, diagnosing stage II human The evolution of in vitro diagnostics based on amplifi-
African trypanosomiasis (HAT) requires spinal cation and detection of nucleic acids over the past two
fluid. Third are the biomarkers that represent only decades has changed the way many diseases, in partic-
a subset of infectious organisms responsible for ular infectious diseases, are diagnosed in the developed
disease. Finally, there are biomarkers that depend world. When a pathogen is present in a test sample,
on a host response, which can be variable and nucleic-acid based tests can offer superior sensitivity
therefore lack sensitivity. Certain TB diagnostics, and specificity over immunological methods due to
for example, measure the human T cell response their ability to detect a few target molecules. As a result,
to the pathogen which can vary depending on the one benefit of this type of test is the early detection of
genetic make-up of the patient. Further hindering disease. Depending on the method used, nucleic acid
biomarker research is the lack of specimen banks amplification can also offer the advantage of quantitative
that enable access to patient samples. With information on the amount of the pathogen present.
adequate investment to resolve these various issues, This is important, for instance, in monitoring patients
biomarker discoveries will support the development with HIV during therapy. Despite these benefits, nucleic
of assays that can be run on an increasingly capable acid-based tests have traditionally been limited by long
armamentarium of instruments. turnaround time, requirements for complex and expen-
sive central lab equipment, multi-step sample prepara-
The remainder of this chapter highlights and character- tion, costly reagents, and the need for a skilled operator.
izes a sampling of emerging diagnostic technologies. Several new nucleic acid detection platforms currently
These technologies are grouped into the four categories in development are automating sample preparation and
described above – those that represent the adaptation amplification procedures and performing tests in a self-
of existing detection platforms, those that represent contained, single-use cartridge. By reducing the number
advances in sample preservation and management, those of steps and the potential for contamination, POC
that rely on entirely new detection technologies, and nucleic acid-based tests are becoming plausible. Ideally
established a non-profit arm of the company for such novel technologies to advance the detection of
distributing products to the developing world. It major developing-world pathogens, but the broad
has a sputum-based TB test (GeneXpert MTB/Rif), adoption of these tests will depend on breakthroughs
developed in collaboration with the Foundation in reducing cost.
cost-effective approaches to molecular diagnostics for When sufficient biomarker is bound, a line material-
the developing world. izes on the membrane, indicating a positive test.21 A
common example of the lateral flow test is the home
pregnancy test sold as an over-the-counter diagnostic
in the developed world. These simple and relatively
robust devices have been adapted to several devel-
oping world indications, including malaria and HIV.
Further details on the lateral flow immunoassay format can be found at: http://www.rapid-diagnostics.org/tech-lateral.htm
21
Improving Sample
Preservation and Management tioning. Because the chemistries
stabilize cells and inhibit nucleic
While point-of-care testing will be attractive when it acid degradation in sample
is available, a significant amount of current funding is matrices rather than relying on
being mobilized to enhance the capabilities of central lysis and precipitation, one blood sample can be
labs with current technology, with the goal of providing used for multiple tests (e.g. molecular testing, flow
testing services to outlying areas. In many cases, this cytometry, and even culture). The chemistries stabilize
strategy is adequate because test results are not required bacterial and viral targets, as well as intracellular RNA.
to make immediate clinical decisions for individual In the HIV context, this means that a single blood
patients. Monitoring patient response to HIV therapy sample can yield HIV primary diagnosis, CD4 counts,
or determining whether a patient with active TB has a viral load measurement, and viral genotyping.
drug-resistant infection, for example, are situations where
immediate results are not required. In the near-term, an • Q
iagen, Life Technologies, and Thermo Fisher
interesting strategy is to send samples collected in the Scientific also offer sample preservation chemistries
field for testing to a centralized laboratory. Under this typically geared towards developed world lab use,
model, the sample may not be tested for hours or even but which can be used in developing world settings
days while it is being transported. Sample preservation as well. For example, Qiagen’s PAXgen offers RNA
– typically requiring refrigeration – would be needed stability in blood samples at room temperature for
to ensure the integrity of the measured analytes, which several days and is commercially available today.
would otherwise degrade over time. Eliminating the need
for refrigeration would broaden access to diagnostics that • F
inally, a relatively simple approach to sample pres-
currently require sample transportation to labs. ervation has been to dry samples onto filter paper.
This method has been employed throughout the
New chemistries have emerged that can enable developing world to increase patient access to HIV
samples to be preserved without refrigeration for viral load testing. Whatman makes customized
several days and even withstand the high ambient collection devices to facilitate sampling and allow
temperatures common in the developing world. One customization, depending on the analyte to be
of the major benefits of this approach is that it permits detected from the sample.
testing using laboratory instrumentation that is avail-
able today without requiring new product R&D. Sample preservation may not be an option for all
sample types or clinical settings, particularly when
Reprinted with permission from Sierra Molecular Corporation, 2010.
• S
ierra Molecular Corporation has developed the immediate feedback to patient or caregiver is required.
AssayAssure® family of sample stabilization chemis- Even for those indications where sample preservation
tries for whole blood, genital tract swabs, and urine. is feasible, one stumbling block has been the sheer
The United States’ Centers for Disease Control & lack of method validation. Performing studies to vali-
Prevention has used the AssayAssure® Molecular date sample preservation and expediting regulatory
Swab Kit for epidemiology studies in both Asia and approvals for these technologies could significantly
Africa, doing primary detection and taking viral load enhance patient access to diagnostic testing by making
measurements from samples self-collected by female available central laboratory testing possible for patients
patients. For whole blood, the chemistries preserve in remote areas. For patients in areas with minimal
lymphocyte cells, cell surface markers, intracellular or no infrastructure, the path to improve access to
proteins, and nucleic acids in a single tube for up to diagnostics in the near-term may be through improve-
seven days without refrigeration or the need for frac- ments in sample preservation and transportation.
11
0.75
0.75
No pattern
0.5
0.5
0.25
0.25
0
0
0 2 4 6 8 10 12 14
-0.25 0 2 4 6 8 10 12 14
-0.25
-0.5
-0.5
-0.75
-0.75
-1
-1 no shift=no diffraction
No shift=No diffraction
1 1 Capture molecule
0.75
0.75
0.50.5
0.25
0.25
0
0
0 2 4 6 8 10 12 14
-0.25
0 2 4 6 8 10 12 14
-0.25
-0.5
-0.5
-0.75
-0.75 -1
-1
slight shift=some energy to diffraction
Slight shift=Some energy to diffraction
0.5 0.5
0.25 0.25
0
0
0 2 4 6 8 10 12 14
0-0.25 2 4 6 8 10 12 14
-0.25
-0.5
-0.5
-0.75
-0.75 -1
-1 increased shift= more energy to diffraction
Increased shift=More energy to diffraction
Axela’s dotLab technology uses light, but instead of from whole blood prior to analysis. Internal controls
measuring emission or absorption of a sample, it relies allow a real-time assessment of diffraction due to
on a physical property, diffraction, to allow quantita- the sample itself, enhancing the ability to distin-
tive measurements of an analyte. Diffraction does not guish signal from noise. Axela’s technology reaches
depend on the bulk properties of the sample, and a picomolar limit of detection while allowing for
is thus much less sensitive to interference from the at least 8-plex multiplexing. The system employs a
biological matrix. dotLab’s relative simplicity paired benchtop reader, so its use is currently restricted to
with high sensitivity make it a promising technology a traditional lab setting. Turnaround time, from 10
for future use in the developing world. minutes to 2 hours, depends on both the concentra-
tion of the analyte and the volume of the sample.
The technology functions based on disposable This timing is compatible with same-visit results in
Reprinted with permission from Axela, Inc., 2010.
diffraction gratings containing regular arrays of most areas of the developing world. Applications
immobilized antibodies or other ligands specific to in development currently include Influenza (rapid
the target(s) of interest. The test sample flows over multiplex strain detection), Bovine Respiratory
the diffraction array and the analyte binds to the Disease (BRD) including Pl3, BRSV, BVD, IBR, food
regular array causing a change in the diffraction of borne zoonosis including campylobacter, escheria
incident light. The geometry of the system is such coli, salmonella, and shigella species, and strongy-
that light impinges the bottom of the sample, and lodies, leishmaniasis and cyctercersosis. The open
the refracted light is not absorbed by the bulk solu- platform allows anyone to develop assays using this
tion. Thus, an analyte does not need to be purified detection technology.
nity health workers. An area of high medical need is results from stored blood is problematic. The need
diagnostics for monitoring patients on anti-retroviral is for an inexpensive, portable, and robust solution to
therapy for HIV. Therapeutic monitoring can take two CD4 counting so that HIV therapy can be extended to
forms: 1) CD4 counts; or 2) viral load measurements. patients in the rural areas of the developing world.
Top: Reprinted with permission from Diagnostics for All, 2010. Photo: Andres Martinez. Bottom: Reprinted with permission from Diagnostics for All, 2010. Photo: Felice Frankel, Harvard University
of dust and temperature, and adequate ventilation are
often driven by concerns regarding instrumentation,
not the underlying assay. Innovations allowing assays
to be simplified to the point where they do not require
equipment can, in many cases, address these other
needs as well. Conventional lateral flow tests are an
example of assays that have been simplified to allow
sophisticated performance without laboratory equip-
ment. The ability to quantify and to multiplex assays
on a single disposable will be the next advancement in
lateral flow.
The technologies featured in this chapter are arrayed on the following chart with their potential attributes
highlighted. The chart vividly demonstrates that while meaningful pieces of the diagnostics puzzle are being
tackled, the ultimate solution will require a portfolio of products and intense collaborations.
Claros Diagnostics
Inverness Medical
Gen-Probe
Cepheid
Biohelix
Abaxis
Alverix
DxBox
Ionian
Axela
Small Sample
Volume
No/Auto Sample
Preparation
*
Non-Optical
Detection
High Sensitivity
Capability Goals
Rapid Result
Simple to Use ? ? ? ?
Low Cost ? ? ? ? ?
Minimal Power
Required
No Running
Water Required
Reagents Stable
at Room Temp
Seventh Sense
T2 Biosystems
Draper Labs
Quanterix
Bioscale
Zyomyx
Vivacta
Daktari
Ionian
Axela
N/A
? ? ? ? ? ?
? ? ? ? ? ?
Note: Ionian Technologies device does not require sample preparation for most sample types,
with the exception of whole blood, for which preparation is required
Historically, the diagnostics industry has migrated The technologies outlined in this chapter represent
technologies from the laboratory-sized instruments some of the most recent innovations in diagnos-
on the left to the smaller formats on the right and tics that could be applied to the developing world.
combined detection technologies within common By repurposing current detection technologies in a
instruments as part of this general trend. The sample platform more appropriate for developing world,
preservation technologies are critical during the next improving sample preservation technologies, inno-
five years while the developing world must continue vating entirely new detection platforms with the
to rely on large laboratory instruments and samples ability to address specific developing world challenges,
must be transported from the field to the laboratory. or working on biomarker discovery and discovery
As new detection technologies and new biomarkers methods for neglected diseases, these technologies —
emerge, they will enable more rapid solutions for POC and the institutions that are developing them — will
and portable benchtop needs. help revolutionize patient diagnosis and treatment
paradigms in the developing world.
Developed world markets are driving many of these There is a growing trend for the developing world to
improvements, as the need for lower costs as well play a lead role in the adoption of new diagnostics
as ease of use, simpler procedures, and more robust technologies. For instance, South Africa has taken the
instruments benefit developed as well as devel- lead internationally in blood screening by adopting
oping world applications. The developing world also the most sensitive approach available for HIV detec-
represents a potentially large market for diagnostics. tion: single donor nucleic acid testing (NAT). South
Non-governmental organizations and government Africa wants to provide the highest assurance of safety
bodies are increasingly aware of the need for and value for its blood supply in response to the high prevalence
of diagnostic products. Funding to purchase existing of the virus among its population. Similarly, in the
diagnostics and improve training and laboratory facili- field of viral load testing in HIV patients, South Africa
ties has increased dramatically through programs such and Brazil are the second and third largest markets in
as the Clinton Global Initiative, PEPFAR, and the the world behind the United States. This trend will
Fondation Mérieux. Yet the funding to support needed become increasingly apparent as the governments of
innovation for ensuring broader access throughout the India, China, South Africa, and Brazil strive to extend
developing world has not received comparable backing. health care coverage to their burgeoning populations.
“Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report: September, 2009”. World Health
22
Organization, 2009.
• Abaxis
• Alverix, Inc.
• McLaughlin-Rotman Centre for Global Health
• Axela, Inc.
• MicroPhage, Inc.
• Beckman Coulter, Inc.
• Microsens Biotechnologies
• Becton, Dickinson and Company
• Mindray Medical International Ltd.
• BD Medical Center
• Nanosphere, Inc.
• Bill & Melinda Gates Foundation
• Novartis Vaccines and Diagnostics, Inc.
• BioHelix Corporation
• Omega Diagnostics Group PLC
• BioScale, Inc.
• OraSure Technologies, Inc.
• Caprion Proteomics, Inc.
• Ortho Clinical Diagnostics, Inc., Johnson &
• Cellabs Pty Ltd.
Johnson
• Cepheid
• Oxford Immunotec Ltd.
• Claros Diagnostics, Inc.
• Peregrine Pharmaceuticals, Inc.
• Cleveland Clinic
• Phthisis Diagnostics, LLC
• Dako North America
• Quanterix Corporation
• Daktari Diagnostics, Inc.
• Quidel Corporation
• Diagnostics for All
• Scott Development Group, Inc.
• Duke University Medical Center
• Sequella Inc.
• Foundation for Innovative New Diagnostics (FIND)
• Seventh Sense Biosystems, Inc.
• Gen-Probe, Inc.
• Siemens Healthcare Diagnostics, Inc.
• Genzyme Corporation
• Sierra Molecular Corporation
• Genzyme Diagnostics
• SomaLogic, Inc.
• Global Health Initiative, Kellogg School of
• T2 Biosystems, Inc.
Management, Northwestern University
• Tamil Nadu R. M.G.R. Medical University
• Global Scientific Solutions for Health, Inc.
• Tethys Bioscience, Inc.
• Handylab, Inc.
• The Charles Stark Draper Laboratory, Inc.
• Harvard Vanguard Medical Associates
• Thermo Fisher Scientific, Inc.
• Idaho Technology, Inc.
• Trinity Biotech
• InBios International, Inc.
• University of Victoria
• Inverness Medical Innovations, Inc.
• University of Massachusetts Medical School
• Ionian Technologies Inc.
• University of Washington
• IQuum, Inc.
• William J. Clinton Foundation Health Access
• Iris Diagnostics, division of IRIS International, Inc.
Initiative
• J. Craig Venter Institute
• Vivacta Ltd.
• Laboratory Corporation of America (LabCorp)
• Zyomyx, Inc.
• Life Technologies Corporation
• Luminex Corporation
• Marafiki Foundation, Inc.
Global Burden of
Disease 2008 Global
Infectious Agent and Route of Transmission
R&D
DALYs At Risk
Acute Lower • Pathogen focus: Streptococcus pneumoniae and Haemophilus
Respiratory Tract 94.5MM Global $91MM influenzae type b
Infections • Transmission: aerosol
Since the primary focus of this study is to identify diagnostic technologies. The examples will hope-
novel diagnostic technologies that could address a fully prove useful as broader indicators of the types
range of unmet needs in the developing world, the of unmet needs that exist in other neglected diseases
unmet needs identified for each of these diseases are and the range of issues to consider in designing novel
not meant to be comprehensive, but rather to serve diagnostic tests to address them.
as examples to aid in the broader identification of
M
26
oran, M., J. Guzman, et al. (2009). G-Finder 2009. ”Neglected disease research & development: new times, new trends?” The George Institute for
International Health; “The Global Burden of Disease: 2004 Update,” World Health Organization, 2008; Health Advances interviews
Globally, ALRI is a major source of disease burden test to diagnose bacterial ALRI, but not discern the
in the developing world; pneumonia is ranked as specific pathogen type, with 85% sensitivity and 70%
the number one cause of morbidity and mortality specificity, could potentially save >117,000 children
of any neglected disease. Diagnostics fulfilling the per year in Africa alone. A test with 95% sensitivity
unmet needs listed below will have a major impact and 85% specificity could save up to 152,000 chil-
on the global burden of ALRI.27 A study published in dren per year, even if only 33% of children with
Nature, in 2006, considered two different diagnostic ALRI symptoms in the three continents modeled
testing options for ALRI and the expected health sought care. It also estimated that an additional
benefits in children under five years of age in Africa, 253,000 lives could be saved indirectly by reducing
Asia, and Latin America. The study predicted that a over-treatment with antibiotics.28
Figure C: Key Diagnostic Unmet Needs for Acute Lower Respiratory Infections (ALRI)29
• Clinical diagnosis • Clinical case management • Low specificity and inability to • Rapid, accurate, affordable,
protocols developed by the quickly and accurately point of care pneumonia
World Health Organization differentiate cause of fever diagnostic to discern bacterial
(pneumonia vs. malaria vs. versus viral pneumoniae
• Health care workers note dengue, etc.)
elevated respiratory rate and • Pathogen typing test to discern
inward movement of the lower • Inability to differentiate viral vs. infectious agent by species or
chest wall on breathing (90% bacterial cause of pneumonia virus type
sensitivity when performed by
experts, 70% specificity) • Indiscriminant use of antibiotics • Fever panel to differentiate
due to low specificity of clinical cause of fever including
diagnosis contributes to regionally co-occurring agents
increase of antibiotic resistance
• Simpler methods to obtain and
process sputum samples
27
Scott, J. A., W. A. Brooks, et al. (2008). “Pneumonia research to reduce childhood mortality in the developing world.” J Clin Invest 118(4): 1291-1300.
28
L im, Y. W., M. Steinhoff, et al. (2006). ”Reducing the global burden of acute lower respiratory infections in children: the contribution of new
diagnostics.” Nature 444 Suppl 1: 9-18.
29
UpToDate (2009).
While adult diagnostic screening technologies for HIV 570,000 AIDS-related deaths occurred in children
are improving in developing world settings, there are under 15 years of age; an improved diagnostic would
major unmet needs in low-infrastructure monitoring have a major impact on this subset of the population.30
technologies as well as infant diagnosis. In 2005,
• Routine testing
Rapid diagnostic • Antenatal screening as a part of prevention of mother-to-
tests (lateral flow) child transmission
• Whole blood, serum, or plasma • Lack of rapid, low-complexity diagnostics in infant
screening and monitoring that avoids interference by
• High-throughput screening of HIV Ab or HIV Ab/p24 maternal antibodies
using whole blood, serum, or plasma
ELISA • Few unmet needs and limitations for testing adult
• p24 Antigen detection for infant diagnosis, early acute population
phase HIV diagnosis, with plasma or dry plasma spots
IFA, LIA,
• Confirmatory tests using whole blood, sera, or plasma
Western blots
• Molecular tests with
• HIV RNA or DNA measured to diagnose infant HIV, • Molecular tests require
lower training and
identify acute infection (pre-seroconversion), monitor extensive training
intuitive read-outs
response to therapy • Tests are expensive
• Lower cost/test
• HIV gene sequence used to identify drug resistance • Reagents have limited
Molecular tests • Reagents stable in
• Molecular NAAT HIV tests shelf-life at ambient
higher temp and
• Isothermal amplification, PCR, RT PCR or branched temperature
humidity
DNA for viral load testing in conjunction with HIV therapy • Expensive instrumentation,
• Simple instrumentation
using plasma or dry plasma spot dedicated facilities
or no device required
Flow cytometry or • Tests with less
dedicated cell instrumentation that
• Cost of flow cytometry
counter • CD4 cell counting used to stage patients for antiretroviral can be done in the field
equipment
therapy and to monitor response to therapy
Light microscopy • Extensive training and QC • Lower cost/test
(uncommon) • Fresh or stabilized whole blood sample
required • Tests that don’t require
extensive training
30 Aledort, J. E., A. Ronald, et al. Ibid.”Reducing the burden of HIV/AIDS in infants: the contribution of improved diagnostics.” 19-28.
31 Health Advances interviews and analysis.
31 UpToDate (2009).
33 Aledort, J. E., A. Ronald, et al. (2006). ”Reducing the burden of HIV/AIDS in infants: the contribution of improved diagnostics.” Nature 444 Suppl 1: 19-28.
34 Yager, P., G. J. Domingo, et al. (2008). “Point-of-care diagnostics for global health.” Annu Rev Biomed Eng 10: 107-144.
As the fourth highest cause of global morbidity and TB, including: cytokines expression as biomarkers
mortality from neglected diseases in 2004,35 the impor- of immune status, immune cell surface molecules as
tance of finding improved diagnostic and therapeutic biomarkers for inflammation, cell surface receptors
solutions for TB is critical. Continued research to find and their shedding, genomic and proteomics-based
additional biomarkers for latent and active TB, and biomarker discovery, and even TB serodiagnostics,
detection methods beyond sputum smear microscopy which have been largely unsuccessful to date.36 A
(SSM) will be valuable in alleviating TB’s global disease Nature study published in 2006 found that a rapidly
burden. The World Health Organization (WHO) and widely available diagnostic for TB with 85%
TDR/European Commission joint expert consulta- sensitivity for sputum smear positive and sputum
tion group recently outlined a number of potentially smear negative cases, and 97% specificity could save
promising biomarkers for different disease stages of ~400,000 lives annually.37
Available Diagnostic
Diagnostic Overview Current Diagnostic Limitations
Diagnostics Unmet Needs
35 Moran, M., J. Guzman, et al. (2009). ”Neglected disease research and development: how much are we really spending?” PLoS Med 6(2): e30.
36 Doherty, M., R. S. Wallis, et al. (2009). “Biomarkers for tuberculosis disease status and diagnosis.” Curr Opin Pulm Med 15(3): 181-187.
37 Keeler, E., M. D. Perkins, et al. (2006). ”Reducing the global burden of tuberculosis: the contribution of improved diagnostics.” Nature 444 Suppl 1: 49-57.
38 M
ichael J A Reid, N. S. S. (2009). “Approaches to tuberculosis screening and diagnosis in people with HIV in resource-limited settings.” Lancet Infectious
Diseases 9: 173-184
39 UpToDate (2009).
40 Doherty, M., R. S. Wallis, et al. (2009). “Biomarkers for tuberculosis disease status and diagnosis.” Curr Opin Pulm Med 15(3): 181-187.
41 Keeler, E., M. D. Perkins, et al. (2006). ”Reducing the global burden of tuberculosis: the contribution of improved diagnostics.” Nature 444 Suppl 1: 49-57.
Malaria is a major cause of morbidity and mortality sary treatments. A 90% sensitive and 90% specific
in the developing world. When left untreated, diagnostic requiring no infrastructure would avert
P.falciparum is often fatal in children under five years >300,000 malaria-related deaths and around 450
of age and pregnant women. The less fatal P.vivax million unnecessary treatments, assuming adherence
is estimated to account for 25-40% of the global to test results and prompt and effective treatment
burden. A 2006 study published in Nature found that following diagnosis. In addition, the ability to detect
a 95% sensitive and 95% specific diagnostic requiring placental infection by antigen detection could have a
minimal infrastructure would avert >100,000 malaria- significant impact on maternal/fetal medicine.42
related deaths and around 400 million unneces-
Available Diagnostic
Diagnostic Overview Current Diagnostic Limitations
Diagnostics Unmet Needs
42 Murray, C. K., R. A. Gasser, Jr., et al. (2008). ”Update on rapid diagnostic testing for malaria.” Clin Microbiol Rev 21(1): 97-110.
43 UpToDate (2009).
44 Malaria RDT Product Testing (WHO, FIND, TDR, CDC – 2008).
45 Rafael, M. E., T. Taylor, et al. (2006). ”Reducing the burden of childhood malaria in Africa: the role of improved diagnostics.” Nature 444 Suppl 1: 39-48.
46 Murray, C. K., R. A. Gasser, Jr., et al. (2008). ”Update on rapid diagnostic testing for malaria.” Clin Microbiol Rev 21(1): 97-110.
47 N
icastri, E., N. Bevilacqua, et al. (2009). ”Accuracy of malaria diagnosis by microscopy, rapid diagnostic test, and PCR methods and evidence of
antimalarial overprescription in non-severe febrile patients in two Tanzanian hospitals.” Am J Trop Med Hyg 80(5): 712-717.
Helminth infections, including lymphatic filariasis and of these diseases will lead to direct improvements in
schistosomiasis, carry a major global disease burden individual health, in addition to improved surveillance
with high estimates of morbidity and mortality rates. and epidemiology data that is currently lacking.
Improved technologies to address the unmet needs
UpToDate (2009).
48
Bockarie, M. J. and D. H. Molyneux (2009). “The end of lymphatic filariasis?” BMJ 338: b1686.
49
Molyneux, D. H. (2009). “Filaria control and elimination: diagnostic, monitoring and surveillance needs.” Trans R Soc Trop Med Hyg 103(4): 338-341.
50
Available Diagnostic
Diagnostic Overview Current Diagnostic Limitations
Diagnostics Unmet Needs
Dengue fever shares many of the unmet needs with Asia.54 Echoing the unmet needs in malaria, a multi-
neglected diseases presenting febrile symptoms, but has plexable diagnostic platform that could address several
a unique commercial market due to travelers, military, fevers would be a valuable diagnostic contribution.
and prevalence in emerging markets such as Southeast
Available Diagnostic
Diagnostic Overview Current Diagnostic Limitations
Diagnostics Unmet Needs
54 Moran, M., J. Guzman, et al. (2009). ”Neglected disease research and development: how much are we really spending?” PLoS Med 6(2): e30.
55 UpToDate (2009).
56 World Health Organization
57 Kyle, J. L. and E. Harris (2008). “Global spread and persistence of dengue.” Annu Rev Microbiol 62: 71-92.
11
0.75
0.75
No pattern
0.5
0.5
0.25
0.25
0
0
0 2 4 6 8 10 12 14
-0.25 0 2 4 6 8 10 12 14
-0.25
-0.5
-0.5
-0.75
-0.75
-1
-1 no shift=no diffraction
No shift=No diffraction
1 1 Capture molecule
0.75
0.75
0.50.5
0.25
0.25
0
0
0 2 4 6 8 10 12 14
-0.25
0 2 4 6 8 10 12 14
Reprinted with permission from Axela, Inc., 2010.
-0.25
-0.5
-0.5
-0.75
-0.75 -1
-1
slight shift=some energy to diffraction
Slight shift=Some energy to diffraction
0.5 0.5
0.25 0.25
0
0
0 2 4 6 8 10 12 14
0-0.25 2 4 6 8 10 12 14
-0.25
-0.5
-0.5
-0.75
-0.75 -1
-1 increased shift= more energy to diffraction
Increased shift=More energy to diffraction
Diagnostic Type:
Platform:
• Immunoassay
• Lateral flow on paper-based microfluidic chip
Purpose:
Description:
• Inexpensive, equipment-free diagnostics
• Fingernail-sized paper chip, which is pretreated
with dried reagents that change color when
exposed to bodily fluids (single drop of blood,
urine, sweat)
• Paper is patterned with hydrophobic polymers
forming a series of channels that guide sample
throughout chip
• Sample binding resulting in a color change that
can then be visually read and translated into a
diagnosis
• Proof of concept completed with glucose (mM
concentration, 2.5-50mM clinical range) and
protein (BSA, µM concentration .38-7.5 µM clin-
ical range)
• First application will be for liver function tests
samples
• No pumps or power sources are required
• Tested with dirt, pollen, and graphite with robust
results
• Multiple tests can be performed on one chip
• TAT is within minutes
• Cost target is currently less than $1
Innovation:
• Extremely low-cost paper-based lateral flow
Diagnostic Type:
• Immunoassay
Purpose:
• Robust, rapid point-of-care (POC) detection of
infectious diseases Iris: NADIA
Description: Purpose:
• Currently available are lateral flow, rapid diagnostic • Ultra-sensitive immunoassay
tests (RDTs) for Chagas (research and ex-US only)
and Visceral Leishmaniasis (FDA cleared) Platform:
• Lateral flow test using standard antibodies and • Immuno-PCR
proprietary antigens
• Described as a RDT with a “different twist;” tech- Description:
nology specifics undisclosed • Nucleic Acid Detection Immunoassay
• Currently cleared tests require 20ul sample of (NADIA)
serum and 3 drops of buffer • Reagents consist of antibody pairs attached
• Results are readable in 10 minutes to nucleic acid linkers
• Sensitivity is advertised as greater than 95% • Binding of an antibody pair in close prox-
imity enables hybridization and priming for
Key Differentiating Features: PCR reaction
• 10-15 minute TAT • Requires a traditional PCR platform
• PSA in serum for recurrence monitoring is
Potential Developing World Application: the first assay under development
• Point of care • Proof of concept demonstrated for direct
• Note: Serum is required for some assays. For detection of E. coli
these assays, centrifuge equipment is required to
first spin the samples, limiting POC applications Key Differentiating Features:
• Sensitivity superior to core lab immuno-
assay instruments Reprinted with permission from inBios International, Inc., 2010.
Innovation
• Ultra-sensitive protein detection
Diagnostic Type:
• Immunoassay
Purpose:
• Rapid HIV screening
Platform:
• Lateral flow immunoassay
Description:
• Highly accurate – greater than 99% agreement
with Western Blot OraSure Technologies:
• Rapid – reliable results in 20 minutes OraQuick ADVANCE® Rapid
• Flexible – the only test approved by U.S. FDA for oral HCV Antibody Test
fluid, whole blood, and plasma. Also has received the
CE Mark for sale in the European Union. Diagnostic Type:
• Ideal for both clinical and non-clinical settings. Immunoassay
Key Differentiating
Reprinted with permission from OraSure Technologies, Inc., 2010.
Features:
Needle-free sample collection
Rapid and easy to use
Innovation
Detection of HCV from saliva
Diagnostic Type:
• Immunoassay
Purpose:
Quanterix: SiMoA (Single Molecule
• “Ultimate” point-of-care diagnostic – ability
ArrayTM) Technology
to diagnose and monitor with diagnostics
that are applied to the skin (“on-skin”) or
Diagnostic Type:
that are imprinted into the skin (“in-skin”)
• Immunoassay
Platform:
Purpose:
• Bioresponsive switchable materials
• Detection of proteins in blood or other body fluids
• Fluid access technologies
using minimally invasive, low volume samples
Description:
Platform:
• Biphasic particles consist of distinct hemi-
• Novel, ultra-sensitive immunoassay technology
spheres
utilizing an optical system
• Each phase is differentially loaded with
material and independently surface-func-
Description:
tionalized
• Based on optical fiber arrays and microfluidics to
• Capture groups that bind analyte of interest
perform ELISAs in very small volumes
are loaded onto one side
• Individual glass fibers are preferentially etched;
• Binding of analyte causes orientation of
Reprinted with permission from Quanterix, Inc., 2010. Reprinted with permission from Seventh Sense Biosystems, Inc., 2010.
resulting femtoliter-sized micro-wells capture and
particles and color change
retain desired analytes
• Fluid access technologies for painless access
• Simple detection technology: fluorescent labels
to blood or interstitial fluid
and light source imaging combined with software
that analyzes the images to determine analyte
Key Differentiating Features:
concentrations based on number of positive wells
• Diagnosis through skin patches or imprints
• Automated sample handling system
• Equipment-free
• Time to result is currently several hours; the
• No sample preparation required
company is developing a consumable that will
enable a 30-60 minute turn-around time
Innovation
• The instrument costs in the low thousands of
• “On-skin” or “in-skin” diagnostics
dollars, and consumables are roughly 10 cents each
Diagnostic Type:
Nanosphere: Verigene® and Verigene SP®
• Chemistry
Diagnostic Type:
Purpose:
• Immunoassay or molecular
• Health screening and treatment monitoring
Purpose:
Platform:
• Benchtop workstation for rapid nucleic acid detec-
• Enzymatic reagent discs and spectrophotom-
tion
eter/centrifuge
Platform:
Description:
• DNA barcode-based molecular or immunoassay
• 100uL of whole blood, serum, or plasma is
collected and transferred to a self-contained,
Description:
single use reagent disc that contains all
• The Verigene system has three parts:
reagents and diluents necessary to perform a
• Reader tracks, monitors, and reports
complete, fixed multi-test panel
• Processor completes random access processing of
• Following touch-screen commands, user
four cartridges simultaneously
places disc into the analyzer, enters requested
• Each cartridge is a sample-ready consumable
information
containing prepackaged reagents and array/solid
• Instrument produces results, including
substrate for target analysis
patient demographics, chemistry absorptions,
• Extract genomic DNA, add to cartridge (shears to
reference ranges, sample integrity indices,
300-500bp fragment), target fragment binds to
and iQC on the display, as well as a print-out
probe and nanoparticle-bound barcode simultane-
• Up to 5,000 patient records can be stored
ously, silver deposition amplifies signal
in memory
• Turn-around time is less than 3 hours after sample
• Uses a series of concentric channels in a spin-
preparation. The Verigene SP (not launched yet) will
ning disposable to reflect chemical reactions
remove sample prep and combine the reader and the
typical of a large chemistry analyzer
processor in one small benchtop machine, allowing
• Originally designed for NASA, currently used
for direct placement of flexible sample types in to
routinely by military, physicians’ offices,
the system; turn-aroudn time less than 2 hours
clinics, and small hospitals
• Molecular tests in development: infectious disease,
• 3 simple steps, results in about 12 minutes
SNPs for genetic testing (cystic fibrosis), metabolic
disorders and pharmacogenetics (warfarin)
Key Differentiating Features:
• Protein tests: troponin, PSA (recurrence), RA anti-
• Largest test menu of any single point-of-
bodies
care analyzer
• 11 of 13 available panels are CLIA waived
Key Differentiating Features:
• Fast, lab-accurate results
• Ultrasensitive detection (2-3 times more sensitive
• Multi-functional platform allows for future
than ELISA)
development of immunoassay, hematology
• Robust cartridge/disposable
and specialty tests
• Multiplexable
Diagnostic Type:
• Immunoassay or molecular
designed for the field performed without external power and does
not require running water; HDA amplification
Potential Developing World Application: requires incubation temperature around 65°C
• Point of care which can be achieved by using heat packs
Diagnostic Type:
• Molecular
Purpose:
• Rapid, easy-to-use, molecular diagnostics
Platform:
• RT-PCR (Real time PCR, not limited to Reverse
Transcriptase PCR)
Description:
• Automated from sample prep through interpretation
• Ultrasonic lysis (integrated into cartridge) enables
processing of difficult samples (e.g. sputum) and
targets (bacterial spores, TB)
• Following amplification, rapid detection by • Cartridges handle a range of sample volumes to obtain
vertical flow occurs with an instrument-free higher concentration of target
disposable BioHelix Express Strip (or BESt™) • Enclosed cartridge and fluid handling enables nested
cassette PCR, increasing sensitivity
• Kits are available for rapid staph and MRSA • Can detect multiple target sequences in a single
detection, for research only cartridge (6 colors for assays and controls)
• In development for C dif, HIV, Herpes, CT/ • Does not require water supply
NG, Factor V Leiden • Requires 110 or 220V electrical power; in theory could
• Turn-around time is 2 hours for factor V be powered by a car battery
Reprinted with permission from BioHelix Corporation, 2010.
Leiden and MRSA • Assay shelf life is around 1 year at room temp, higher
• The lyophilized HDA reagents are stable at temperature for TB assay
room temperature for 12 months • Turn-around time is between 30 min and 1 hour
(depending on test)
Key Differentiating Features: • Tests available for MRSA/MSSA, C. difficile, Group B
• Isothermal amplification Strep, enterovirus, TB, BCR-ABL, Factor II/V
• Low sample volume of 1-10 µl
Key Differentiating Features:
Potential Developing World Application: • Ease of use in a fully-integrated cartridge; one cartridge
• Labs can be used across a broad range of platforms
• Scalable, modular instrument design
Innovation
• Fully automated and integrated nucleic acid extraction,
amplification, and detection
Diagnostic Type:
• Molecular
Purpose:
• Automated nucleic acid detection with minimal
sample preparation
• Disposable pouch ($5-7 cost of goods sold)
Platform: where everything happens inside
• Direct tube sampling and nucleic acid amplification • Isothermal amplification and fluorescent chem-
by TMA (transcription-mediated amplification) istry with real-time reporting
• First developed for water testing
Description: • TIGRIS and Panther assays: CT, GC, GBS, Group
• Tube-based nucleic acid detection: all steps of A strep, HIV viral load using dried blood spots on
sample prep occur through detection TIGRIS
• RNA or DNA amplification 109-fold in 15 to 30
Key Differentiating Features:
Diagnostic Type:
• Molecular
Purpose:
Becton Dickinson (formerly Handylab): • Viral and bacterial pathogen detection
Jaguar, Lynx, Raider
Platform:
Diagnostic Type: • Automated, RT-PCR, PCR and detection
• Molecular
Description:
Purpose: • Inject water and unprocessed sample into
• Rapid, automated, nucleic acid detection and disposable pouch ($130 list price)
quantification with minimal sample preparation • Insert pouch into FilmArray instrument
• Simple loading: no pipetting or centrifuga-
Platform: tion
• Microfluidic RT-PCR • Everything happens in the pouch: instru-
ment extracts/purifies RNA/DNA, performs
Description: RT-PCR, multiplexed PCR (up to 120 tests/
• Jaguar: automated extraction and RT-PCR sample), dilution, singleplexed PCR, and
• Lynx: extraction only then reports results for each targets
• Raider: RT-PCR only, desk-top sized instrument • Reagents are freeze-dried
• 4-5uL sample volume • Current indication: respiratory panel (17
• 45 cycles in 15 minutes viral, 4 bacterial), for research only
• Reagents stable at room temperature • FDA clearance trials began in Q4 2009
• Detection by fluorescence
Key Differentiating Features:
Key Differentiating Features: • Turnaround <1 hour
• Reagents for Jaguar and Raider do not require • Flexible sample type
refrigeration • Multiplexable
• Multiple sample formats allowed on Jaguar • Sample to solution
Purpose: Purpose:
• Rapid, easy-to-use, nucleic acid detection • Automated nucleic acid testing (NAT) and
detection
Platform:
• Isothermal nucleic acid amplification and detec- Platform:
tion • Single step NAT, lab-in-a-tube
Description: Description:
• Nucleic acid amplification combined with fluores- • A flexible tube is a sample vessel containing
cent of lateral flow read-out all assay reagents pre-packed in segments
• Commercially available polymerases amplifies separated by peelable seals; actuators in the
short oligonucleotides (8-16 nt) analyzer compress the tube to selectively
Photo Courtesy of: DARPA Strategic Technology Office, Approved for Public Release, Distribution Unlimited. , Reprinted with permission from Ionian Technologies, 2010.
• Reiterative steps of DNA polymerase extension release reagents from the tube segments,
and the activity of a nicking enzyme produce moving sample from one segment to another
rapid exponential amplification under isothermal and controlling reaction conditions
conditions • The small, portable device performs reagent
preparation, target enrichment (magnetic
Key Differentiating Features: beads), inhibitor removal (capture/wash),
• Ultra-rapid nucleic acid detection – 1012 fold nucleic acid extraction, amplification, and
amplification in less than 5 minutes detection
• Stabilized reagents • Steps: collect raw sample (whole blood,
• Lateral flow readout plasma, urine, swabs) into a tube, scan
barcode, and insert tube in analyzer
Innovation • Quantitative results on-screen: turn-around
• Extremely rapid nucleic acid detection (does not time is less than1 hour
require DNA extraction) • The Liat FlowCycler™ is another available
machine that has the capability to run PCR
Potential Developing World Application: on multiple samples simultaneously
• Labs
Key Differentiating Features:
• Sample to result in less than 1 hour
• Completely closed system prevents contami-
nation
• Can accommodate several assays and samples
Innovation
• Single step nucleic acid testing
Diagnostic Type:
• Cell-based
Purpose:
• Simple, affordable point-of-care test for moni-
toring CD4 lymphocytes in patients with HIV/
AIDS
Platform:
• N/A
Description:
Cellabs/Special Phage Services:
• Binary measurement: e.g., less than 350 cells or
Phage Diagnostics
greater than 250 cells
• Finger prick blood draw and reading of measure-
Diagnostic Type:
ment through simple lines
• Cell-based
• Part of the CD4 initiative funded by the Imperial
College: Developed by the team from Beckman
Purpose:
Coulter (now ImmunoSite Technologies, LLC)
• Detection of bacterial infections
• Sybil D’Costa, Ph.D., V.P. Research and
Development, is the principal investigator, grant
Platform:
awarded in 2007
• Bacteriophage-based lateral flow technology
Platform:
Description:
• Phage amplification combined with lateral flow for
• Finger prick of blood (10ul) is added to a
detecting pathogens
miniature chamber coated with anti-CD4 anti-
bodies
Description:
• Rapid fluid flow elutes un-bound cells
• Sample (blood or nasal swab) is added to amplifica-
• Electrochemical sensing using MEMS measures
tion broth containing a cocktail of pathogen-specific
resistance, determines CD4 count
bacteriophage
• $600 cost of goods sold for the instrument
• Bacteriophage infect the target pathogen, replicate,
(which the company plans to give away);
and lyse cells releasing thousands of progeny phage
plastic assay cards sold at under $10 at low
• A bacteriophage-specific marker is detected using an
volume and under $5 at high volume
equipment-free lateral flow test (10 minutes to result)
• Clinical trials to start in mid-2010
• For susceptibility testing, the process is performed
• Tuberculosis, HIV viral load tests in develop-
in parallel in the presence of an antibiotic; resistant
ment
bacteria are able to grow and support phage amplifi-
• Optimized for clinically relevant CD4 range
cation (giving a positive result on lateral flow), while
of 80 to 1000. Reduced sensitivity below 80
susceptible bacteria do not (giving a negative result)
enables lower cost instrument for developing
• Current turn-around time is 5-10 hours (10 hours
world.
for bacteria that take longer to grow or for resistant
bacteria differentiation)
Key Differentiating Features:
• Bacteriophage cocktail discovery for any bacte-
• Turn-around time is 6 minutes
rial pathogen believed to be a 1 to 2 year process,
• Label-free
including for TB
• Low sample volume
• Initial indication in development is MRSA
• Entirely automated system, operates like a
glucose meter
Key Differentiating Features:
• Not reliant upon optics
• Requires no equipment or sample preparation
• Likely to accommodate wide range of sample types
Innovation:
• Handheld, rapid CD4 count using stabilized
Innovation:
reagents
• Rapid identification and susceptibility (faster than
culture)
Potential Developing World Application:
• Point of care (community health worker,
Potential Developing World Application:
villages, homes)
• Labs
Diagnostic Type:
• Emerging technology
Purpose:
• Diagnosis through detection of pathogen or
disease-related metabolites
Platform:
• Gas phase ion separation (differential mobility T2 Biosystems: NanoDx
spectrometry)
Diagnostic Type:
Description: • Emerging technology
• Disease diagnosis through quick analysis of clinical
cultures, working towards patient breath analysis Purpose:
• Micromachined differential mobility spectrometer; • Diagnostics without sample preparation
described as “mass spec, without machinery”
• Applied pattern discovery/recognition algorithms Platform:
to analyze volatile metabolic compound signature • Use of magnetic resonance with nanotech-
generated by DMS to reliably discern multiple nology
species of bacteria in vitro
Description:
Key Differentiating Features: • Superparamagnetic iron oxide metal core is
• Detection of metabolites in sputum (70-90% surrounded by dextran polymer layer with
sensitivity) analyte-specific binding agents (nanoparticles)
• Inexpensive consumable ($2-4) and instrument • Presence of analytes results in change of char-
($1000-2000) costs acteristic signal, which is measured by MR
• Easy to use, wide range of samples detectors. The particles move into specific
• No need for ambient temperature control clusters, changing the T2 of the solution
• Sample is added to a cartridge and inserted in
Innovation: bench-top reader
• Indirect detection of pathogen • Cartridge has a 1 to 2 year shelf life, costs
Reprinted with permission from The Charles Stark Draper Laboratory, 2010.,
Diagnostic Type:
• Sample preservation
Purpose:
• Stabilization of samples in poor environmental
conditions
Platform:
• Sample stabilization chemistries
Description:
• Chemistries preserve cells, cell surface markers,
intracellular proteins, and nucleic acids in a single
tube for up to seven days without refrigeration.
• Sample stabilization chemistries for whole blood,
genital tract swabs, and urine
• Stabilizes bacterial and viral targets as well as
intracellular RNA .
• Because chemistries appear to stabilize
cells and detoxify sample matrices rather
than relying on lysis and precipita-
Key Differentiating Features:
tion, one sample can be used for
• Label-free
multiple tests (e.g., molecular, flow
• Non-optical
cytometry, culture)
• Very robust: DOD has been interested due
Reprinted with permission from T2 Biosystems, Inc., 2010.
assay platforms
and interpreting models to improve diagnostics in Murray, C. K., R. A. Gasser, Jr., et al. (2008). “Update
The Diagnostics Innovation Map: Medical Diagnostics
developing countries.” Nature 444 Suppl 1: 3-8. on rapid diagnostic testing for malaria.” Clin Microbiol
for the Unmet Needs of the Developing World
Rev 21(1): 97-110.
Han, Z. G., P. J. Brindley, et al. (2009). “Schistosoma
Copyright © 2010 BIO Ventures
genomics: new perspectives on schistosome biology Nicastri, E., N. Bevilacqua, et al. (2009). “Accuracy
for Global Health
and host-parasite interaction.” Annu Rev Genomics of malaria diagnosis by microscopy, rapid diagnostic
Hum Genet 10: 211-240. test, and PCR methods and evidence of antimalarial
All rights reserved
overprescription in non-severe febrile patients in two
Keeler, E., M. D. Perkins, et al. (2006). “Reducing Tanzanian hospitals.” Am J Trop Med Hyg 80(5):
This report was written by Priya Mehta and David
the global burden of tuberculosis: the contribution of 712-717.
Cook, with the support of Health Advances, LLC.
improved diagnostics.” Nature 444 Suppl 1: 49-57.
Rafael, M. E., T. Taylor, et al. (2006). “Reducing the
Authors’ note:
Kyle, J. L. and E. Harris (2008). “Global spread and burden of childhood malaria in Africa: the role of
persistence of dengue.” Annu Rev Microbiol 62: improved.” Nature 444 Suppl 1: 39-48.
We thank the Bill & Melinda Gates Foundation for
71-92.
its financial support. We are grateful to the team at
Rodriguez, B. (2009). H. Advances, Daktari.
Health Advances: Kristin Pothier, Sonia Gupta, Paula
Lim, Y. W., M. Steinhoff, et al. (2006). “Reducing the
Ness Speers, Philina Lee, Kimberly Howland, Mark
global burden of acute lower respiratory infections in Scott, J. A., W. A. Brooks, et al. (2008). “Pneumonia
Speers, and Donna Hochberg for their hard work and
children: the contribution of new diagnostics.” Nature research to reduce childhood mortality in the devel-
significant contributions to this document. We thank
444 Suppl 1: 9-18. oping world.” J Clin Invest 118(4): 1291-1300.
Christopher D. Earl for his continued contributions
and valuable feedback. We also thank our Scientific
Michael J A Reid, N. S. S. (2009). “Approaches to Yager, P., G. J. Domingo, et al. (2008). “Point-of-care
Advisory Board for their feedback and support: N.
tuberculosis screening and diagnosis in people with diagnostics for global health.” Annu Rev Biomed Eng
Leigh Anderson, Deborah Burgess, David Kelso,
HIV in resource-limited settings.” Lancet Infectious 10: 107-144.
Alan Magill, Francis Moussy, Rosanna Peeling, Mark
Diseases 9: 173-184.
Perkins, Mark Reynolds, William Rodriguez, Samuel
Sia, John J. Sninsky, Amy Wong, and Paul Yager. We
Molyneux, D. H. (2009). “Filaria control and elimina-
thank all those interviewed during the course of this
tion: diagnostic, monitoring and surveillance needs.”
project for their time and effort to ensure the accuracy
Trans R Soc Trop Med Hyg 103(4): 338-341.
of the report.