LF LAM slides.pptx

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1. Kiambu County: LF LAM testing sensitization National TB, Leprosy and Lung Disease Program & National AIDS and STIs Control Programme Ministry of Health (MoH), Kenya PRESENTED BY P.C.E.A KIKUYU HOSPITAL LABORATORY TEAM

2. Testing facilities- Kiambu County n=12

3. Outline Introduction to TB LAM Collection, packaging storage and transportation of TB LAM specimen Safety precautions for TB LAM TB LAM testing and quality assurance procedure Commodity & supply chain management Monitoring and evaluation

4. INTRODUCTION TO TB LAM

5. Learning Objectives By the end of this module participants should be able to: Describe the current basis and rationale for TB LAM Describe evidence supporting the use of TB LAM Understand the Kenyan TB LAM algorithm

6. Screening of TB Health care workers should have a high index of suspicion to be able to diagnose TB Screening of TB entails the following: History taking Physical examination Screening for 4 cardinal signs in PLHIV - cough of any duration, fever, night sweats and weight loss Presence of any one symptom - investigate for TB If all 4 symptoms are absent, patient likely has no TB (with 97% probability).

7. Basis For Use Of TB-LAM In TB Diagnosis A LAM antigen is a lipopolysaccharide present in mycobacterial cell walls, which is released from metabolically active or degenerating bacterial cells. LAM appears to be present predominantly in people with active TB disease and has shown only low cross-reactivity with nontuberculous mycobacterial infections. Determine™ TB LAM Ag test (LF-LAM) is a urine test used for the detection of LAM antigen. Urine-based testing has certain advantages over sputum-based testing because urine is easy to collect and store, and lacks the infection control risks associated with sputum collection.

8. Rationale For Use Of TB LAM HIV-positive patients with TB disease may be missed: Sputum bacillary load is typically low in these patients They may not be able to provide sufficient and high quality sputum specimens Substantial proportion of these patients have sputum negative TB or extra-pulmonary TB LF-LAM demonstrates improved sensitivity in TB-HIV co-infection which further increases with lower CD4 counts. Due to high rates of mortality among this patient group, if accurate,(LF-LAM) assay would be a useful tool to facilitate the early initiation of anti-TB treatment.

9. Evidence supporting TB LAM in PLHIV – The MSF Homabay Study A prospective observational cohort study in 474 ambulatory (either severely ill or CD4<200 cells/ μl or with Body Mass Index <17 Kg/m2) and hospitalized symptomatic HIV infected adults in Kenya The findings showed that LAM could allow same day TB treatment initiation for PLHIV at higher risk of death and guided the Kenyan adaptation of the WHO guidelines to use LAM at CD4 count <200 cells/ μL . 9

10. Incremental yield increased by Adding TB LAM to TB Testing

11. Is a Positive LAM Result a Predictor of Mortality Risk? 11

12. TB LAM evidence in HIV Infected Children A randomized control trial in 165 HIV infected children in Kenya published in 2018 by Maleche-Obimbo E.., et al found urine LAM had lower sensitivity and specificity in general compared to sputum or gastric aspirate TB culture, but improved among children with severe HIV-immunosuppression. This study showed that the ease of the urine dipstick TB LAM highlighted its utility as an add-on test in severely ill HIV-infected children due to the challenges of pediatric respiratory sample collection.

13. Indications for TB-LAM – Kenya ART Guidelines, 2022

14. TB LAM Algorithm, Kenya ART Guidelines, 2022

15. COLLECTION , PACKAGING STORAGE AND TRANSPORTATION OF TB LAM SPECIMEN  

16. Learning Objectives….

17. Materials required PPEs Urine container Catheter for hospitalized patients Cooler box Sample tray Mark pen

18. Client Preparation for sample collection Prepare the patient/ supporter for the procedure Prior to urine sample collection, inform the patient to first clean their genital area. Collect fresh midstream urine in a standard urine collection container For clients who are bedridden sample can be collected from urine bag connected to catheters.

19. Sample collection The required volume should be between 1-2 mls . Label the container with patients details ( name/ID/ and the date sample collected). Urine samples can be used within 8 hours if kept at room temperature.

20. Sample Packaging TB LAM is a POC test therefore no packaging is required for urine sample collected. In the event that the sample collected are being taken to the lab within the same facility-use  sample transportation trays/ cool boxes . The sample should be accompanied by duly filled requisition forms . In the event that samples need to be transferred from spoke-hub site triple packaging technique will be required Urine samples should be stored at 2-8°C if the test is to be run within 3 days of collection

21. Sample transportation and shipment Sample from spoke to hub sites should be transported using the existing sample networking system i.e. motor riders, courier services and personnel.

22. SAFETY PRECAUTIONS FOR TB LAM  

23. Infection control measures (personal health, safety practices and healthcare environment) Adherence to standard precautions is necessary to minimize the risk of Hospital -acquired infections and to promote a safe environment for all health care workers and patients in the hospitals . Well-designed facility, well-trained personnel as well as adherence to safety policy contributes to the protection of healthcare workers and patients and minimize environmental pollution.

24. PPE is the least effective control because it involves a high level of worker involvement and is highly dependent on proper fit and correct, consistent use.

25. Intervention Examples Engineering controls Infrastructure Ventilation Water and sanitizers Protective equipment e.g. Biosafety cabinet Creating barriers Administrative controls Policies, regulations, guidelines Telework, shifts IEC and job aids Staff training IPC committees and rapid response teams Spacing clinic appointments for stable patients Work flow e.g. triage and fast-tracking of symptomatic patients Environmental controls Cleaning and disinfection of f requently touched surfaces/items Waste management Laundry 25

26. Key Steps in Waste Management Waste avoidance & Minimization Segregation Decontamination Packaging and Labeling Handling and Storage Containment Transport Treatment or Destruction

27. Waste segregation job aid ….

28. TB-LAM Testing and Quality Assurance Procedure

29. Learning Objectives By the end of the module the participant should: Understand the principle of TB LAM testing Be able to know the limitations of TB LAM as a diagnostic tool Be able to state the eligibility criteria for LAM testing Be proficient in conducting TB LAM test practically Be aware of Quality Assurance measures for TB LAM testing 3/8/2023 29

30. stoptb.org Principle of TB LAM Testing LAM stands for L ipoarabinomannan . It is a compound that makes up part of the outer cell wall of the TB bacteria. LAM is an antigen, meaning it causes an immune response when it enters the human body. It sheds off from TB bacterial cells in the body. Many people with advanced HIV have disseminated TB, including TB in their kidneys (renal TB ). When TB bacteria in the kidneys shed off LAM, the kidney clears LAM into urine, which is how the LAM urine test can detect it .

31. Cell walls of mycobacteria : Thin layers of peptidoglycan + arabinogalactan Thick layer of mycolic acids Porins Lipoarabinomannan anchored to the cell membrane by diacylglycerol Gram negative bacteria

32. Mycolic acids  are lipids found in cell walls of  Mycobacterium  and  Corynebacterium which make up 50% of the dry weight of the Mycobacterial cell envelope.  Strongly hydrophobic Form lipid shell around bacteria Increased resistance to chemical damage and dehydration Prevent the effective activity of some antibiotics and chemicals Determine virulence in MTB by - Prevent attack by cationic proteins, lysozyme, and oxygen radicals in the phagocytic granule. - Protect extracellular Mycobacteria from complement deposition in serum Structure of the cell wall of mycobacterial species

33. Lipoarabinomannan Major cell wall component Major virulence factor in Mycobacterium. Immunoregulatory Anti-inflammatory effects as neutralizes cytotoxic oxygen free radicals produced by macrophages Structure of the cell wall of mycobacterial species

34. 34 Limitations of the test Low sensitivity—the LAM test can miss cases, so a negative test must be followed by other diagnostic tests for TB. No drug susceptibility testing Cannot be used to monitor treatment LAM testing is only recommended for people living with HIV who have low CD4 cell counts or are seriously ill ( Refer the eligibility criteria ) LAM cannot distinguish between Mycobacterium tuberculosis, which causes TB, and other types of mycobacteria (which could be harmless or could require different treatment).

35. 35 Limitations of the test: cont …. TB LAM Ag should be followed up with confirmation test such as bacterial culture and with a drug susceptibility test, if possible. Testing diuretic/dilute urine may affect the ability of the test to detect LAM antigen in urine of TB patients. Excretion of LAM antigen in urine may vary depending on the individual patient's condition and his underlying illness or treatment. The effect of treatment of the patient with broad spectrum antibiotics on the TB LAM Ag test performance has not been established.

36. 36 Test Requirements TB LAM Ag kit , Pen/ Permanent marker Urine collection container Pipette capable of accurately delivering 60 μL • Timer Gloves Waste disposal bags Reference card Disinfectant

37. separated single strip TB LAM Kit Ten-strips card

38. 38 Warning and precautions Appropriate biosafety practices should be used when handling specimens as per the laboratory SOPs These precautions include, but are not limited to the following: Wear gloves. Do not eat, drink, smoke, apply cosmetics, or handle contact lenses in areas where these materials are handled. Clean and disinfect all spills of specimens using suitable disinfectant, such as 0.5% sodium hypochlorite, or other suitable disinfectant. Decontaminate and dispose of all specimens and other potentially contaminated materials in accordance with local Regulations

39. 39 Kit Storage TB LAM Ag testing devices must be stored at 2-30°C until the expiration date. • Kit components are stable until expiration date when handled and stored as directed. Do not use kit components beyond expiration date. • Immediately reseal all unused tests in the foil pouch containing the desiccant by pressing seal from end to end to close. • Do not use devices that have become wet or if the packaging has become damaged.

40. Prepare Test Tear one strip from the right and remove cover. © 2016 Alere. All rights reserved. The Alere Logo, Alere and Determine are trademarks of the Alere group of companies. 12000980E-02 01/16 Product Information : Lot Number Patient Identification Area Product Name Control Line Area Patient Test Result Area Sampling Area 1 Result Key Read Results Wait 25 minutes and read the results . 4 Before you begin: Please read the Package Insert in its entirety Put on disposable gloves. Gather the materials you will need. Cover your work space with a clean, disposable absorbent workspace cover. Caution: Do not lift the capillary tube from the Sample Pad before all the urine has been transferred. 3 Add Sample Apply 60μL of urine to sample pad. Place Test Place one strip on a flat surface where the test is to be performed. 2 25 min Test Procedure

41. 41 Reading the result and interpretation LAM Antigen POSITIVE; (Two bars – Control and Patient Bars) Purple/gray bars appear in both the control window (labeled “Control”) and the Patient window (labeled “Patient”) of the strip . LAM Antigen NEGATIVE; (One bar – Control Bar) One purple/gray bar appears in the control window of the strip (labeled “Control”) and no purple/gray bar appears in the Patient window of the strip (labeled “Patient”). INVALID; (No bar ) If there is no purple/gray bar in the control window of the strip, even if a purple/gray bar appears in the patient window of the strip, the result is invalid and the test should be repeated.

42. Test results & interpretation INDEFINITE Result One purple/gray bar appears in the control window of the strip (labeled “Control”) with unclear or incomplete (broken line or dot) purple/gray bar in the patient window of the strip (labeled “Patient”) For a better clinical decision the test should be repeated; :Note for clinical evaluation only retest can be done only on the same sample. If the retest is indefinite, the result should be considered as negative. Alternatively, collect a new urine sample in the following days from the patient and test. Early morning urine is recommended. 42

43. Recording results 43 Read and record the; results lot number expiry date and patient information

44. TB-LAM Quality Assurance Should address pre-analytical, analytical and post analytical phase of testing

45. Ensure the sample and test strip are appropriately labeled with patient ID Use of appropriate sample Urine (clean catch, midstream) Minimum volume of 60µL Adhere to manufacturer’s procedures for storage of urine Within 8 hours of collection (ideally) < 3 days refrigerated 2-8C > 3 days: frozen -20C or colder Centrifugation required to remove aggregates prior to testing Development of sample rejection policy, if required Sample QA

46. Test use Within 2 hours of opening kit Kit storage and documentation requirements Unopened, stored 2-30°C Document receive date, in use date, and ensure expired kits are discarded Lot to lot verification using established procedures Monthly QC (independent of lot) Positive control result Negative control result Document lot number and expiration date Test kits QA

47. Well characterized patient samples QC materials required for training, monthly QC and lot to lot verification Collected monthly from known TB patients positive for TB-LAM and TB negative individuals Stored as 1.0mL aliquots -20°C or colder for long term storage Centrifuged to remove aggregates before use Preparation of QC materials

48. Confirmation of positive and negative results Reviewed by 2 nd reader prior to release Establish TAT and monitor One hour TAT; document the following using the appropriate form: Time of sample collection Test start time Test end time Monthly register review by supervisor Interpretation of results and reporting

49. Issuing LAB Commodities from one facility to another

50. Conduct monthly physical stock to obtain 1.stock on hand 2. Days out of stock 3. Near expiry stock Complete the m-CDRR after aggregating the data from all testing sites(Wards and Lab) Send duplicate copies of m-CDRR to the CMLC at 3 rd of every month together with the FCDRR CMLC will review and endorse Forward the endorsed m-FCDRR to the national program officer Reporting & Requesting LAB Commodities (TB LAM)

51. Importance of Recording and Reporting Helps in monitoring and evaluation by health workers and managers at different levels Monitor patient’s response to treatment Assess program performance Aids in effective program planning Aid staff to provide adequate services to the individual patient Ensure patient quality of care, continuum of care, sharing of information with patient and transfer of information between health facilities Accountability Continuous improvement of processes.

52. Importance of M&E in TB Management Helps in assessing progress towards achieving the set objectives and goals Facilitates timely decision making It allows learning from experience and improves planning and management of program For accountability to stakeholders Accumulates a pool of evidence for policy and planning

53. Monitoring and Evaluation framework for TB LAM WHO reporting and recording definitions and framework 2013 guidelines A bacteriologically confirmed TB case : Is positive by smear microscopy, culture or WRD- WHO-recommended rapid diagnostic test ( such as Xpert MTB/RIF) Evidence of bacteria WHO Rapid recommended diagnostic tests TB LAM WHO recommended in 2015 TB LAM done alongside Gene xpert Clinically diagnosed: D oes not fulfil the criteria for bacteriological confirmation but has been diagnosed with active TB

54. Monitoring and Evaluation framework for TB LAM Further classification, done according: Anatomical site of disease History of previous treatment Drug resistance HIV status

55. Indicators to Monitor No. of patients eligible for TB LAM test No. of TB LAM tests done No. and Proportion of patients with + ve TB LAM results No. and Proportion of patients with + ve TB LAM result and positive gene xpert result No. and Proportion of patients with + ve LAM result and Rifampicin Resistant (RR) No. and Proportion of patients with + ve TB LAM test and negative gene xpert result No. and proportion of patients with + ve TB LAM results started on treatment

56. Treatment outcomes Cured : A PTB patient with bacteriologically confirmed TB at the beginning of treatment who was smear- or culture-negative in the last month of treatment and on at least one previous occasion Treatment complete: A TB patient who completed treatment without evidence of failure BUT with no record to show that sputum smear or culture results in the last month of treatment and on at least one previous occasion were negative Either because tests were not done or because results are unavailable Died: A TB patient who dies for any reason before starting or during the course of treatment

57. Flow of TB LAM Data National Tuberculosis, Leprosy and Lung Disease Program (NTLD-P )/NTRL National Aids and STI Control Program (NASCOP) Aggregate, Analyze, Act, Develop and distribute data capture tools. Provides Technical Assistance and conducts DQA Service Delivery points (Facility/ SDPs) Record, Collect, Analyze, report , Act County Tuberculosis and Leprosy Coordinator ( CTLC/CASCO/CMLT) Aggregate, Analyze, Act, Supervise Sub counties Sub County Tuberculosis and Leprosy Coordinator ( SCTLC/SCASCO/SCMLT) Aggregate, Analyze, Act, Supervise facilities and notify cases Data flow Technical Assistance Reporting Platform DHIS/TIBU