WHO Prequalification of Diagnostics Programme PUBLIC ...€¦ · PQDx 0045-018-00 WHO PQDx PR...

PQDx 0045-018-00 WHO PQDx PR October/2011, version 1.0

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WHO Prequalification of Diagnostics Programme PUBLIC REPORT

Product: IMMUNOQUICK® MALARIA falciparum

Number: PQDx 0045-018-00

Abstract IMMUNOQUICK® MALARIA falciparum with product codes1 0502_K25, 0502_K50 and 0502_K100, manufactured by BIOSYNEX, 12, rue Ettore Bugatti CS28006, 67038 Strasbourg Cedex France, CE-marked regulatory version was accepted for the WHO list of prequalified diagnostics and was listed on 18 October 2011. IMMUNOQUICK® MALARIA falciparum is intended for in vitro diagnostic of Plasmodium falciparum. It is a visually read, qualitative immunochromatographic assay for the capture of the specific soluble antigen of Plasmodium falciparum “Histidine rich protein 2” (PfHRP-2) which is present and diffuse from infected red blood cells. IMMUNOQUICK® MALARIA falciparum is designed for whole blood samples utilization and does not require any instrumentation or dedicated facilities. It can be used on general population including neonates and pregnant women. The test is intended for use by health care professionals in clinical laboratories or on the point of care. The IMMUNOQUICK® MALARIA falciparum is an immunochromatographic test composed by a nitrocellulose membrane precoated with monoclonal antibodies anti-HRP-2 of Plasmodium falciparum on a test Line. The red blood cells are lysed by a lysis buffer thus releasing the antigen PfHRP-2 which reacts with monoclonal anti-HRP-2 antibodies conjugated with gold colloidal, the complex HRP-2/Antibodies anti-HRP-2 will migrate along the membrane, and be captured by the anti-HRP-2 antibody present in the test line, and form a purple line generated by colloidal gold particles. The presence of a purple control band in the higher part of the test makes it possible to check the correct performance of the test. The test kit contains:

Strips individually packed in aluminum pouch containing desiccant bag 6 ml dropper vials containing the lysis buffer Patient cards Plastic tubes Instructions for use Tube rack

1 0502_K25: 25 test strips and 1 buffer vial

0502_K50: 50 test strips and 2 buffer vials 0502_K100: 100 test strips and 4 buffer vials


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Storage: The test kit should be stored at 2-30 °C. Shelf-life: 24 months The IMMUNOQUICK® MALARIA falciparum was accepted for the WHO list of prequalified diagnostics on the basis of data submitted and publicly available information.

Summary of prequalification status for Insert product name

Initial acceptance

Date Outcome

Status on PQ list 18 October 2011 listed

Dossier assessment 07 September 2011 MR

Inspection status 13 October 2011 MR

Laboratory evaluation 25 April 2009 MR

MR: Meets Requirements NA: Not Applicable

Background information In 2009, BIOSYNEX submitted an application for prequalification of the IMMUNOQUICK® MALARIA falciparum. Based on the results of the WHO product testing of malaria RDTs Round 1, the IMMUNOQUICK® MALARIA falciparum was given priority for prequalification. Product dossier assessment In 2011, BIOSYNEX submitted a product dossier for the IMMUNOQUICK® MALARIA falciparum as per the Instructions for compilation of a product dossier (PQDx_018 v1). The information submitted in the product dossier was reviewed by WHO staff and external experts (assessors) appointed by WHO in accordance with the internal report on the screening and assessment of a product dossier (PQDx_009 v2). Based on the product dossier screening and assessment findings, a recommendation was made to accept the product dossier for the IMMUNOQUICK® MALARIA falciparum for prequalification. Commitments for prequalification: The manufacturer has amended and submitted additional documentation as per the product dossier assessment findings. No further amendments are required.


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Manufacturing site inspection A ‘fast track’ inspection was performed 29-30 November 2010 at the site of manufacture (12 Rue Ettore Bugatti 67038 Strasbourg Cedex 2, France) of the BIOSYNEX IMMUNOQUICK® MALARIA falciparum diagnostic test according to the ‘Information for manufacturers on WHO prequalification inspection procedures for the sites of manufacture of diagnostics’ (PQDx_014 v1). The inspection found that the manufacturer had a quality management system (QMS) and manufacturing practices in place that should ensure the consistent manufacture of a product of good quality. The manufacturer's responses, in the form of an action plan, to the nonconformities found at the time of the inspection were submitted by the manufacturer and accepted on 13 October 2011. Commitments for prequalification: 1. As changes in manufacturing procedures and scale up continue to occur, a WHO inspection team will be invited in Quarter 4 2011 or Quarter 1 2012 to confirm the responses to the nonconformities identified at the initial inspection and that the BIOSYNEX QMS is able to support the manufacture of the IMMUNOQUICK® MALARIA falciparum diagnostic test at a high level of quality. 2. Documented records that support the action plans that were submitted in response to the nonconformities found during the initial inspection, will be available for review at the re-inspection. 3. As automation is introduced, analysis by the manufacturer of the nonconformities identified at the initial inspection will be further extended to include related quality management issues particularly in the area of validation of new manufacturing processes. Laboratory evaluation The first round of WHO product testing of RDTs for malaria antigen-detecting detection RDTs was completed in November 2008. The product was evaluated against prepared blood panels of cultured Plasmodium falciparum parasites, patient-derived Plasmodium falciparum parasites and a parasite-negative panel. Thermal stability was assessed after 2 months of storage at elevated temperature and humidity, and a descriptive ease of use assessment was recorded. Based on the demonstrated P. falciparum detection score, false positive rate and invalid rate, the IMMUNOQUICK® MALARIA falciparum meets the current laboratory evaluation requirements for prequalification.


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Labelling

1. Labels

2. Instructions for use


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1. Labels

TOP OF THE BOX


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RIGHT HAND SIDE OF THE BOX


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Diluent

IMMUNOQUICK

® MALARIA

Diluant / Diluent

Qty: 6 mL

DILMDxxxxxx

YYYY-MM

Test strip


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2. Instructions for use

IMMUNOQUICK® MALARIA falciparum

Rapid test for detection of Plasmodium falciparum in blood

Ref. N°: 0502_K25 ; 0502_K50 ; 0502_K100

For in vitro use only

1- OBJECTIVE

IMMUNOQUICK® MALARIA falciparum is intended for in vitro diagnostic of Plasmodium

falciparum.

It is a visually read, qualitative immunochromatographic assay for the capture of the specific soluble

antigen of Plasmodium falciparum “Histidine rich protein 2” (PfHRP-2) which is present and

diffuse from infected red blood cells.

IMMUNOQUICK® MALARIA falciparum is designed for whole blood samples utilization and

does not require any instrumentation or dedicated facilities. It can be used on general population

including neonates and pregnant women. The test is intended for use by health care professionals in

clinical laboratories or on the point of care.

2- PRINCIPLE

The IMMUNOQUICK® MALARIA falciparum is an immunochromatographic test composed by

a nitrocellulose membrane precoated with monoclonal antibodies anti-HRP-2 of Plasmodium

falciparum on a test Line. The red blood cells are lysed by a lysis buffer thus releasing the antigen

PfHRP-2 which reacts with monoclonal anti-HRP-2 antibodies conjugated with gold colloidal, the

complex HRP-2/Antibodies anti-HRP-2 will migrate along the membrane, and be captured by the

anti-HRP-2 antibody present in the test line, and form a purple line generated by colloidal gold

particles. The presence of a purple control band in the higher part of the test makes it possible to

check the correct performance of the test.

3- LIMITS OF THE TEST

1) The method is based on the presence or absence of Plasmodium falciparum HRP-2 protein. The

definitive clinical diagnosis has to be confirmed by the physician on the basis of other clinical

and biological findings. IMMUNOQUICK® MALARIA falciparum cannot replace the

microscopic examination which is recommended to use as a complement.

2) In P. falciparum malaria infection, HRP-2 is not secreted in gametogony stage. Hence, in

“healthy carriers”, the HRP-2 band may be absent.

3) Pf HRP-2 antigen can persist for about fifteen days after treatment; a positive result does not

indicate necessarily a therapeutic failure.

4) If the test is used as a control of therapy, it is recommended to carry out control at least fifteen

days after the end of the treatment.

4- PROVIDED MATERIAL

Reference Quantities

Strips individually

packed in aluminium

Six ml dropper

vials containing

Patient

cards

Plastic

tubes

Instruction

for use

Tube rack


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pouch containing

desiccant bag

the lysis buffer

0502_K25 25 1 25 25 1 1

0502_K50 50 2 50 50 1 1

0502_K100 100 4 100 100 1 1

5-REQUIRED MATERIAL (NON PROVIDED)

Stop watch with alarm

Laboratory pipettes (optional) and disposable tips

Sterile lancets (optional)

Disinfectant tissues (optional)

Disposable gloves

6- COLLECTION AND CONSERVATION OF THE SAMPLE

Capillary or venous blood can be used. Clean the skin with a disinfectant solution and wait until the

zone becomes dry. In the case of collection of venous blood, heparinized, oxalate, citrate de sodium

or EDTA tubes can be used because none of these anticoagulants interacts with the test. In case the

test cannot be run immediately, whole blood can be stored a maximum of 72 hours at 2-8°C. Do not

freeze it.

7- PRECAUTIONS

- For diagnostic in vitro use only.

- Do not use after the expiry date.

- Do not to eat, drink or smoke during the handling of the samples and the test.

- Do not pipeting with the mouth. Use disposable gloves and if possible ocular protections when

performing the test. - All patient samples should be handled as capable of transmitting infection.

- All materials used to perform the test should be treated in order to ensure the inactivation of

pathogenic agents.

- Test strips and plastic tubes provided in the kit are intended for single use. Do not re-use.

- Not to exchange reagents from different kits and lots.

- Do not use foreign reagents

- Close the dropper vial after each use.

- Do not use a strip which aluminium pouch had been opened or damaged

8- COMPLEMENTARY PROCEDURE TO QUALITY CONTROL

Good Laboratory Practices recommend the use of positive and negative controls to check the correct

operation of the test. Control samples specific for this product are available separately.

The control line is used for internal procedural control, and indicates the test has been performed

correctly: proper flow occurred and that the test reagents were active at the time of use.

A red colour background along the membrane is normal and indicates a satisfactory lysis of

erythrocytes. In case of a white background on the membrane after migration, the result is invalid.

The test should be repeated with another strip.


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9- STORAGE AND STABILITY

Provided reagents are stable at temperature range of 2 to 30°C. until the expiry date indicated on

the box.

Strip are provided in the aluminium pouch with desiccant and must be stored in the pouch only..

NOT TO FREEZE. The dropper vial has to be closed after each use and conserved with the other components in the box

. After first opening, the vial of lysis buffer is stable until the expiry date indicated on the vial.

10- PROCEDURE

1. In the event of storage at 4°C, let return components of the kit to room temperature, wait 30

minutes for return to room temperature.

2. Open the aluminium pouch right before use and take out the strip.

3. Add 6 drops of buffer in a plastic tube (Fig. 1).

4. Sampling and collection of the sample:

a) Protocol on capillary blood

1. Select the zone of puncture (usually the side of 3rd or the 4th finger). Clean the zone with a disinfectant solution and wait until it dries. (Fig. 2).

2. Finger to be punctured should massaged to increase circulation. Squeeze the finger and pierce it with a sterile lancet.

3. Collect the freely flowing drop of blood directly on the uncovered white zone at

bottom of the strip under the arrows. Remain in contact with the drop of

blood for approximately 5 seconds. (Fig. 3).

b) Protocol on venous blood When venous blood is used, gently mix the tube containing the sample before taking the test specimen. Take 20 µl of blood with a laboratory pipette. The blood sample must then be dropped under the arrows on the uncovered white zone located at bottom of the strip (Fig. 4).

5. Dip the strip in the tube containing the lysis buffer with the arrows pointing downwards (Fig. 5).

Gently hit the dipstick on the bottom of the tube to enhance migration. Keep the strip in the tube

in vertical position for at least 10 minutes.

6. Remove the strip from the tube and lay the strip on shaded zone of the patient card along with

the band model (Fig.6) to read the result.

Important : The test result is only valid up to 15 minutes starting at the moment that the the strip

is dipped in the tube.

7. After the reading, eliminate tube and IMMUNOQUICK® MALARIA falciparum strip

according to local regulations for potentially infectious waste.

11- INTEPRETATION OF THE RESULT A proper reading requires:

- A minimum visual acuity

- Correct lighting conditions

POSITIVE:

Appearance of two distinct bands.

A purple control band appears at the level of

the control zone C and a purple test band appears

at the level of the test zone T.


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The result is positive even if the intensity of the purple test band T is very weak.

The colored test band T may appear before the 10th minute in case of strong positive samples.

Note : In case of strong positive sample, the intensity of control line C may be weak.

NEGATIVE:

Only one purple band appears at the level of the

control band C. No purple band appears at the

level of the test zone T.

The result is negative.

INVALID :

Absence of purple control band C. The procedure was not followed correctly or the

test was defective.

Note : In the case the result is invalid, the test

has to be performed with a new strip and a new

plastic tube.

12- PERFORMANCES CHARACTERISTICS

1)Clinical evaluation

An hospital evaluation of IMMUNOQUICK® MALARIA falciparum was run comparatively to

microscopic parasite examination of thick (Giemsa) and thin (Diff-quick) blood smears. Results are

summarized in the following table :

Number of

samples

Results of thin and/or thick films IMMUNOQUICK® MALARIA falciparum

Negative Positive

50 Plasmodium falciparum positive 0 50

15 Other Plasmodium positive 15 0

28 Absence of Plasmodium 27 1*

* This sample was negative by microscopic examination but was found positive on Plasmodium

falciparum DNA PCR amplification assay confirming the high sensitivity of the test.

2) Interferences

A WHO interference and specificity evaluation was performed:

In a study performed on 84 negative samples for Plasmodium falciparum, a false positive rate of

0.6% in negative samples was observed.

Sensitivity Specificity Negative

predictive value

Positive

predicitive value

50 / (50 + 0) 42 / (42 + 1) 42 / (42 + 0) 50 / (50 + 1)

100 % 97.7 % 100 % 98.04 %

Confidence Interval Confidence Interval

92.9-100% 87.7-99,9% 91.6-100% 89.6-99.9%


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A possible cross reactivity was evaluated assaying samples from 42 individuals with different

clinical conditions that may be cause unspecific reaction with the IMMUNOQUICK® MALARIA

falciparum, this conditions included Chagas, Dengue or Leishmania positive samples. No

interference with other infectious diseases was obtained.

In a population of 54 samples positive with other immunological factors (rheumatoid factors, anti-

nuclear antibodies, heterophile antibodies), the false positive rate has averaged 1.85%.

13- BIBLIOGRAPHY

1. Howard RJ, Uni S, Aikawa M, Aley SB, Leech JH, Lew AM, Wellems TE, Rener J, Taylor DW.(1986). Secretion of a malarial histidine-rich protein (Pf HRP II) from Plasmodium falciparum-infected erythrocytes. J. Cell. Biol. 103(4), 1269-1277. 2. Rock EP, Marsh K, Saul AJ, Wellems TE, Taylor DW, Maloy WL, Howard RJ. (1987). Comparative analysis of the Plasmodium falciparum histidine-rich proteins HPR-I, HPR-II and HPR-III in malaria parasites of diverse origin. Parasitol. 9 (pt 2) 209-27. 3. Parra ME. Evans CB, Taylor DW. (1991). Identification of Plasmodium falciparum histidine-rich

Protein 2 in the plasma of Humans with malaria, J. Clin. Microbiol. 29 (8),1629-34.

4. Rodriguez del Valle M, Quakyi IA, Amuesi J, Quaye JT, Nkrumah FK, Taylor DW. (1991).

Detection of antigens and antibodies in the urine of humans with Plasmodium falciparum malaria J.

Clin. Microbial. 29(6), 1236-1242.

5. Houzé S, Boly MD, Le Bras J, Deloron P, Faucher JF. (2009). PfHRP2 and PfLDH antigen

detection for monitoring the efficacy of artemisinin-based combination therapy (ACT) in the

treatment of uncomplicated falciparum malaria. Malar. J. 7 (8), 211.

6. Murray CK, Gasser RA, Magill AJ, Miller RS. (2008). Update on rapid diagnostic testing for

malaria. Clin. Microbiol. Rev. 21 (1), 97-100.

Protocol:

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Uni%20S%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Aikawa%20M%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Aley%20SB%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Leech%20JH%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Lew%20AM%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Wellems%20TE%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rener%20J%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Taylor%20DW%22%5BAuthor%5D




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Fig.1 : Add 6 drops of buffer in a plastic tube.

Fig.2: Clean the zone with

disinfectant solution and wait until it dries.

Fig.3: Finger to be punctured

should be massaged to increase circulation. Squeeze the finger and pierce it with a steril lancet. Collect the freely flowing drop of blood directly on the uncovered white zone at bottom of the strip under the arrows. Remain in contact with the drop of blood for 5 seconds.

Fig.4: Shake the tube of blood.

Take 20 µl of blood with a laboratory pipette. The blood sample must then be dropped under the arrows on the uncovered white rectangle located at bottom of the strip.

Fig.5 : Dip the strip in the

plastic tube the arrows pointing downwards. Keep the strip in the tube in vertical position for at least 10 minutes.

Protocol on capillary whole blood Protocol on venous blood

Fig 6 : Lay the strip on shaded zone of the

patient card along with the band model. Read the result between the tenth and the fifteenth minute after dipping the strip into the tube.

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