tan kian shing, mimls (mal) - patelkitan kian shing, mimls (mal) b.sc (hons) biotechnology ucsi...

TAN KIAN SHING, MIMLS (Mal)

B.Sc (Hons) BiotechnologyUCSI University, Malaysia

Assistant General ManagerSynapse Laboratory (Synapse Sdn Bhd), Malaysia

Medical Laboratory Scientist with over 10 years of scientific andmanagerial experience in medical diagnostics industry

Particular interest in Nucleic Acid Amplification Testing (NAT) forHepatitis B, Hepatitis C and HIV, Newborn Screening for InheritedMetabolic Diseases (IEM) and Molecular Studies of Thalassaemia

Honorary SecretaryMalaysian Institute of Medical Laboratory Sciences (MIMLS)

SARS-CoV-2Antigen Testing:

TAN KIAN SHING BSc (Hons), MIMLS (Mal)

Assistant General Manager, Synapse Laboratory (Malaysia)Honorary Secretary, Malaysian Institute of Medical Laboratory Sciences (MIMLS)

Preanalytical and Analytical Considerations

WEBINAR PATELKI IX28 June 2020

SYNAPSE SDN BHD is a medical laboratory and healthcare group withstrategic focus on development and implementation of referencetechnologies for healthcare testing.

• Facilitate innovative new technologies in medical sciences with focus onmolecular diagnostics

• Provides medical testing services to government and private hospitals, clinicsand healthcare institutions throughout Malaysia

Our Services:• Nucleic Acid Amplification Testing (NAT) for Hepatitis B (HBV), Hepatitis C (HCV) and HIV• Newborn Screening for Inherited Metabolic Diseases (IEM)• Molecular and genetic testing services• Research and experimental work

Head Office + Laboratory:Unit 203 & 205, Block D, Kelana Square,17, Jalan SS 7/26, Kelana Jaya,47301 Petaling Jaya, Selangor, MALAYSIA.

T: +603-7880 8730 / 8820F: +603-7880 8750

www.synapselaboratory.com

Advancing Excellence In Healthcare Testing

Advancing Excellence In Healthcare Testing

COVID-19 Testingby Synapse Laboratory

In light of the recent COVID-19 pandemic caused by SARS-CoV-2, Synapse Laboratory has set up testingfor COVID-19 in our laboratory to help expand testing capacity for the infection in the country.

• One of the private laboratories certified by Ministry of Health Malaysia to perform COVID-19 rRT-PCR testing• Offers a comprehensive testing solution for COVID-19 that can meet the needs of patients, healthcare professionals,

employers and even third-party administrators

COVID-19 Triple Gene Real-Time RT-PCR• Real-Time Reverse Transcription Polymerase Chain Reaction (RT-PCR) technology for detection of SARS-CoV-2 from suspected patient’s

nasopharyngeal and oropharyngeal swab sample• Simultaneous detection of both E gene and RdRp gene RNA, as recommended by the World Health Organisation (WHO), as well as N gene RNA

COVID-19 Antigen Test• Rapid Chromatographic Immunoassay for the qualitative detection of specific antigens to SARS-CoV-2 in human nasopharynx• Using rapid testing kit that has been validated by the Institute for Medical Research (IMR) and National Public Health Laboratory (MKAK), Ministry of

Health Malaysia for screening of COVID-19

COVID-19 Pandemic in MalaysiaA Quick Glance

• 24 Jan 2020: National Public Health Laboratory (MKAK)detects the first 3 imported COVID-19 cases in Malaysiafrom contact tracing based on communication fromSingapore.

• Institute for Medical Research (IMR) detects 1 positive casein a symptomatic patient (Patient Under Investigation).

• 3 Feb 2020: First Malaysian tests positive for COVID-19(Case No. 9) with history of attending a conference inSingapore involving delegates from China.

• 6 Feb 2020: Malaysia records its first human-to-humantransmission of COVID-19.

• 16 Feb 2020: Case No. 22 marks the last case in the firstwave and Malaysia subsequently experience zero case until11 days later – the 2nd wave.

Source: The COVID-19 Chronicles of Malaysia, National Institutes of Health, Ministry of Health Malaysia


• 27 Feb 2020: MOH detects 1 case - the starts of the2nd wave.

• 27 Feb - 1 March 2020: A religious event took place ata mosque in Sri Petaling, Kuala Lumpur andsubsequently become the country’s largest cluster -The Sri Petaling Cluster.

• 11 Mar 2020: The International Health Regulations(IHR) Focal Point for Brunei informs Malaysia of thetravel history of a case detected in Brunei Darussalam.The patient had attended a religious gathering in SriPetaling. Estimates gauge 10,000 individuals fromseveral countries, including Malaysia, participated inthis gathering.



• 16 Mar 2020: Malaysian Government announcedMovement Control Order (Perintah KawalanPergerakan) - a nationwide lockdown effective 18March 2020.

• 17 Mar 2020: Malaysia sees first 2 death cases fromCOVID-19.

• 25 Mar 2020: Movement Control Order extended for14 days. Subsequently extended to 28 April 2020,followed by Conditional MCO till 9 June 2020.

• 10 June 2020: Malaysia entering into RecoveryMovement Control Order (Perintah KawalanPergerakan Pemulihan) through August 31, 2020.


Source: MOH Malaysia

Source:

Source: Kenyataan Akhbar Ketua Pengarah Kesihatan 26 Jun 2020 – Situasi Semasa Jangkitan Penyakit Coronavirus 2019 (COVID-19) di Malaysia

COVID-19 Testing in Malaysia

• Real-Time RT-PCR• Performed by 53 laboratories in Malaysia:

• Virology Unit, Institute for Medical Research (IMR),MOH

• 14 State Hospitals, MOH

• 5 Public Health Laboratories (MKA), MOH

• Hospital Angkatan Tentera Tuanku Mizan (MilitaryHospital), MinDef

• Malaysia Genome Institute, MOSTI

• 14 universities and university hospital’s laboratories

• 17 private medical laboratories evaluated by MOH


• Real-Time RT-PCR• Gold standard

• Detects presence of SARS-CoV-2 RNA

• E gene and RdRp gene RNA as recommended by WHO

• Some with additional N or S genes

• Sample type:

• Nasopharyngeal (NP) AND Oropharyngeal (OP) Swabsin Viral Transport Medium (VTM)

• Sputum (if produced), tracheal aspirate orbronchoalveolar lavage (for symptomatic patient)

• Used to detect current / on-going infection


• Antigen (RTK)• Using Rapid Test Kit which has been validated by

Institute for Medical Research (IMR) and National PublicHealth Laboratory (MKAK), MOH

• Performed by laboratories with Biosafety Cabinet (BSC)

• Screening at country’s entry point at KLIA and KLIA2 andfor transit passengers to Sabah and Sarawak

• For Sabah and Sarawak: Vast and logistics are challenging

• Detects presence of viral proteins

• Sample type: Nasopharyngeal swab

• Used to detect acute / early phase of infection


• Antibody (RTK)• Using Rapid Test Kits which has been validated by

Institute for Medical Research (IMR) and National PublicHealth Laboratory (MKAK), MOH

• Detects presence of antibody in infected individuals

• Day 13 of quarantine for close contact:• Ab negative: Allow discharge

• Ab positive: Do PCR test to confirm

• Sample type: Blood (whole blood, serum or plasma)

• Used to detect convalescence phase / past infection

IgM/IgG Antibody Test

Antigen Test

PCR Test


• Malaysia is among the countries with the highestnumber of COVID-19 testing among other ASEANnations

• Malaysia’s testing rate of 13 people per 1,000population (as of 15th May 2020)

• Singapore: 25 tests per 1,000 population

Source: South China Morning Post, 28 April 2020https://www.scmp.com/news/world/united-states-canada/article/3081819/coronavirus-latest-3-million-people-infected

Source: The Edge Markets, 15 May 2020 https://www.theedgemarkets.com/article/malaysia-among-asean-countries-performing-most-covid19-tests-%E2%80%94-health-dg

• Indonesia: 0.5 tests per 1,000 people

• United States’ testing rate is 16 people per 1,000 while the UnitedKingdom’s is 10 per 1,000 population

Source: MOH Malaysia

Malaysia’s Daily COVID-19 Testing Capacity:

• March 18: 6,210 tests per day

• June 25: 36,812 tests per day

Testing is the key to defeating this pandemic!

Preanalytical Considerations

• All specimens must be considered potentially infectious

• Wear Personal Protection Equipment (PPE) whileprocessing samples:• N95 mask or equivalent

• Eye Protection - face shield or goggles

• Disposable isolation gown (fluid-repellent longsleeved gown)

• Gloves

• Transportation of specimens to be within leak-proofcontainers (triple layer packaging)

• Not recommended to use pneumatic transport systemsdue to risk of aerosol release


• Within 5 to 6 days of the onset of symptoms, patients withCOVID-19 usually demonstrate high viral loads in their upperand lower respiratory tracts

• Nasopharyngeal (NP) and/or Oropharyngeal (OP) swabs arerecommended for screening or diagnosis of early infection

• Flocked swabs feature perpendicular nylon fibers that optimizespecimen collection and elution into transport media (for PCRsamples)

• DO NOT use calcium alginate swabs or swabs with woodensticks as they may contain substances that inactivate someviruses and inhibit PCR assays.

Source: Tang Y-W, Schmitz JE, Persing DH, Stratton CW. 2020. Laboratory diagnosis of COVID-19: current issues and challenges. J Clin Microbiol 58:e00512-20.


Unlike Antibody RTK that uses blood samples from afinger prick:

• Nasopharyngeal and/or oropharyngeal sampling needto be performed by trained healthcare professionals

• This procedure potentially increased the risk oftransmission of the virus to healthcare workersespecially to those who lacked sufficient PPE

• Nasopharyngeal sampling is an invasive process thatcan cause considerable distress to patient

• Poor sampling and inappropriate handling byinexperienced staff might cause false negative results


• Ministry of Health Malaysia in collaboration withhospitals and private medical service providerslaunched home-based COVID-19 sampling services

• Allows those who wish to have the infection testedbut do not meet the criteria as a patient underinvestigation (PUI) to get undergo testing

• Enable people with no symptoms to undergoCOVID-19 testing at home without having toattend a health facility


• Home-based sampling service performed bytrained private medical practitioners andparamedics

• Specimen sent to private laboratories for analysis

• Ease the presence of the public to conduct COVID-19 testing in government hospitals and healthclinics

• Subject to charges imposed by the private serviceproviders

• Available for PCR testing only


• Ministry of Health Malaysia also provide drive-thru screening services for COVID-19 testing atselected health clinics in the country.

• Many private hospitals and laboratories inMalaysia also offered drive-thru screeningservices for COVID-19 testing

• Make COVID-19 testing more convenient andeasily available to the community

• Available for PCR testing only


Source: Annex 5C Guidelines COVID-19 Management No.5/2020Ministry of Health Malaysia

Triple Layer Packaging

• First layer: Label Viral Transport Medium (for PCRsamples) or Swab Container (for Antigen RTK) withpatient’s name and ID, and ensure cap is properlytighten before insert into a sealable biohazard bag




• Second layer: Put the VTM or Swab Container withsealable biohazard bag into a clean, empty screw-capped container

• Wipes the outer part with disinfectant

• Label the container with patient’s name and ID




• Third layer: Put container into styrofoam box withice pack to maintain temperature of 2-8°C

• Or alternatively specimen carrier bag or anothercontainer


• Specimen should reach laboratory as soon as possible after collection

• Specimens that can be delivered promptly to the laboratory can bestored at 2-8°C, or alternatively store at -80°C if transportation ofsamples is more than 72 hours (only for PCR samples)

• For swab specimen of Antigen RTK, specimen should be tested within 4hours after specimen is collected

• Samples to be processed in Class 2 BiologicalSafety Cabinet (BSC Class II) as there is a riskof spilling the specimen during the mixingprocess

Analytical Considerations

• Selection of a suitable assay is very important aslaboratory testing is key to beating the COVID-19 pandemic

• Immunoassays have been developed for rapiddetection of SARS-CoV-2 antigens or antibodies

• These rapid point-of-care immunoassays aregenerally lateral flow assays for detectingantigens or antibodies (IgM & IgG) againstCOVID-19

• High-throughput immunoanalyzer assays are alsoin development for population-level screening


• RTK provides advantage of a fast time to resultand low-cost but limited sensitivity especially inearly infection

• Given the variability of viral loads in COVID-19patients, antigen detection may also miss casesdue to low infectious burden or samplingvariability

• IgM responses are nonspecific, and given theweeks required to develop specific IgG responses,serology detection is not likely to play a role inactive case management


• For geographically vast and resource-limitedcountries, RTK testing especially Rapid AntibodyTesting is commonly being used

• Point-of-care testing: Rapid and on-site testing

• Processing of COVID-19 PCR / Ag samples requirespecialised biocontainment laboratories (BSL2)operated by highly trained laboratory personnel

• COVID-19 pandemic is pushing these testingfacilities to their capacity limit - sample backlogand longer turnround time!

• Shortage of reagents, consumables


• A person tested Antibody (RTK) negativeneeds to be re-tested again on Day 7

• A person tested Antibody (RTK) positiveneeds to proceed with PCR testing asconfirmation

• 11 May 2020: Antibody RTK for COVID-19or serological tests that use blood samplesfrom a finger prick cannot be used todiagnose the disease - Director-General ofHealth Malaysia, Datuk Dr Noor HishamAbdullah

Source: Director General of Health Malaysia’s letter to PERKESO dated 21 April 2020

• Presence of antibodies cannot confirm activeinfection

• Negative antibody test result does not guaranteethat the tested individual is free of COVID-19infection

• Can be used to conduct COVID-19 sero-prevalencestudies in the community or in targeted populations

• World Health Organization (WHO): Antibody RTK canbe used in surveillance activities andepidemiological research

• No evidence so far that people who have recoveredfrom COVID-19 and produced antibodies are immuneor protected from a second infection

Source: WHO - "Immunity passports" in the context of COVID-19https://www.who.int/news-room/commentaries/detail/immunity-passports-in-the-context-of-covid-19

Comparison of PCR vs Antigen RTK

Source: Science Valley Sdn Bhd (Distributor of SD Biosensor in Malaysia)

Rapid Antigen Testing in Malaysia

• 16 April 2020: Ministry of Health Malaysiaapproved the use of Antigen RTK from SouthKorea to help Malaysia boost its COVID-19testing capacity

• The test kits undergone evaluation by IMR andmet the Ministry’s accuracy requirement with asensitivity rate of 84.4% and a specificity rateof 100%

• First batch sent to Sabah and Sarawak to helpboost COVID-19 testing as the two states arevast and the logistics are more challenging


Guideline on COVID-19 Testing Using Rapid TestKit (RTK-Ag) for Health Facilities, Ministry ofHealth Version 2.0 (dated 22 May 2020):

• RTK-Ag has the advantage of detecting COVID-19outbreaks quickly and in large quantities

• Since sample used is from NPS - an area with highpotential for viral content, sampling should be performedby fully trained health personnel using appropriate PPE.

• Test should be conducted in the Biological Safety Cabinet(BSC) Class II as there is a high risk of spilling thespecimen during the mixing process between the swaband extraction buffer solution.


• The use of RTK-Ag is made priority in cases or samples that require urgent result for aprompt patient management to be given.

• List of appropriate cases / samples as follows:• Emergency and semi-emergency procedures or surgical cases with high probability of COVID-19

infection

• Brought in dead (BID) cases with high probability or high suspicion of COVID-19

• Screening for Severe Acute Respiratory Infection (SARI) and Influenza Like Illness (ILI)

• A wider coverage for screening in the area of Enforced Movement Control Order (EMCO)

• Screening under the order from Pegawai Kesihatan Daerah

• OKT (Orang Kena Tahan) to Depoh Tahanan Imigresen (DTI)

• PATI (Pendatang Asing Tanpa Izin) who is locked in prison cell less than 6 months and transfer to DTI

• Screening at the country’s entry point KLIA and KLIA2

• Government Servants who travel to Sarawak since 4 June 2020

Source: MOH Malaysia and Science Valley Sdn Bhd (Distributor of SD Biosensor in Malaysia)


• Importation and placement of a medical device in the Malaysian market requiresthe device to comply with the requirements of the Medical Device Act 2012 (Act737) and the medical device shall be registered with the Medical DeviceAuthority (MDA)

• Medical Device (Exemption) Order 2016 however has provided for exemptionfrom registration requirements of certain medical devices through special access ifthey fulfill the criteria and submit a notification to the Authority

• This is to ensure the availability of medical devices in healthcare facilities, tominimise a disruption of treatments during an emergency situation such asduring the COVID-19 pandemic period


Source: Science Valley Sdn Bhd (Distributor of SD Biosensor in Malaysia)


Source: Guideline on COVID-19 Testing Using Rapid Test Kit (RTK-Ag) for Health Facilities, Ministry of Health Version 2.0 (dated 22 May 2020)

SIMKA = Sistem Informasi Makmal Kesihatan Awam


COVID-19 RTK-Ag testing by team of Ministry ofHealth Malaysia’s Medical Laboratory Technologistsat Kuala Lumpur International Airport (KLIA) andklia2:

• 9 units of Biological Safety Cabinet (BSC) at KLIA

• 4 units of Biological Safety Cabinet (BSC) at klia2

• 2 operators each BSCs

Photo credit: En. Sanadi and MLT team at KLIA/klia2


Photo credit: En. Sanadi and MLT team at KLIA/klia2


• Preanalytical and analytical challenges for COVID-19Rapid Antigen Testing varies among different types oflaboratories

• For standalone laboratories:• Unlike hospital lab, patient sampling is not conducted within

the same building or premise

• Nasopharyngeal swab must be properly packed in triplepackaging with ice pack to maintain temperature of 2-8°C

• Ensure specimen was brought back to the laboratory fortesting within 4 hours

• Numbers of Biological Safety Cabinet (BSC) Class II must besufficient to ensure testing for all samples received can bedone within the 4 hours period


• For on-site screening facilities e.g. KLIA:

• Numbers of Biological Safety Cabinet (BSC) Class IImust be sufficient to ensure testing for big batch ofsamples can be performed fast enough to avoidlong queue (social distancing)

• Ensure sufficient number of laboratory personnelto carry out the testing in a timely manner(preferably 2 operators each BSC)

Thank you for listening!Terima kasih!

Any enquiries, please email to:

[email protected]

tan kian shing, mimls (mal) - patelkitan kian shing, mimls (mal) b.sc (hons) biotechnology ucsi...

Documents