U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

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FOOD AND DRUG ADMINISTRATION

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CENTER FOR DEVICES AND RADIOLOGICAL HEALTH

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SARS DIAGNOSTICS:

SCIENTIFIC AND REGULATORY CHALLENGES

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PUBLIC MEETING

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MONDAY

JULY 14, 2003

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The Public Meeting was held in The Plaza Ballroom, Double Tree Hotel and
Executive Center, 1750 Rockville Pike, Rockville, Maryland, and called
to order at 8:00 a.m., **Dr. David Feigal, Jr.**, CDRH Center Director,
presiding.

[PARTICIPANTS]{.underline}:

LARRY ANDERSON, MD NCID, CDCP

DAVID FEIGAL, JR., MD, MPH CDRH, FDA

MARIA Y. GIOVANNI, Ph.D. NIAID/NIH

MARK GOLDBERGER, MD, MPH CDER/FDA

STEVE GUTMAN, MD CDER/FDA

JIM KOZIARZ, Ph.D. Abbott Laboratories

LINDA LAMBERT NIAID, NIH

MURRAY M. LUMPKIN FDA

MARK MCCLELLAN, MD, Ph.D. FDA

JOSHUA METLAY, MD, PH.D. CCEB

[PARTICIPANTS]{.underline}: (Continuing)

JANET K.A. NICHOLSON, Ph.D. NCID

DAVID NORWOOD, Ph.D. U.S. Army Medical Research

Institute of Infectious

Disease

STEPHEN OSTROFF, MD NCID, CDCP

MALIK PEIRIS University of Hong Kong

Queen Mary Hospital

BETTY H. ROBERTSON, Ph.D. NCID, CDCP

PATRICIA A. SOMSEL, Dr.P.H. NICP & Biological Products

MARIA ZAMBON, BM, BCH, MA Enteric,

Respiratory & Neurological Virus Laboratory

[STAFF]{.underline}:

VICKI BABB, Pharm.D. CDRH, FDA

MONICA CANCINO CDRH/FDA

SHIRLEY MEEKS CDRH/FDA

JENNIFER L. WEBBER LCG, Inc.

I-N-D-E-X

**Opening Remarks** \-- Mark McClellan 4

**Elements of FDA Review for a New Diagnostic** 18

**Assay** \-- Steve Gutman

**Session I \-- Evaluation of SARS Diagnostics**

Steve Gutman, Moderator

**Experience with SARS Laboratory** 29

**Diagnostics**, Malike Peiris

**Laboratory Testing in China**, Wang Youchun 39

**UK Experience**, Maria Zambon 49

**Real Time Under IDE \-- CDC\'s PCR and** 67

**ELISA Investigational Protocols**, Betty Robertson

**Evaluating a New Diagnostic Assay:** 76

**Industry Perspective**, Jim Koziarz

**NIAID Funding Opportunities**, Maria Giovanni 90

**Session II \-- Incoporating Diagnostic Testing**

**into Clinical and Public Health Practice**

Mark Goldberger, FDA

**Clinical Perspective**, Joshua Metlay 119

**Public Health Perspective**, Stephen Ostroff 136

**Session III \-- Specimen and Control Materials for**

**Test Development and Evaluation**

Janet Nicholson, Moderator

**WHO Agenda for Test Development and** 158

**Evaluation**, C.E. Roth

**Experience with Collecting and Banking** 173

**Specimens**, Larry Anderson

**Specimen Handling**, Patricia Somsel 183

**Using Non-Human Sourced and Banked Human** 199

**Specimen Material**, David Norwood

**Research Sources**, Linda Lambert 209

**National Taiwan University Hospital** 231

Pei-Jer Chen

**Partnerships: Round Table** 245

**Wrap Up and Adjourn** 320

P-R-O-C-E-E-D-I-N-G-S

COMMISSIONER McCLELLAN: ‑‑ to new diseases with timely development of
diagnostics and therapeutics as well as public health control measures.
And we\'re here today to try to do some work towards more enduring
solutions to these problems that I think are going to be with us for
quite a while to come.

The best defense against any outbreak is robust science and public
health practice that can be applied effectively into safe and effective
treatments as quickly as possible. More attention and resources need to
be devoted to this end, and we need to recognize that effective
strategies will require building on the kinds of global coordination and
partnerships around the world that have been in many ways a hallmark of
the response to this illness.

Since the very beginning of the SARS outbreak, the professional staff at
FDA and the professional staff throughout the Department of Health and
Human Services in the U.S. government have worked hard and quickly to
help contain it. I\'d particularly like to acknowledge the work of the
Centers for Disease Control, Dr. Ostroff is here today with us, on both
themselves and with the World Health Organization and other public
health authorities in disease containment and identifying and responding
to this new threat, as well as the National Institutes of Health,
particularly the National Institute of Allergy and Infectious Diseases,
and many other federal government agencies as part of HHS as well;
USAMRIID, Department of Defense have also contributed.

As a result of all of these efforts, both here in the United States and
around the world, we identified the etiologic agent for this illness and
implemented some quite effective, largely voluntary quarantine measures
for its containment. Also, we\'ve made some real progress toward
reliable, quick and easy to use diagnostic tests with private developers
building on some of the early insights from the government labs and
research work related to diagnosing the disease.

After SARS was first identified, our Center for Biologics here at FDA
immediately issued guidance on blood screening to take account of the
potential implications of SARS for blood exposure, and in many other
ways we were working as part of a broad coordinated international
effort, for example, working with the CDC and private developers of
diagnostic tests to help support the rapid development of SARS
diagnostics.

This is part of a broad and coordinated international effort from people
around the world joining to identify the etiologic agent and develop
hopefully diagnostic tests and reliable treatments in a timely way as
well. We\'re not there yet, there\'s still a ways to go. We need to move
from the concepts that we\'ve proven about this virus to the development
of safe and effective treatments. This is a complicated process that
will require coordinated efforts across many different disciplines, but
I\'m quite hopeful that we\'ll succeed.

We\'ve made a significant amount of progress already. Already a number
of first generation tests, including a relatively quick PCR test
developed by the Centers for Disease Control and subsequent versions of
PCR developed by private companies, are able to probe for viral presence
in serum samples. And, in addition, viral culture tests and ELISA tests
for comparing acute and convalescent sera have been developed as well.
These latter tests are clearly important for epidemiologic purposes, but
obviously for clinical benefits, a rapid and reliable test that can be
used in the acute phase of the illness is most important for guiding
therapy as well as other public health decisions. Even though no
specific therapies have yet been fully demonstrated to be beneficial for
SARS patients, rapid and accurate diagnosis would be useful for ruling
out other illnesses that might require different treatments and would
also be useful for targeting public health measures efficiently, for
example, in avoiding unnecessary quarantines or delays in travel and
international commerce.

The FDA has worked closely with the CDC, NIH and leaders from across the
globe in putting this program together today to help us address the next
steps on these issues. And, again, we\'re very grateful for everyone\'s
effort, including researchers who have traveled here from a very long
way away to help make this event possible. And we hope that it can serve
as an important step forward for international collaboration on other
global health problems.

In the case of SARS, the need for sharing information and specimens and
the need for close collaborative work between governments and industry
from around the world was quite self evident from the very beginning.
And so as a result, we held a meeting early between Secretary Thompson
and leaders from the medical diagnostics community and we were charged
by the Secretary as part of that meeting with sponsoring with this
follow-up workshop to allow for open public discussion of the issues as
a way of formulating a more effective plan for the next steps in making
reliable diagnostic tests available.

This is not something that\'s completely new for FDA. Our experience
with the West Nile virus provides a model for how we can go forward
here, although there are some important differences as well. In the case
of West Nile virus, a major public health threat that emerged in full
force last year, our Center for Biologics worked closely with the blood
and diagnostics industries in order to facilitate the development of
what are now widely available investigational tests for West Nile virus.
This is going to allow us to screen the entire U.S. blood supply within
only nine month of the initial steps towards the development of these
tests.

The model for accomplishing this included early communication and
scientific exchange with industry to identify our priority public health
needs and to encourage interest and engagement of appropriate industry
expertise. In addition, the use of workshops very much like this one
today as well as continued close interactions with product developers on
both the private sector and the public sector helped establish some
suitable product specifications and methods that were widely accepted
for validating potential diagnostics. And we also helped assure the
availability of needed samples of strains and reagents. Each of these
elements in our West Nile virus response was critical.

The FDA\'s Center for Devices has also worked closely with industry to
quickly and thoroughly evaluate and approve a new diagnostic test for
West Nile virus, a test that now provides this capacity for a same-day
result. And we\'re looking for the same kinds of progress in SARS.
We\'re looking forward to achieving the same kinds of results. We
recently allowed an investigational device exemption, an IDE, to proceed
to allow the availability through CDC of investigational SARS diagnostic
testings. So all of us by working together are making some real and
rapid progress on SARS diagnostics.

But as you know, there are a number of remaining challenges when it
comes to developing accurate and reliable diagnostic tests for SARS.
First, it\'s been difficult for diagnostic test developers to get access
to standardized samples for test validation. I hope we can continue to
work on ways to improve our ability to meet this challenge. If SARS
reemerges this coming winter or at some other time in the future, most
of the samples that would be needed for further test development are
unlikely to be from the United States, yet the disease may potentially
have worldwide impact in a short time period, including here in the
States.

We may well need to work with samples that have been spiked with virus
in lieu of real, well-collected samples from actual patient cases in the
meantime. We also need to determine what standard capabilities should be
demonstrated for a test to gain regulatory approval given the various
strains of the virus, various samples out there and the possibility that
the virus or the sampling needs may change further. We probably need a
standardized panel of virus samples to test prospective diagnostics in
order to validate the results, and if that\'s the case, we need to
decide what the panel should include, or, if not, what alternative
standards for test approval should be developed for benchmarking.

We need to determine how much clinical benefit must be needed for
approval of a new test. In that meeting that I mentioned between the
Secretary and some private companies, for example, they expressed a
desire to focus an initial approval decision on analytic sensitivity
claims for detecting a virus. And given the clinical characteristics of
this disease, a test must be able to detect a small number, a small
viral titre. This would presumably be used for an initial approval in
labeling and then further field studies would be done after that initial
approval with appropriate modifications to be made on the labels. Is
this a possibility that we want to pursue? Well, if so, we need to more
fully delineate the approach.

Many other issues come up as well. One that was mentioned prominently by
product developers in our discussions with them was reimbursement. An
extensive discussion of this issue is probably well beyond the scope of
today\'s meeting. However, it\'s clear that the more validated and
well-accepted a new test is the easier it will be for that test to
obtain reimbursement.

So these are just a few of the remaining questions that have brought us
together here today. I\'m confident that our work here will take us in
useful new directions towards resolving these challenges, and I hope
that the exchange of information about diagnostic test development and
resources today will enable us to refine and further develop the
diagnostic tests we brought to market. Thanks to a quite effective
worldwide public health response, as I mentioned, SARS is on the decline
right now, but it could very well return. And this is not the last
serious new infection we\'re likely to face. We need to recognize that
SARS is only one of a series of new and potentially deadly infectious
diseases that have emerged and that may emerge in the years ahead, not
to mention old diseases that have resurged often in new and more
frightening forms as a result of developed drug resistance. And still
worse, we live in an era when we need to think seriously about the
potential for intentional use of biological agents as weapons of harm,
possibly even with genetically engineered organisms produced to enhance
their lethality or infectivity.

And so with a smaller and closer and in some ways more dangerous world
from the standpoint of infectious diseases, we all need to be better
prepared, not just to identify the etiologic agent when a new infection
emerges, but to develop effective diagnostic tests and therapies as
well.

Several decades ago there was a lot of optimism that the threat of
infectious diseases was receding as a result of technological advances,
including new types of antibiotics as well as effective vaccines along
with improved sanitation. This was especially true in the industrialized
world. We know today that that optimism in many cases was premature. It
didn\'t take into account many critical factors such as the huge
increases in international travel, immigration and trade or the movement
of people into urban settings where the opportunities for disease spread
are amplified.

Our optimism didn\'t take into account changing agricultural practices
and environmental manipulations that alter disease vectors and alter
opportunities for exposure. It didn\'t take into account the continuing
difficulties in translating existing medical knowledge and tools into
effective action, effective diagnostic and therapeutic treatments for
those who need it. And it didn\'t take into account the resilience and
adaptability and new forms that have emerged in the microbes themselves.

So as we enter the 21st century, infectious diseases continue to burden
people around the world. These infections hold increasing potential to
cause sickness, disability and death unless we fine new and more
effective ways to respond. The ability of infectious agents to
destabilize populations, to have major economic impacts as well as to
cause significant loss of life and morbidity is fast becoming an
unfortunate fact of life. One nation\'s problems in this regard soon
become every nation\'s problem.

Over the past decade, we\'ve taken a number of steps in the United
States to strengthen our capacity to address the threats posed by
infectious agents, but the present reality is that we have more to do.
Looking ahead, we need to realize that public health is public safety
and an essential part of our national and international security
programs. There have been dramatic advances in science, technology and
medicine which have permitted great strides forward in our ability and
our struggle to prevent and control infectious diseases, yet we need to
do more. The emergence of SARS, a previously unidentified microbial
threat is an example of our continuing vulnerability.

So we\'ve learned from SARS already that surveillance is critical, that
surveillance works, early detection of a pattern of symptoms early
enough to contain it has given us a degree of control in just a matter
of months for this disease. But we also know that we still have more to
learn about the disease so that we can develop the tools needed to
prevent and contain it.

What was different this time with SARS is that there were only a few
cases in the U.S. and only a limited number of cases by many infectious
disease outbreak standards worldwide. And so while our public health
measures for containment have been quite effective, it\'s been
challenging to take the steps needed to develop and validate diagnostic
tests. This challenge is likely to apply not only in identifying a new
coronavirus like SARS but also in developing diagnostic tests in a
timely fashion for other new and emerging infectious diseases in the
future. This won\'t be the last time we face a deadly new infection.
Improved and rapid international collaboration in test development
standards is an essential part of speeding that life cycle along beyond
the stage of disease containment and making sure that we can provide
effective diagnoses and treatments.

And so we need to work now to create a system that will really work and
so that we can be prepared for the next attack, whether it\'s a natural
one or an act of terrorism or something in between. Our continued
efforts to identify and contain SARS remind us that we must always be
ready today for the unexpected health threats of tomorrow. And while
it\'s never going to be possible to fully prepare for every potential
threat, there\'s a great deal that can and should be done.

So like David mentioned earlier, I view this conference as a very
important step, not only from the standpoint of SARS but also from the
necessary goal of improving our ability to work together worldwide to
speed the development of reliable and effective and inexpensive
diagnostic tests. It\'s an essential step in disease containment and
it\'s a step that we\'re going to need to make sure it can work more
effectively in the years ahead given the public health challenges that
we face.

I want to thank all of you again for coming and very much look forward
to hearing about the results of this conference as we continue to work
together worldwide to meet the important public health challenges of
emerging infectious diseases. Thank you.

(Applause.)

MR. GUTMAN: Good morning. My name is Steve Gutman. I\'m in the Office of
In Vitro Diagnostics. I would like to start by thanking the Commissioner
and Dr. Feigal for being the spark behind this meeting, members of the
Office of In Vitro Diagnostics and members of Dr. Feigal\'s central
office in particular, Vicky Babb and Cassie Miller, for being the fuel
behind this meeting, and like the Commissioner, I would like to thank
all of you for coming, some from rather long distances and all on rather
short time to participate in this meeting.

In spite of what is nothing short of an explosion in knowledge about
SARS since the first reports early this year, it is fair to say that
there are still many unknowns about this disease and its pathogens.
Evaluations of laboratory diagnostics for SARS, as has already been
pointed out, has been challenging, in part, by non-specific and changing
case definitions, by specimen availability and access problems, by the
urgency of the public health needs and by the complex spectrum of
diagnostic needs.

From the FDA perspective, products for SARS coronavirus are Class III
devices. These are high-risk devices because the results are used to
communicate information for managing a highly contagious virus causing a
potentially fatal disease with many unanswered questions. There are no
obvious predicates, and use of these devises raises new issues of safety
and effectiveness. From the FDA perspective, ASRs for SARS would also be
Class III because they are used in the diagnostic of a contagious
condition that is highly likely to result in a fatal outcome, and
accurate diagnosis offers the opportunity to mitigate the public health
impact of the condition.

To date, as the Commissioner has already pointed out, FDA\'s experience
has been interacting with firms and entities in the investigational
stage of development. There are, to remind you, a variety of different
levels of oversight in FDA regulation of investigational diagnostic
devices. Depending on the device, the nature of the investigation in
place and the impact and use of test results generated, IVD
investigations may require an investigational device exemption or IDE
subject to FDA review, may require an abbreviated IDE subject to local
IRB review or may in fact be IDE-exempt.

We have, as the Commissioner pointed out, approved one highly visible
IDE from CDC for a nucleic amplification assay. The two agencies worked
closely and collaboratively on this IDE. As a result, what is
underappreciated is the fact that an approvable letter was issued the
day after receipt of this submission. Reagents for a CDC ELISA assay are
also being used under IDE, in this case an abbreviated IDE.

So the FDA experience would belie the notion that IDEs are particularly
burdensome. Neither the patient safety controls put into place by an IDE
nor the protocols inherent in ensuring proper data collection are unique
to the IDE process. It would be our view these are core requirements for
good investigational practice in the year 2003 with or without FDA
regulation. And the IDE, in fact, offers unique opportunities for
investigational use of a new test. Two perks are allowance for both cost
recovery and potentially for rather broad use by sponsors with a
provision of expanded treatment access.

While there are a wide menu of regulatory tools available to FDA, the
fundamental issues focus on the safety and effectiveness of a new
diagnostic device. Both of these terms are actually defined in our Code
of Federal Regulations. Safety is the reasonable assurance that the
probable benefits to health from use of the device outweigh any probable
risks. And effectiveness is the reasonable assurance that use of the
device for its intended use and conditions of use will provide
clinically significant results.

For in vitro diagnostics, there is a unique synergy between these two
terms. The safety of a diagnostic device is not related to its
interaction or contact with a patient per se, it is instead a function
of the impact of the information generated; that is, a balance between
the benefits and risks of true versus false positive and negative
results.

The flexibility for FDA to consider various kinds of scientific evidence
in making decisions about the safety and effectiveness of a new
diagnostic may also be underappreciated. While the scientific evidence
presented is most commonly well controlled investigations or
observations, other evidence can be used, including partially controlled
studies, studies and objective trials without match controls, well
documented case histories conducted by qualified experts, results of
significant human experience or any combination of the above.

New assays are usually developed using a scientifically and acceptable
and carefully designed two-stage approach. First is the process of
procedural optimization. This requires that all elements of the assay be
carefully defined and that feasibility studies be performed to gather a
knowledge base to set up appropriate cutoffs, controls and challenges
appropriate for the assay. Second is the proof of concept or performance
evaluation performed to help define performance, that is safety and
effectiveness. This two-stage approach allows for proper labeling and
informed product use.

Among the most important parameters that need to be set up-front in
designing a new assay are the target organism or analyte, the intended
use and the technology to be applied. These are critical to both the
optimization phase and to the proof of concept for an assay, and
they\'re key factors in determining appropriate study design and minimum
data requirements. Additional important parameters in defining an assay
are the samples to be used, the methods and materials to be employed and
the endpoints of interest.

Feasibility studies should be grounded in knowledge of the biologic
nuances at play. One cannot cogently understand the analytical strengths
and weaknesses of an assay without also having knowledge of levels of
analyte expected to be seen during the course of a disease. Questions
central to feasibility studies include the ability of an assay to detect
analyte in a clinically relevant range, to detect analyte variance of
the organism, to distinguish the analyte from other non-analyte
organisms and to yield reproducible results. These types of studies can
often be performed using contrived or spiked samples, using banked
samples and/or using carefully selected clinical samples.

Once estimates of performance have been established in feasibility
studies, the proof of concept is ideally sought. To ensure that proof of
concept studies adequately provide insight into real-world performance,
optimal studies should be done using real-world operators, real-world
samples and carefully defined yardsticks for truth. This allows for
estimates of sensitivity and specificity of test results and for
reasonable assessment of interpretive criteria.

Once common core scientific principles are addressed, studies for any
particular methodology may require a whole accompanying set of unique
issues. For nucleic acid amplification technologies, challenges include
issues of inhibition, contamination and characterization of performance
against appropriate standards. For direct antigen testing, issues of
specimen preparation and dealing with background, straining or
interference may be unique and problematic. For serological testing,
obviously the timing of collection and the natural and unnatural
fluctuations in antibody appearance may be of special interest.

The most common question FDA is asked on the development of new
diagnostics and the most problematic question is how many samples is
enough samples to provide enough information to characterize
performance? This is unfortunately sometimes akin to the question, how
many angels can dance on the head of a pin? There is unfortunately not
always a single or pat answer to the numbers question. The number of
samples required to characterize a new assay depends on statistical and
biological variables, including the pre-knowledge of clinically useful
endpoints, clinically required level of confidence, the ability to
account for biases and any design limitations that might be identified.

FDA is very sensitive to the challenge of obtaining specimens with rare
pathogens such as SARS but from patients with any unusual infections,
and we have a long history of working with companies to design
scientific valid approaches for establishing safety and effectiveness
under unusual circumstances.

A major objective of the meeting today, as both Dr. Feigal and the
Commissioner have pointed out, is to find mechanisms for discussing how
labs, companies and interested research parties can work collaboratively
to assist each other in obtaining and sharing access to specimens and in
understanding the principles needed to standardize performance
yardsticks. Patient samples, which are the gold in this El Dorado, must
be selected carefully, stored carefully, collected with insight in terms
of understanding potential selection and/or verification bias in
gathered data sets. This will be possible only if mechanisms for
conserving and sharing effectively for the greater good can be
delineated.

To aid in a good evaluation of new diagnostic products, there is a rich
and growing literature available for method evaluation, there are dozens
of voluntary standards, and FDA has itself published dozens of guidances
of use in eliciting good studies for in vitro diagnostic devices.
Nonetheless, we recognize that there are many challenges to good
evaluation and many reasons to approach this area with the full intent
and spirit of the law that is charging us with being least burdensome in
pre-market review. The public health stakes are high, and we are intent
on charting a proper course. We are hopeful that this workshop will
provide great opportunities for dialogue that will help us collectively
work towards rapid availability of diagnostic tests, not just for the
detection of coronavirus but for other rapidly needed and badly needed
diagnostics.

Okay. We\'re going to begin Session 1. Dr. Giovanni and I will be
co-moderating that session, and we would like to ask all the session
participants to please come to the front table.

(Pause.)

MR. GUTMAN: Okay. A couple of ground rules. We\'re going to be a bit
informal this morning, so we\'re going to ask the speakers to introduce
themselves. That way we won\'t garble the names, and we also won\'t get
the affiliations mixed up. As you may have gathered, this was put
together on the fly with information coming into us literally as late as
last night, and we\'ve decided to share our moderating duties with our
participants. So that\'s informal.

What will be formal is the structure itself. We\'re going to try and
keep our participants honest men and women and keep them to ten or 15
minutes. And Dr. Giovanni and I are going to use a hallowed new
technique, which is we\'re going to stand up at about 15 minutes to
remind them they\'re on shaky grounds. And, last, we\'re going to ask
that everyone hold their questions until the open discussion at the end.
Okay. So you\'re on first.

MR. PEIRIS: Thank you. Good morning and thank you for the invitation to
take part in this meeting.

(Pause.)

MR. PEIRIS: Okay. Sorry about that. I\'ve used up three or four minutes
of my time already. But let me just ‑‑ so let me just quickly go through
the different phases that we followed during the outbreak of SARS in
Hong Kong. With the isolation of the virus and the initial partial
sequence of the PG chain that was available by March 28, we already had
online first generation assays for the SARS coronavirus, and that was
based on RT-PCR and also indirect immunofluorescence assay using the
virus grown on cell cultures.

And this summarizes results from the three major labs that were
providing these diagnostic tests across Hong Kong for the Hospital
Authority of Hong Kong. Just to keep in mind that the Hospital Authority
covers about 40 of the major public hospitals in Hong Kong and accounts
for 90 to 95 percent of all hospital admissions, so the bulk of
suspected SARS and confirmed SARS patients ended up in this public
hospital network. And the letter that is there is from the three major
labs that were offering these two tests: The Department of Health, Dr.
Billy Lalim\'s (phonetic) lab, our own lab at Queen Mary Hospital, the
Prince of Wales Hospital, John Tam and Paul Chen.

And what you can see there is that in the group of patients with
confirmed SARS, this is clinically confirmed SARS, not just fitting the
case definition but clinically after lack of response to antibiotics and
towards the ‑‑ close to the discharge of patients, the clinicians
thought that this fitted the overall picture of SARS. And you can see
that 92 percent of those patients did seroconvert to the coronavirus.
The group that is called \"other\" there are also patients who were
admitted and were investigated for SARS with respiratory disease and
about three percent of those patients seroconverted. The control group
are true controls, meaning these were patients who admitted without
respiratory problems, and none of those seroconverted to the virus.

The lower row there you can see the RT-PCR positivity, and you can see
that about 63 percent of the confirmed SARS group did have one or more
positive PCR results. In the control group, what you have there are
stool samples. One positive in 180 odd stool samples from patients
admitted for conditions that were not thought to be SARS and 148 throat
swab samples from people coming to a general practice type of setup,
again for non-respiratory diseases.

This shows the serological profile based on the immunofluorescence tests
that we were using. GAM is using a conjugate that picks up IgG, IgA and
IgM, and that is the earliest one to become positive and comes up at the
highest titre. The purple line is IgA, the blue line is IgG, and on the
top you have the IgM positivity, and that is after absorbing out IgG
using GAL-SUB (phonetic), which is the normal procedure that we use for
other tests, such as parvovirus, for example.

And, in essence, what you see is that there is no great advantage in the
IgM test in relation to the early detection of virus infection, at least
based on the immunofluorescence type of indirect format. This does not
mean that if you have a good IgM capture ELISA that you might not have a
benefit in terms of time of diagnosis.

This is basically the same data but adding the neutralization serology
there. That\'s the blue line, light blue line. And that again comes up
more or less in time with the IgG, IgA, IgM response.

When we went to the PCR this was, as I said, based on the polymerase
gene fragment that we had available, and this summarizes the PCR
positivity in serologically confirmed patients. And I must say at this
point in time that in one sense this data is out of date because as you
will see in the last few slides that we have, the sensitivity of the PCR
are now much better than what you see here. But I think it\'s still
quite useful data because it gives you an idea of viral load, because we
are using a test that is a fairly low sensitivity, so basically a
positive test means a specimen that has fairly high viral load and also
gives you an ability to compare between specimens to say which are the
specimens that might be more ‑‑ which might have more virus than others.

So the light blue bars are the nasopharyngeal aspirates, the purple or
maroon is stool, and the white is urine. And you can see that the first
four days of illness using this first generation PCR assay we could only
detect virus in the nasopharyngeal aspirates at a rate of about 30
percent. Stools become positive later, and urine later still. In the day
nine onwards time frame, then you have 70 to 80 percent or 90 percent
positivity, and in that time frame stool seems to be the best specimen,
and you have close to 90 percent positive in the stool in that time
frame.

The other point, of course, is that you can see virus shedding going on
for day 40 and you have a small number of patients between day 40 and
day 50 as well. Now, one point is that although you can detect virus by
PCR over one month, by culture we have only been able to isolate virus
up to about day 16. So what that means, one could speculate that once
the antibody response comes in it becomes difficult to isolate the
virus, although clearly the virus is replicating in the body.

This is, again, similar data now comparing the nasopharyngeal aspirate
in blue and the throat swab in maroon. Fairly early in the course of the
outbreak, because of the transmission within hospitals, there was
reluctance to take nasopharyngeal aspirates, and we had to switch to
using throat swabs. But you can see there is that although throat swab
is not as good a specimen as the nasopharyngeal aspirate, it is a
reasonable second best option.

We had smaller numbers of other specimens ‑‑ saliva, endotracheal
aspirates, sputum ‑‑ and saliva is probably not as good a specimen as
either throat swab or nasopharyngeal aspirate. The sputa and
endotracheal aspirates, the few that we had, seemed to be quite
productive, but we did not have many of those, particularly in the early
few days of the illness. I\'m sure you\'re aware that many of these
patients do not produce a lot of sputum, particularly in the early week
of illness.

So if you look at the question of within the first five days of onset
using the first generation assays, PCR assays, that gives you the
greater positivity. Around 30 percent in nasopharyngeal aspirates and
throat swabs, better than that in the small number of sputa, and stool
in that early phase is less good ‑‑ is not as good as the respiratory
specimens. The next five days stool becomes better than the respiratory
specimens.

Then we went on to using real-time PCR using the Roche LightCycler, and
we were using this because it\'s a low through-put technology. I mean
you can run only about 20 odd specimens at a time. So we were using it
more for confirmation and for research purposes. And that shows viral
load in this case in a cohort of longitudinally followed-up patients
over time, and you see the viral load at day 5, day 10 and day 15 after
onset of illness. And you characteristically have this pattern of low
levels of virus early in the illness, peaking around day 10 and then
falling away during the second week. The second week of post-antibody
response is coming in. There\'s one caveat to this data, and this is the
fact that many of these patients were treated with steroids and one is
not totally sure whether this increase is viral load is due to steroids
or whether it\'s part of the natural course of the disease.

Later still we were using the ABI real-time PCR which has a much higher
through-put, and we also compared the p gene and n gene as which one,
which target offers better sensitivity. Because, theoretically, the n
gene should be more sensitive for detection. And, indeed, that was so if
you use cell culture grown virus, the n gene PCR was much more sensitive
than the p. But if you used clinical specimens, at least in our hands,
using the primers we are using for the two genes, we find that there is
really no advantage between the two systems. What you see there is the
CT threshold comparing the two assays. The polymerase assay is Assay 1,
which is on the x-axis, and the n is on the y-axis. And these are all
individual specimens, and you can see the threshold is crossed roughly
at the same time in the two assays indicating that in the clinical
specimens there does not seem to be a major advantage in using the n as
a target. And if you look at that in terms of positivity, again
comparing the two assays now, you can see that there is no major
advantage in using the n gene PCR compared to the PB1 primers that we
had.

Now, using the P gene PCR and also increasing ‑‑ multiplying some of the
specimen extraction protocols that we had to try to extract every ounce
of RNA that might be there in a clinical specimen, now we do have fairly
good sensitivity in PCR detection in the first four days of illness. You
can see the column on the right hand side, we have 50 nasopharyngeal
aspirate specimens within the first four days of illness ‑‑ actually,
within the first three days of illness in the case of nasopharyngeal
aspirates, and 48 of them are PCR-positive. And the breakdown in time is
shown in the blue bars there. So, certainly, by day 2 you\'re having 95
percent or thereabouts positivity.

In stool, we have only one specimen at day 1, but overall you do get the
feeling again that it confirms the data that I showed you previously
that stool positivity seems to be lagging just a bit behind the
positivity in the respiratory tract, but by day 4 again you have
respectable numbers of positive specimens. These are still preliminary
results, and we are working through larger numbers of specimens and also
looking at throat swabs ‑‑

(END TAPE 1, SIDE A)

(BEGIN TAPE 1, SIDE B)

MR. PEIRIS: ‑‑ percent and 70 odd percent positivity in the assays that
we had.

So I think what this shows is that if you really are pushed to the
limits of sensitivity with specimen extraction as well as PCR, you can
diagnose the disease fairly early. And I think the challenge to some of
the folks out here would be to put that into a reproducible form, making
sure that cross-contamination and specimen extraction and problems like
that will not confound matters.

So to finish, let me acknowledge my collaborators. Dr. Leo Poon did most
of the molecular detection methods, K.H. Chan ran the viral diagnostic
lab, Dr. Guong works with me in other aspects of coronavirus biology,
and a lot of this work was funded from a grant from NIAID, and my
colleagues in the Hospital Authority and the hospitals across Hong Kong.
Thank you.

(Applause.)

DR. WANG: Good morning, everybody. First, I\'d like to thank Dr. Steve
Gutman to give this chance to talk about my work. So I work at the
Department of Cell Biology. I\'m from the National Institute for the
Control of Pharmaceutical and Biological Products in China. As a routine
worker, I\'m responsible for the quality control and the evaluation of
HIV-related products. During the SARS period, I was responsible for the
quality control and the evaluation of the SARS diagnostic assays.

In China, several manufacturers and the Institute tried to develop the
diagnostic assays for SARS virus. There should be three diagnostic
assays to detect antibody and try to detect antigen and trhe third
should be the nucleic assays. But as we know, as we develop the antigen
assays, it should have the specific monoclonal antibodies, so it took a
very long time to develop a monoclonal antibody. I know so far in China
no manufacturers have developed the antigen assays. So today I will
focus on the assays to detect SARS virus antibody and nucleic assays.

In China, the antibody assays can be derived from assays,
immunoflurescent assays. These assays can detect the SARS virus IgG and
IgM antibodies. Another is indirect ELISA assays. These are assays that
also can detect the IgM or IgG antibodies. Both of the assays use the
whole virus as coated antigens.

After so many institute ‑‑ many institutes in China have already
expressed the proteins of the SARS virus in E. coli system, so they can
develop the sandwich ELISAs. So the laboratory uses the whole virus, all
recombinant virus ‑‑ the whole protein, all recombinant proteins as
co-proteins. And they also labeled recombinant proteins with enzymes so
they can develop the sandwich ELISAs. Also, some institutes try to
develop the protein cheaper. Use least cheaper that can detect the
different antibodies against different SARS protein. So these slides
gives you the result of the expression of nuclear proteins of SARS
virus. The next slide gives you the result of expressed part of SPARK
(phonetic) proteins.

So I\'m responsible to take quality control and the evaluation of the
SARS study of the assays. In order to do this work, I had to establish
laboratory reference panels. I collected the samples from the different
populations and also collected the samples from the SARS patients. All
the patients had different phases. All the samples were tests of
different antibodies, and according to the results we selected the
different samples composed the candidate panel. So this the laboratory
reference panel for IgM antibodies.

In these panels, we have 20 negative samples. Among the negative
samples, some samples are positive for numerous vectors. Some samples
are positive for measles virus with antibodies, some samples are
positives for flu virus antibodies and others for HIV antibodies. We
used them to check where we have cross-reactions with other viruses.
Among the positive samples, some samples are strong positive, some are
weak positive. Some samples between the stronger and weak positive.
Also, some samples are IgM positive, and some samples are both IgM and
IgG positives.

We also had the dilution samples. We made dilutions, six dilutions, from
one to two, to one to 64. So the dilution samples were positive for IgM
antibody only. We used this sample to evaluate the sensitivity of the
assays. We also have one sample to evaluate the coefficient of the
evaluation of the assays.

After establishing all the reference, we detected the reference with
three different assays. You can find negative or positives, all the
same, it\'s no different. But when detect the dilutions, we found the
sensitivity is different for one to four dilutions. Say we can detect
one to 30 or 32 dilutions, so the assay should be sensitive, but the CVP
and the C for P and the C essays is CV less than 15 percent. But IFA
assays we calculated the CV.

And on the same principle we also make the reference for IgG or total
antibodies. So we make the same negative samples also according to the
principle as we used in the IgM. We make the positive samples 18
positive samples. We also make the seven dilutions ‑‑ the dilution
sample was positive for IgG antibody only. Also, the eleven samples used
the for to calculate the assays of the coefficient of the variations.

After establish of these reference panels, we detected to use the five
different assays. You can find the negative samples all give the
negative result, but when you detect the positive samples, you can find
A, B and D assays that give all the positive results. But for C assays
it just detects 14 positive ‑‑ gives the 14 positive results for assays
E just give ten positive results. But when detected the dilutions, you
also can find the difference for E is less sensitivity. Just detect less
than one to eight, but for D even more sensitivity, it can detect one to
two, five, six.

So we also calculated the CV for B, C and D, less than 15 percent. For
E, this assay detected the CV samples, the samples in negative were so
great, didn\'t calculate the CV. For A assays, is for us, the IFA assay.
We didn\'t calculate the ‑‑ we can\'t calculate the CV.

We also collected ‑‑ in order to evaluate the quality of the assays, we
also collected the serum from the SARS patients. We tested the serum
with IgG assays, IgM assays and also sandwich assays. So this result you
can find at the early stages that positive reach for different antibody
is different. At six to ten days, the IgM positive reached about 11.5
percent. For total antibodies it\'s 7.7 percent. And later stages all
the antibodies are positives to reach the 100 percent positive.

We also collected the serum from SARS patients. We just look at a few ‑‑
we just collected the serum from few patients, just four patients. For
patient A, you can find IgM is positive at the ten days after onset or
14 days it\'s also positive, but IgG is negative at 14 days. For patient
B, after the 15 days, both-IgM and IgG are positive, but we didn\'t
detect the ‑‑ we didn\'t collect serum between the seven and 15 days, so
maybe they have different, just we didn\'t collect the serum. For
patient C, at 12 days only IgM are positive. IgG are negative. At 25
days, both IgM and IgG are positives. For the patient D, after 13 days
both IgM and IgG are positive. So these results we can find is IgM
should be the useful markers for the diagnosis of the SARS.

In order to evaluate the specificities of the different antibody assays,
we also collected the serum from different patients. We collected the
serum from Hepatitis A, B, C, measles and mumps also supplied to donors
and also the person in contact with the SARS patients. So in these
results we can find among the 70 serum from Hepatitis A, only one serum
are positive for IgM and positive to total antibodies. But we repeated
these results ‑‑ all the repeated results are positive. We also found
one positive result for serum from the contacted with SARS patients.
This serum was positive IgG or total antibodies.

So with these results, we can find the specificity of the assays should
be very good. They may have the cross-reactions ‑‑ maybe we have some
cross-reaction but we do not know why. But we check later whether we
have the Hepatitis A, but we know for sure whether we have the Hepatitis
A, have the cross reactions.

So in China, there are several manufacturers also tried to develop the
gene chips and the real-time PCR. So the gene chip has so many
advantages. The main advantage, it can detect the sera respond to virus
at the same times. So also some manufacturer tried to develop a
real-time PCR. Most of them use the Taqman technologies and develop to
the quality and quantity assays. Okay.

In order to evaluate the assay, I had to set up the laboratory reference
panels. So, first, I collect the respiratory virus and the other virus
positive samples, use them for the negative samples. We just check
whether they have the cross-reactions with the virus. We also collect
the SARS virus from the patients and also cell cultures and checked to
the SARS virus IA. And the purified IA was kept in special solutions.
This solution is very much similar to the serum. All the positive IA was
calibrated with WHO standards. So the standard was WHO standard, IA
standard.

We used the WHO standard to calibrate our standards, our reference, so
we repeat about 14 times for each sample, and finally we calculate the
mean of titres. So the P-1, P-2, 2-P-6 so you can find the different
samples. The titers of the gene number is different. For P-1, it\'s
about 9.7 ten power two. For P-2, 1.32 ten power to the three. So these
are different. For P-3 to P-6, it\'s diluted ‑‑ ten times dilution
samples. You can find for P-3 about 8.8 ten power five.

Here\'s another four samples. These samples ‑‑ we use these samples as
sensitivities, so the copy number is much lower. So you can find for P-7
about 7.4 ten power ‑‑ just ten, about 74 copies. So, finally, we make
the SARS virus IA reference panels. In this panel, we have the nine
negative samples. In the negative sample, you include the CV RNA,
HIV-RNA, measles virus RNA, mumps virus RNA, rubella virus RSV, Japanese
encephalitis virus and the Muries hepatitis virus positive. We also have
the ten positive samples, P-1, P-2, P-6 sample use to quality analyze,
P-3 to P-6 samples used for linear analysis, P-3 used for the evaluation
of the CV. P-7 to P-9 sample use the false sensitivities.

I mentioned before we use the purified IA, not a whole virus, as the
positive samples. So we wanted to know whether this kind of assays can
affect the efficiencies of the different assays. So we used the
different assays to purify the IA from the special solutions. We just
checked whether they have different.

So we used the ‑‑ this line we just use Qaigenn domestic assays to try
the same samples. We used the Artus RT-PCR, laser PCR made from the
Germans. We detected IA. So you find this result different assays can
give the different ‑‑ did indicate the different result. The results
were much similar.

We also used the three different methods to track ‑‑ sorry, sorry. We
used the three methods to track the same assays. We also used another
RT-PCR so you didn\'t find the difference. We also used the four assays
to track the IA and used another RT-PCR to test the protein samples. We
didn\'t find the difference.

So the summary is in our laboratory we set the IgM, IgG total antibody
and the virus IA reference panels. All the virus IA panels had to be
calibrated with WHO standards. The purified virus IA used in the panel
cannot affect the efficiency of the detection by different assays. The
panel can differentiate the quality of different assays.

Finally, I\'ll thank my colleagues and my friends. They gave me much
help. Thank you.

(Applause.)

MS. ZAMBON: Good morning, everyone. I\'ll introduce myself while we\'re
waiting for the change of IT stuff here. I\'m Dr. Maria Zambon. I\'m
head of the National Respiratory Virus Reference Laboratory in the
United Kingdom, part of the Health Protection Agency, and also Deputy
Director of the Enteric, Respiratory and Neurological Virus Laboratory
in that Institute, which is the nearest equivalent in the United Kingdom
that we have to the Centers for Disease Control.

The experience that I\'ll describe to you about the United Kingdom and
what we\'ve done in the development of diagnostics I think is closer to
the situation that you\'ll have here in the United States; that is, not
very many cases but a significant amount of noise in the system, which
of course is difficult when trying to develop diagnostics if you also
have a huge burden of potential clinical cases to investigate. And a
second problem which has already been alluded to by our speakers is the
actual absence of truly defined clinical specimens.

As you know, the United Kingdom has a very centralized public health
funded health care system. As a consequence of that, we have the ability
to centralize much of our information capture when there is a huge
public health threat. What I show over here is the United Kingdom
organization, and that is the fact that the cases from wherever they
present in the health care system are captured at whatever point of the
health care system they actually present, whether it\'s to GPs, to
microbiologists, to public health or to hospital cases. And as a
consequence of that, we\'ve been able to build a single database which
allows us to stratify all the cases that we\'ve got according to their
symptoms, their clinical findings, their travel history and classify
those according to probable suspect or other using the WHO case
definition. And, clearly, we then have the ability to investigate those
cases in a single central laboratory by a variety of techniques and add
to that information on other pathogens as it\'s developed.

We\'ve already very elegantly from our previous speakers the fact that
what we now know of SARS coronavirus illness is that respiratory samples
appear to be positive slightly before we have detectable virus and
slightly before fecal material and that there is antibody development
over a period of ten days onwards post-illness onset. So that you can
divide the development of diagnostics into those which are acute phase
occurring during the illness or those where you\'re looking for
footprints of the virus in terms of antibody response. And I\'ll talk to
you about our experiences in acute phase diagnostics and also in
serological work.

Just briefly, to reiterate something that\'s already been mentioned with
respect to the development of nucleic acid diagnosis, most of the first
generation assays relied on development of diagnostics based on the
polymerase gene, was really for reasons of where the first sequence has
become available. But second-phase diagnostics have relied on the
development of detection in the nucleic capsid region of the genome. And
Malik has already alluded to some of the theoretical advantages of
working in the nucleic capsid region that the amount of transcription
that occurs in this part of the genome is approximately 100-fold excess
over transcription here, which can be both a theoretical and practical
advantage.

So molecular diagnosis that we\'ve applied in the United Kingdom has
used the principle of a dual target, both polymerase and nucleic capsid
detection. We have built into that a detection scheme which is
pan-corona, that is capable of detecting all known coronaviruses based
on polymerase gene where we use degenerate primasets to pick out all
coronaviruses and then SARS-specific. And some of the advantages of that
approach I think will become apparent as I talk, but basically it\'s a
principle of confirmation, it\'s not just single target.

We went along the line initially of blocked-based assays, and the reason
we did that is we knew that if we had to roll out assays very quickly in
the United Kingdom, most hospital laboratories do not have access to
real-time PCR in our health care system. It was important to go with
something that we knew we could roll out quickly if we needed to with
robust protocols. And we\'ve always adopted the principle of sequence
confirmation and re-extraction from specimens.

So to just very quickly summarize what is an awful lot of work, in the
probable case definition, using the WHO case definition, we had nine
probable cases. The denominator here should theoretically be the entire
population of the United Kingdom, bearing in mind that we have 20,000 ‑‑
between 20 and 30,000 returning travelers from SARS-affected areas every
week in the UK, suspect cases, 203, and others, 210, and that really is
others where clinicians had somebody who had been traveling who had some
kind of an illness and they were quite sure whether this was a
SARS-affected area or not.

In our probable cases, we found one seroconversion who was also
PCR-positive. In our suspect, we found four seropositives plus one
seroconversion. And in our other, we founnd five seropositives. This
tells you something immediately, and that\'s the difficulty of applying
a WHO-specified case definition which works well in a highly endemic
area, in an area which is much less endemic. And in our case, we also
have less than 50 percent complete sampling in terms of convalescence
sera for the suspect and the other cases, so we\'re not finished yet, in
essence, in terms of finding cases.

If we go to our one UK case of SARS, we see some relevant points here
that I can bring out. If we have here day of onset of illness, the first
time we looked in any of the samples which we had, and we did have a
full collection of samples because by the time this case had come to
light in the United Kingdom, we knew already from the WHO laboratory
confirmation, the laboratory network, that we needed to collect
respiratory samples and fecal samples. We found that initially when we
screened with polymerase target PCRs, everything was completely
negative. As we went back and developed a nuclear capsid PCRs, sample
which were negative started to turn positive. But what I will take you
through on the side here is that the viral load that we have is really
rather low, less than 100 copies per mL. We also detected virus in feces
at around about this same time which correlates with the data that we
have about peak viral shedding from colleagues in southeast Asia. And
we\'ve also detected virus genome in this individual in the plasma at
around about the same time. So, you know, if there\'s one lesson here
just based on one case, it is that second generation diagnostics may
well be more sensitive.

In terms of antibody detection, we saw seroconversion over easily 21
days, but as you will see later, this very first serum here taken at day
seven post-illness onset was actually not completely seronegative.

So the conclusions in our PCR work is that the current PCRs which we\'re
using based on the nucleic capsid region, we have a limit of detection
of 0.1 block-forming units using two different virus strains. We find
the nuclear protein and the nuclear capsid region more sensitive for
detection in clinical material than the polymerase, which is contrast to
Malik\'s experience. Bear in mind that our experience is based on far
fewer samples. We can only say what we\'ve really found in this one
clinical case.

We find that dual target is a useful confirmation and that sensitivity
but not specificity is actually the problem in diagnostics. We think
that the acute phase plasma may be a useful target for nucleic acid
detection, but I think much more work is needed on that. And we also
need samples from acute cases to fully validate any diagnostic
developments.

Our initial approaches to serological assays have been based on the use
of infected cell lysates in comparison with reaction with uninfected
cell lysates, immunofluorescents and also SARS nucleic capsid gene
expression in Bacula virus system.

Here is our one UK case where we see the seroconversion. Here is the
first acute serum that we have, and here is the convalescent serum 21
days later. And along the bottom line here, we have some example of
acute and convalescent sera from influenza-infected cases, a very clean
kind of ELISA reactivity. When we\'ve used panels of serum, which have
been very kindly provided to us by Professor John Tam (phonetic) in Hong
Kong, 33 cases of acute SARS, we see that we start to detect antibody
round about day ten post illness onset, with both ELISA and with IF,
which confirms data that other speakers have presented that you can
actually see quite early on post-illness onset, the development of
antibody.

We use a confirmation strategy of immunoblotting. Here you can see on
the left hand side the convalescent sera. B is the convalescent, A is
the acute sera for blocks in parallel, uninfected cellulizer at the
bottom. You can see very nicely beautiful sera conversion here, and here
we have examples from Hong Kong sera A, acute B convalescent, confirming
that we can see nice seroconversion to SARS-infected cell ELISA.

So the data where we\'ve looked at the ELISA that we\'ve developed first
is IF in 33 pairs of SARS serum indicates that there\'s a very good
correlation between the IF reactivity and the ELISA reactivity. And in
particular the advantage that one might find with an ELISA, of course,
the dynamic range. You can take the sera out much further and you have a
different ‑‑ two different sort of tests that you can apply in parallel.

We also have neutralization which shows that in convalescence sera here
we have a convalescence serum at day 21, here we have the acute serum
with really not much diminution of RS growth, but here we have the clear
detection, clear evidence of neutralizing antibody detecting, becoming
apparent at day 21 or more.

We\'ve gone on and developed a nuclear protein expression, the Bacular
system. Really, the reason for using this is because we have it up and
running in the lab and we tend to go with things that you\'ve got which
are easy to work with and which you can develop that diagnostics very
fast. We tagged our baculovirus with a HIS tag and here we see baculo
infected cells with HIS tag nuclear protein, nice reactions with
antihys, antiserum, and here we have a baculovirus expressing H-7
hemagglutinin without a HIS tag with no reaction. Here we have
convalescent serum-1 from the UK reacting nicely with a SARS nuclear
protein but not with the H-7 hemagglutinin.

When we\'ve gone on to look at the detection of antibody to the SARS
nuclear protein, there are one or two interesting points to come up
with. You\'ll recall that I mentioned that our pan-corona strategy for
detection meant that we were able to detect other corona viruses as part
of our detection strategy. Two of the UK cases that were in the suspect
category did actually have a 229-E coronavirus infection, and we were
able to determine that from sequence analysis. We managed to collect
substantial serum samples from both of these cases who were a husband
and wife who\'d actually traveled to China. I think you\'ll see some
interesting observations.

Here on the right hand side of this western blot we have our SARS UK
case on day 7, 12, 18 and 45 post-infection reacting here with the SARS
nucleic capsid, and you can see very beautifully at day 7 post-illness
onset you already have a decent antibody response to the nucleic capsid,
which increases over time. If you look here at Mr. X, in his acute
serum, no reactivity, as you might expect. In his first post-serum, a
reaction also with the purified nucleic capsid and here in his second
serum taken about two weeks later, also increased reactivity against the
SARS nucleic capsid. However, when you look at Mrs. X who also had that
exact same infection, no reactivity against any of them. So I think that
tells you that the reaction is probably not predictable.

If we go on and look a little bit more in detail, what we have here on
the left hand panel of each lane we have 229-E infected cell lysate and
a purified SARS nucleic capsid. So this here would be the UK case with
229-E reacting against 229-E nuclear protein, which has the correct
molecular weight here of about 48. And here it is again reacting with
the SARS nuclear protein. Reactions against neither in the acute phase
serum.

And here what we have are four sera taken from individuals who presented
with influenza-like illness prior to Christmas last year which reacted
on a specificity panel using the expressed SARS nuclear protein. So
there can have been in this situation absolutely no question that these
people traveled out of the United Kingdom, all were exposed to SARS that
we\'re aware of. And you do see some interesting things here, because
you clearly see in some of these reaction with 229-E protein which ‑‑
but no reaction with SARS on western blot or reactions with both. And
from this we interpret this to mean that there are some cross-reactions
between SARS nuclear protein and the 229-E nuclear protein, which means
that when we are developing diagnostics, particularly based on nuclear
protein, which may be a very good target to use, we need to be aware of
the fact that there are likely cross reactivities with other known human
coronaviruses.

In terms of the work that we\'ve done on the spike-like proteins, we\'ve
made 18 different constructs, six using the VSVG transmembrane domain,
six using a HIS-tag and six using a mono-binding protein. We\'ve gone on
to characterize the ones using the VSV transmembrane tags rather more
than we have the other two tags so far. What I can say if I take you
through this, we\'ve made the six different constructs so that they
incorporate either the whole spike protein or the amino terminus or the
carboxy terminus or the region in between, and I\'d like to ask you to
remember that region in the middle of the protein. We know that all of
these are made when we blot with VSVG transmembrane antiserum, and when
we do facts analysis using convalescent serum from SARS, our UK SARS
case, what we don\'t see is any reaction to the small portion in the
middle, but we do see reactivity to both the carboxy and the amino
terminus. And this is best summarized in this fact analysis,
quantitative facts analysis where the best reactivity is actually ‑‑
sorry, you can\'t see the notation at the bottom, but the best
reactivity is actually with the full-length protein or with the amino
terminus or the carboxy terminus. Now, this is not exactly matched by
what you see on western blot, because on western blot you see the best
reactivity with the full-length protein and with the carboxy terminus.
So there are some distinctions there between obviously antibodies which
react ‑‑ which see confirmation epitopes versus antibodies which react
with linear epitopes. And we haven\'t fully sorted that out yet.

So our conclusions then about serology is that our current United
Kingdom algorithm for serology involves a cell lysate screening test
with a second line immunoblot, immunofluorescence and/or nuclear protein
ELISA with the potential of neutralization. And eventually we will
streamline this such that we have an approach where we have one
screening ELISA followed up by a second more specific ‑‑ or not more
specific, sorry, a second line test which is a different format but
gives us, if you will, confidence in what we\'ve got.

We do believe there is some cross reaction with 229-E proteins which are
not well elaborated. I should say that we think that these cross
reactions occur at the level of the nuclear protein, not at the level of
the spike protein, because where we\'ve looked we so far don\'t see much
evidence in the material that we have available to us for cross
reactions with the spike protein. We need to determine the relationship
in kinetics of neutralization to see how useful that will be for us as a
confirmatory test and to finalize with some strain variation and epitope
mappings so that we know exactly the precise regions which will be most
useful diagnostically.

To finalize then, I\'ve mentioned that we have a kind of whole virus
approach but not any whole virus, a whole virus family approach to
trying to figure out what diagnosis is. And it is a salutary reminder
that much of what we\'ve had to deal with in the United Kingdom is not
SARS at all but the highest other ‑‑ featuring other pathogen is
influenza, and this is a real problem in the sense that many of the
things that have come to us as a reference laboratory we\'ve determined
that we have influenza diagnosed but yet these samples have also been
handled by hospital laboratories in parallel looking for other
diagnoses, and that influenza has not been picked up. So one question is
within the system to make sure that you also have good influenza
diagnosis. But, clearly, the case definitions are rather non-specific,
and you will pick up other pathogens.

And from the point of view of the sequence analysis of our flus, it was
actually rather nice to see the flu cases that we picked up, in general,
tended to cluster together, and for us clustered with other cases of
influenza that we knew had come from Southeast Asia, so one or two
signature motifs in there indicating that we were looking at virus
infection which had been acquired abroad but it wasn\'t SARS.

I think I\'d like to stop there and acknowledge the work of the people
in my laboratory and our Division, in particular Dr. Robin Gopal who
developed the serological ‑‑ the first-line serological assays that
we\'ve used; Dr. Allison Birmingham who arrived in the laboratory after
post-doctoral experience at NIH and has been in the laboratory three
weeks before SARS arrived. I should say she should be working on RSV but
is actually working on SARS. Dr. Joanna Ellis who\'s led on the
influenza work; Dr. Paul Heinen, who\'s done the baculovirus expression
work; and the whole of the influenza team in my laboratory. And we\'ve
been very ably advised by Stuart Cidell in Bristol University and Ian
Jones in Redding University who\'s helped us to develop the baculovirus
work. And also other members of the WHO laboratory network who so freely
have given of their information to allow us to develop good diagnostics.
Thank you.

(Applause.)

MR. GUTMAN: Okay. We are running just a bit behind. We\'re going to take
a ten-minute break. Please note there is a second break this morning,
but actually we\'ll have to break in place while we change panels. So
this is hopefully a short, sweet but the main break for the morning
session. Thank you.

(Whereupon, the foregoing matter went off

the record for ten minutes.)

DR. ROBERTSON: Good morning, I\'m Betty Robertson from the Center for
Infectious Diseases within CDC, and the title of my talk, which was
graciously given to me by the individuals at FDA, is called, \"Real Time
under an IDE: CDC\'s PCR and ELISA Investigational Protocols.\" And in
contrast to the previous speakers who described the process they went by
and the information that they learned from the various assays that they
developed, I\'m going to basically talk about the process that we went
through in getting the IDE approval.

Okay. During the SARS outbreak, the real time under the IDE, the CDC
SARS laboratory response, was basically divided into three phases, and
I\'m going to go through these phases with you. The first phase was
agent identification, phase two was assay development, and the third
phase, which I\'ve called, is assay deployment.

Actually, the first phase was really quick and very rapid. It occurred
during March 2003 and it was started during March 14 when the outbreak
investigation was organized at CDC. On March 15, 16 and 17, samples
arrived from Toronto and Thailand, and these were the samples, the
initial samples that we used for virus isolation. Between March 18
through the 22, the virus was isolated by cell culture, identified by EM
and an IFA assay was developed, much of the same technology that was
described earlier by Malik, Maria and Dr. Wang. Between March 23 and 24,
the virus was verified by PCR in sequencing, and a prototype ELISA had
been developed. Now, this was phase one. This was the agent
identification.

Phase two was the assay development, and it initiated in April 3. And
this is the time frame in which we initiated discussions about a
real-time RT-PCR assay which we would deploy to our laboratory response
network laboratories. Between April 3 and April 8, we had discussions
with the FDA regarding filing of an IDE for the real-time PCR assay, and
then much of the month of April, between 7 and 18, was spent developing
additional PCR signatures, and these ended up being ?

(Joined in Progress)

DR. ROBERTSON: \-- The other work that had to take place during April
was to synthesize the primers and probes, and optimize the conditions,
and evaluate the performance of the assay.

We then initiated once we had an assay that we felt was working
appropriately, we did large scale production of primers and probes,
dispensed and labeled them, and QC\'d those for large scale product for
performance.

We had to alert the LRN members of reagents that they would need to
purchase in order to perform the assay that was going to be deployed. At
the same time, we were generating a large scale production of ELISA
antigen, and that was completed on April 21st.

On April 28th, we had some discussions with the FDA, and they determined
that the ELISA assay was low risk and that an abbreviated IDE was
appropriate. And we are now going to change tax just a little bit and
give you a little bit of flavor of the kind of documents and paperwork
that we had to develop for both the IDE and for the abbreviated IDE.

Under th IDE process this particular slide illustrates the documentation
that had to be developed. Published reports, unpublished reports, and an
investigational plan, including purpose, protocol, risk analysis, a
description of the device, and the monitoring procedures for how the
device worked.

Manufacturing information, investigator information, IRB information,
labeling, and then an informed consent documents. Now, since the IDE and
the abbreviated IDE necessitated IRB approval, we also had to go through
and develop the appropriate documentation for the IRBs at CDC.

And this is a list of the documents that were necessary for the real
time PCR assay, and they included, and I want you to know, that this is
an assay protocol , and this is the human subjects protocol, in addition
to a number of the documents that were also necessary for the IDE.

But documents that were necessary for clinical management, once of which
was the health care provider\'s information, the informed consent, the
participant information sheet, and a fact sheet for clinicians.

And I have highlighted these documents because as time evolved, we ended
up having some confusion regarding these documents in some manner, way,
shape, or form. This overhead lists the documents that were necessary
for the ELISA assay.

Now, the ELISA was an abbreviated ID, and so there is not as many pieces
of paper necessary. Once again though, we had to develop a human
subjects protocol for the IRB.

In addition to this Attachment G, which was actually the protocol, we
ended up calling it a procedure for the actual performance of the ELISA
protocol.

And this is assay deployment, and this is Phase III. On April 30th, we
submitted a preliminary IDE application for the PCR assay to the FDA. On
May 2nd, the FDA granted conditional approval of our IDE for PCR assay.

Now, as one of the earlier speakers alluded to, it was overnight, and
actually on April 30th \-- and this is definitely preliminary, but it
was May 1 that we actually submitted the actual documentation. So he is
correct. It was an overnight approval.

On May 1st, we submitted a PCR assay protocol and the associated
documentation to the IRB, and followed by that the IRB responded that
the protocol that was written following the FDA guidelines did not
accurately reflect the public health intent, and the protocol had to be
rewritten.

On May 14th the protocol for the EIA was submitted to our IRB for
approval, and on May 15th, the real time PCR IRB protocol was approved.
On May 19th, the following EIA protocol was approved.

On the day after the EIA protocol was approved, we discovered that there
were discrepancies between web documents in our clinicians\' fact sheet
and the one that had been IRB approved. This occurred because this whole
outbreak was a dynamic process and information changed.

So we had the ability to rapidly alter and change the information on the
website. However, since the documents that had gone to the FDA had been
developed earlier, there was inconsistencies there.

These inconsistencies necessitated that we submit amendments for both
the EIA and the PCR documents to our IRB on May 28th. The IRB approved
them rather quickly overnight, but then on May 30th, we then were able
to finally post these documents on the CDC, HPHL, and the LRN websites.

And just parenthetically, the EIA assay was deployed to a State public
health department through the APHL, and the RTPCR assay and that
technology was deployed through the laboratory response network, which
is the reason for the different postings.

On June 3rd, we had a strong feedback from our Council of State and
Territorial Epidemiologists regarding issues with the instructions
within the health care provider letter.

This letter had been developed at CDC and we have not had the
opportunity to vet it with outside people and our CSTE group had some
strong opinions about some changes that they felt needed to be made.

After a conference call with them on the third, we gave them a week to
provide us feedback from various individuals, which they did, and we
then once again submitted amendments to the IRB for both the EIA and the
PC protocols, and are June 18th the IRB approved the amendments to the
health care provider letter.

The assays actually went out and were approved and ready to use at the
end of May. The paperwork that had to be changed, we just had to let it
stand until we could get it changed through the IRB.

In closing, I am going to talk about lessons learned. First of all, we
learned that even within CDC that definitions, that we need to make sure
that we know exactly what we are talking about.

Definitions from an IRB perspective, it\'s when you say protocol that it
means one thing, and when you talk from a laboratory perspective, a
protocol means something else.

And so we ended up that in order to be clear on the information as we
were talking between groups, we ended up calling the laboratory
protocols procedures and the IRB protocols, protocols.

Secondly we learned that CDC and FDA sometimes speak in different
languages, and we had some difficulties applying FDA regulations for
manufacturers in a public health setting.

Due to the public health emergency, multiple authors were needed for \--
and we had multiple versions of the documents that I had shown you
earlier, which resulted in the confusion and the contractions in the
written documents, and once again since this is a dynamic process, and
you almost had to be present to appreciate it, this caused some
additional problems.

Next, CDC excels in developing assays rapidly for a public health
emergencies. However, we are not designed to be a manufacturing facility
and we have learned this in a very clear manner.

The CDC IRB had no experience and perspective in reviewing device
protocols in a public health response setting, and so this is another
lessons learned that we needed to address.

The necessity to obtain IRB approval delays the rapid release of current
information in an outbreak situation, and in both of the situations in
which we had to go to the IRB for amendments, we had to let either
contradictory documents stand, or postpone putting documents up.

And then lastly, but probably most importantly, we learned that
cooperation between the CDC and FDA was able to facilitate the
completion of this process. Thank you.

(Applause.)

DR. KOZIARZ: Good morning everyone. My name is Jim Koziarz and I am VP
of R&D at Abbott Laboratories, but this morning I am here to report to
you on \-- and as you can see from the title \-- the industry
perspective on just about everything that we have been talking about
here today.

And what I am going to do in this brief presentation is just review once
more what kind of a challenge we are presented by this SARS outbreak,
and give you an example of some of the industry recommendations.

This morning, Dr. McClellan referred to a meeting at HHS back in May,
and I am going to ask part of my representation of industry take you
through the recommendations and discussions that we had at that meeting.

And then I would like to close this brief presentation by some
implications to what those types of issues mean to product evaluation
and approval. If we talk about the challenge, and again this is
something that we have been through more than once this morning.

But clearly we are dealing with sporadic outbreaks of this disease in
very diverse geographic locations, and as you saw this morning from some
of the presentations the management of the patient is essentially
syndromic, and I think we can all agree that the pathogenesis of this
virus really has not been very well elaborated.

And key to us as part of the next step in this morning\'s process, going
from research to development through the CDC, toward a routine
manufacturing for products like these, the patient sampling and sample
handling is an issue that we need to address.

And also as you look forward to what may or may not be as Dr. McClellan
mentioned, another bout of this disease. Obviously, we have a very
limited opportunity for perspective clinical trials in these cases.

So what we are looking at here really is a test development that I would
not by any means call traditional, and again as we heard this morning,
we are dealing with situations like this that can in fact be a role
model for how we respond to any type of other issue. and a bioterrorist
attack was mentioned as well this morning.

And I think that we could all agree that the cooperation between
industry, science, and government agencies, is going to be very
essential for us to be able to expedite any type of response.

But as Dr. Gutman mentioned in his presentation this morning, safety
efficacy and compliance have to be addressed, and they are givens in any
type of procedure that we go forward with.

So as Dr. McClellan mentioned, there was a meeting held at HHS back on
May 29th. The participants were members of the FDA, the CDC, and other
portions of HHS, as well as the companies that I have listed here.

And the goal there was very much like we talked about here today, was
what can be done to mount a rapid response to what at that point was a
much more critical issue with SARS.

We came back with a couple of recommendations. The first one is very
generally that a public-private cooperation in a partnership that
expedites the R&D and approval of any test for emerging pathogens is
gong to be essential.

And also as you heard this morning, the model of the West Nile Virus,
the response to that was used as a very good model of what had been very
good cooperation. And as Dr. McClellan mentioned this morning, with 9
months from the identification of West Nile as a problem, assays were
under I&D, and in this case with Sieber (phonetic), and were in use.

And that type of collaboration we think is going to be essential for a
response to any other type of emerging pathogen. We also recommended
that everyone build on their core competencies.

You heard this morning of the scientific organization both in the U.K.
and in China, and you have heard what the CDC can do in terms of
developing and rapidly getting a test together.

And we feel that the industry\'s portion of this collaboration obviously
is in bringing forward tests, good manufacturing practices, and being
able to commercialize what we build on from the other parts of the
organization.

We also came back with some more specific recommendations. We did ask
that a public meeting on SARS be convened, and I don\'t think that this
is the result of that. I think that this was in the works before we made
that recommendation.

We also asked that the CDC, as you saw from Dr. Benningham\'s comments
here, is very important for us to have the CDC get involved in the
quarterly FDA-industry roundtable updates.

We obviously are looking for guidelines for the clinical study and FDA
approval standards for any type of rapid evaluation of a pathogen. We
have to agree on what might be the key elements that have to be
addressed on risk mitigation, and I will get to it in a couple of more
slides.

But we think to move rapidly that we have to understand how we best
understand the potential risk for moving rapidly and mitigate those
risks in an intelligent manner.

We would like to look for an expedited approval process that allows
post-market surveillance, and I will get to that in a few slides as
well. We think that in any one of these cases that industry will need
and identify a point of contact both at the FDA and the CDC, and that is
being done.

And we also felt from an industry standpoint that the CDC was best
positioned to serve as a clearing house for picking up these samples of
emerging pathogens, and also probably cooperating with organizations
like the WHO.

And in the case of the SARS epidemic or SARS outbreak, we are really
seeing that as was mentioned this morning that these samples are not
coming from the United States.

And for us to be effective, we have to have some way of being able to
acquire those samples and use them in test development and evaluation.
There are also a couple of other recommendations that really looked
forward in terms of the rapid development of these types of tests.

A number of companies, particularly companies that are smaller, and some
of the biotech companies are really looking for help in R&D funding in
some of these cases.

They mention the fact that to a small company there is a lot of risk
involved in moving forward and committing resources to these types of
tests, and they requested that there be some type of way for these
smaller companies to get some help in the R&D funding.

We discussed the issue of intellectual property, and I think as you saw
here with the SARS outbreak, as the research progressed, so did the
filing of patents. And a number of our industry partners were concerned
about access to intellectual property and being able to use it rapidly
and effectively.

The concept of sample acquisition and characterization is one I think
that we have covered a number of times this morning. But clearly to be
able to get at a well-characterized test, you need a set of well
characterized samples that link back to the clinical indication.

The regulatory requirements are something obviously that we have talked
about before, and as Dr. McClellan mentioned this morning, too, a number
of companies mentioned the problem or the issue of reimbursement.

That if a test is developed and needs to be widely distributed, that
reimbursement is obviously a vehicle that needs to be put in place to
allow rapid deployment of a clinically useful test.

So what are the implications for us in industry? Obviously the goals of
clinical validation are still there. We have to demonstrate medical
benefit, and we have to understand what the indication of a positive
test result is, both to diagnosis and the patient management.

And clearly we have to be able to link the test result to the patient
history and to the symptoms, and in some cases that is something that we
are going to have to try to do retrospectively in the case of the SARS
outbreak.

We also have to demonstrate the experience of the product in its
intended use population as we talked about this morning, and that is
going to have to in this case allow us to be able to demonstrate to the
regulatory bodies what the product performance is and with as you saw
this morning a number of different sample types.

We also have to be able to understand what the sensitivity and the
specificity of the assay is in a given population and with a given set
of samples. So what does that get us to?

Well, we feel that the idea, and I think that Dr. Feigal really did a
nice job of showing that this morning with his cyclical patterns, is
that we do have a product life cycle model that needs to be looked at.

We think that if we try to move forward quickly, and again we won\'t
have all the information that we may need for what I would call in
comparison a traditional type of submission, we have to understand what
the risks are, and we have to understand risk management and how to
mitigate those.

And failure mode analysis we think is one of the ways to look at that.
In the case of a lot of assays that are currently available, how much of
component re-use can we take advantage of.

To give you an example, in some tests that would for instance detect IGM
from a serological standpoint, a number of companies already has assays
in place that, for instance, capture IGM non-specifically and then probe
specifically to find what particular IGM is there.

These companies have the ability to re-use those components to rapidly
respond. They now then can bring into their test kit a number of
components that have already been validated and for which they have a
lot of history.

And therefore the risk mitigation should be able to do, or the risk
management should be easy to do. We also need to have a very strong
feedback loop if we are going to really take advantage of the product
life cycle.

We have to be able to enhance product performance, and labeling, as more
data becomes available. So what we propose for a test, for instance, for
the SARS coronavirus? Well, one proposal, and this is one that I brought
forward at that meeting, would be to look at the intended use and early
on limit it to the detection of coronavirus.

And with that supplement the patient diagnosis with the use of the CDC
or the WHO guidelines. We would then submit the datasets that we have
from sources around the world, knowing full well that some of them may
need supplementation downstream.

We would look at the labeling that would provide sensitivity and
specificity as we know it by sample type, and clearly state the test
limitations. For post-approval, we would then propose that we go forward
and that we repeat those studies at multiple sites using well-documented
and characterized samples.

And then supplement the PMA as required as more knowledge becomes
available. To give you some example of the type of dataset that we would
be looking at, those are just some of the studies that are underway or
are proposed for the ARTEST (phonetic) SARS test that you saw alluded to
from the data from Beijing.

And as you can see the datasets are numerous, but they are also very
diverse. In some cases we are looking at numerous types of samples, or
sample types, excuse me, that are being taken.

And so as a result, we have to look at this type of a dataset to
understand how the product is operating right now, and again take that
into account in our labeling and understand that we have to move forward
and modify or enhance the labeling and product performance
characteristics as we learn more about this.

What types of feedback mechanisms would I propose? The first one is
post-approval meetings with the agencies, and this is both the FDA and
the CDC, to review product performance. We would also use our internal
quality control or quality system, excuse me, to monitor test
performance and be able to identify places where improvements are
necessary.

Those that would be taken into account in second generation tests under
design control. It is also essential for us as we respond quickly here
to get scientific feedback, not just on the virus itself, but also on
its pathogenesis and serology that would suggest to all of us what the
next generation product has to be.

And I think that you have seen some of that here this morning with the
data from the U.K. that is suggesting, for instance, that the region
that coats for the nucleoid capsid is a better primer set maybe than
what is being used right now.

That kind of information obviously is very important for us and it
underscores the point that the feedback mechanism has to be there for
all the manufacturers.

And finally as we go along, we have to collect and continue to collect
clinically relevant samples. Not just for internal and external quality
control, but also to be able to validate the next set of generation
assays.

So in summary, speaking for industry here, I would tell you that SARS
does represent a case for us to move rapidly and bring tests to market
as quickly as we can.

I think you have heard very loudly and clearly that in the case of SARS
in particular that sample acquisition has really limited a lot of
companies\' abilities to not only get into the development cycle, but
also to be able to validate the product.

And I think as you have heard from all of us this morning, there are a
lot of opportunities for us to respond to threats like SARS, but they
have to be done rapidly, and they have to be done safely and
effectively.

And obviously in closing, and this is why we are here today, we feel
that close cooperation between industry and the government agencies is
the key to accomplishing these objectives. Thank you very much.

(Applause.)

DR. GIOVANNI: So actually that was a very good introduction to my talk,
because I am going to talk about NIAID, the National Institutes of
Health and the National Institutes of Allergy and Infectious Disease,
funding opportunities.

And what I will focus on is cooperation between government agencies,
industry, and academia. So I was not sure what the audience was going to
be, but just so I bring everybody in the same place, let me just tell
you a little bit about our Institute.

So the National Institutes of Allergy and Infectious Diseases is part of
the NIH obviously, and we basically have very much a research mission.
It is basically basic research and implied research, and our whole goal
is to prevent, diagnose, and treat infections and immune-mediated
illnesses, including as you must know HIV/AIDS, and other sexually
transmitted diseases, illness from potential agents of bioterrorism,
tuberculosis, malaria, SARS, emerging and re-emerging diseases.

So we really run the whole gamut of infectious diseases, and also
learning about the normal immune system also. And let me just tell you
what our platform is, whether it is biodefense, or whether it is SARS,
or emerging or re-emerging diseases, malaria, whatever it is.

We basically have this platform that runs from basic research to applied
research, and all along the pathway we actually have different ways that
we can communicate and interact with academia, industry, other
government agencies, to actually get our goal done.

And that really is to make products \-- vaccines, therapeutics, drugs,
diagnostics \-- for the American people. I mean, that really is simply
our mission. We have a very strong fundamental basic research program,
whether it is at the pathogen side, whether it is at the host side, and
that moves all along to product development.

Another important part of what we do is providing research resources to
the community, because we realized early on that we can provide funds,
grants, cooperative agreements, to do research, hypothesis doing
research, but if we don\'t provide the basic research resources for the
community to get that research done, then we really haven\'t done our
job.

And I will be talking about that a little bit, and Dr. Linda Lambert
from our Institute will also be talking about that. So this is what our
platform on SARS looks like. It is very multidisciplinary.

It runs from basic research to applied research. It runs from looking at
the basic research of the coronavirus, the pathogenesis, other viruses
that may actually give us more information about coronaviruses, and to
our applied research program; clinical research, vaccines, drugs, and
diagnostics.

We also are very much interested in animal models, building in vitro and
animal models so we actually can do basic research and we also have
platforms that actually test vaccines, drugs, and diagnostics.

But when we think about medical diagnostics at NIAID, we really, I want
to emphasize, don\'t have requirements, and we don\'t have specific
requirements that we are looking for in terms of medical diagnostics.

When we think of medical diagnostics right now, and the platform will
probably change, we are thinking very much in terms of RND and
technology development. We think that the NIAID can provide a niche in
that area, because a lot of people that we have talked to, especially at
the other government agencies, have said that there is a lot of
technology out there to actually support new and emerging technologies,
and would be something that would be very good.

Not just for today, but for the future as we look into the future of
medical diagnostics. So I won\'t go over all these details, but we are
very much interested in technology development, whether it is sample
preparation, whether it is the actual technology, whether it is assay
development.

And actually also the analysis of the data. You mow, bioinfomatics,
software development, to the actual hardware of the technology. So we
run the whole gamut in terms of what we can support in terms of medical
diagnostics.

So how can we do that? Well, we can do that through a very extensive
grants and contract mechanisms. And when we think about medical
diagnostics, what I show here is we can actually fund the gamut of it.

We can fund emerging and innovative technologies, and I will explain
some of them, and we can also go to technologies that actually have been
in place and that maybe need a little bit more tweaking, a little bit
more supports, and maybe apply it to the SARS coronavirus, or other
biodefense agents.

Or actually if there is a technology that needs some clinical research
involved with it, development, validation, we can actually fund the
whole range of that, depending on what the community needs.

And I think that what Linda and I actually want to actually emphasize
today is that we are responding to the community and the other
government agencies and what they need to actually put forth the SARS
research and clinical agenda.

And I will explain some of these different programs that we actually
have in place that we can engage with other government agencies,
industry, academia, to actually develop, do research and development in
terms of technologies.

And we are interested in early \-- we can actually support early
diagnostic technologies for pre-symptomatic patients, and monitoring
infection, and treatment, and the whole range.

And I will be saying that over and over again, that our platform is
broad, and we can fund a whole range of different technologies. And
again, you know, we have the ability, and actually we have things in
place already that we can support new emerging technologies.

You know, it is not the PCR of today, or the AREAS assay today. It is
actually looking to the future, whether it is nanotechnology, whether it
is in vitro molecular imaging, but just looking to the future and
actually starting the development of these technologies and giving
industry a boost that we actually put money in RND to actually do some
research into these technologies, and I want to emphasize research.

We are also \-- when we think about diagnostics, what we are seeing in
front of us in terms of grain applications and interacting with industry
and academia, we are interested in both sides of it, whether it is the
pathogen, or whether it is the host response.

And we actually have been really excited by engaging in industry to
actually look at things like microrays. We hear a lot about microrays,
in terms of how they can be used in terms of a diagnosis to look at
multiplex things, lots of different agents.

And we are actually engaging in industry to actually once before us to
put money in research and development to actually ask the question is it
really going to be a diagnostic.

What can we do to move it from a research tool into a diagnostic, and so
we are excited about that part of it. And actually as you know the way
that we do our business is through research is through grants and
contracts, and in a peer-reviewed system to actually help us decide what
we can fund and how we can engage with industry.

Traditionally, we have used grants, cooperative agreements, and
contracts, but we realized right after September 11th that we really had
to develop some new mechanisms to actually engage with industry and
academia so that people can actually come together \-- academia,
industry, Federal agencies, to come together and present us with a
package that we actually can review, and then eventually fund in terms
of whether it is vaccines, drugs, or diagnostics.

And successful partnering is really our message that we want to present
to people, whether it is with other government agencies, small
companies, large companies, and private-public partnering is something
that we are seeing before us that we are hoping is going to be very
successful.

And we have some new mechanisms that we actually have forth right now
that are actually geared towards cooperation between academia, industry,
and other Federal agencies.

And we actually had them in place now for the last year, in terms of
biodefense, and we have now added SARS to them. The first program is
what we call the NIAID cooperative research program for biodefense and
SARS.

And it really will support research projects for the development of a
product, and right now of course we are focused on diagnostics. And this
program is really to bring together academia, industry, government
agencies, to actually put forth a product, a development of a
technology, in terms of medical diagnosis, for us.

And this one really looks for earlier technology development. We have
another program that we have in place and we can give you more details
later \-- it is all on our website \-- about receipt dates and stuff. It
is called the NIAID biodefense and SARS partnership.

This one absolutely is geared towards industry. If you want to come in
for this grant program, you have to have a substantial industry
component. And along with that you could have academia, other Federal
agencies, but it really is geared towards industry to help in the
research and development of a technology of a drug or a vaccine.

And we have invested pretty heavily in these programs, and I can tell
you that we see grants, and people always ask us how large are these
grants, you know, and that is the first question that we get from
industry.

You know, we have seen a range of up to \$2 million of direct costs that
come to us. We are not encouraging everyone to come in for that large of
a grant, but we are serious in our investment in terms of research and
development for technology.

So these programs are ongoing, and they have been very successful for
us, and you will see them in the fiscal year coming up. And we have our
usual small business programs that we can still use in terms of
technology development, and we encourage people to use that.

The second quick part of my talk I want to talk about is we have things
in place, and messages, and we have grant programs in place where we can
engage in industry, academia, in terms of technology development for
diagnostics.

We also have \-- and I think that it is really actually is part of part
of our technology development program, we have a very intensive
microbial genomics program at NIAID, and it runs from sequencing, to
functional genomics, to prodionomics, to bioinfomatics.

And just for an example, last year NIAID put more than \$28 million in
terms of microbial sequencing. And I think in terms of diagnostics that
is going to have a large input in terms of diagnostics, providing
targets for new and improved diagnostics when it is a PCR, or some other
new technology.

So we are really excited about that program, and that is going to
continue very strong for the next couple of years. But let me just tell
you what it is going to look like, and the message after all this is
that NIAID has contracts in place that we can respond very quickly to
the needs of the scientific, academic, and industry, and government
agencies, in terms of what we can provide.

By the end of September, we actually are going to have sequencing
centers in place that we can respond to national needs, industry needs,
needs of the academic community, to get sequencing done.

So that is going to have a large input on some place where we can get
sequencing done and we can move on, whether it is a clinical sample,
whether it is an animal, genom, anything like that.

As accompanying to that, we are also going to have bioinfomatics centers
in place, because if you are going to do sequencing, you are going to
need the bioinfomatics.

We are going to have bioinfomatics centers in place where we actually
can collect the data, and analyze the data, do comparative genomic
analysis anything that is needed. build software tools, so again we have
resources out there for the communities that need it.

We also have \-- and that is in place right now, something called the
pathogen functional genomic resource center that we actually can respond
very quickly to the needs of the community, and I can show you a good
example of that. And these are all in the handouts and so I won\'t bore
you with all the details.

Right after the SARS coronavirus genom sequence was actually out there
in the public, we actually developed a private public partnership with
Affymetrix, TIGR, and NIAID, and within a month of the sequence being
out there, NIAID has made the human \"SARS chip\" freely available to
anyone that wants it.

And it is a very easy process to get at NIAID, and the staff, the NIAID
staff and myself, can give you information about it. We have chips
available, so we actually can move the research community forward. And
again, you know, they are out there. We want people to use them, and
this is just the beginning of the genomic resources that we are going to
make available for emerging and re-emerging diseases, and biodefense.

And then I will just quickly summarize. You know, when we look into the
future, this is really our future, and what we call it is our infectious
diseases preparedness, and our vision for the future.

And it involves antibiotics, safe and effective vaccines, looking at the
immunology, learning about broad-based pathogenesis of the pathogens,
and also to help in the development of simple and rapid diagnostics to
detect, characterize, and quantify any infectious threat.

So that was really quickly, but I will stop there and I wanted to keep
on time since I was the moderator trying to do that. I hope that I kept
on time. Did I? Okay. Good. So I guess we open it up to questions.

(Applause.)

DR. GIOVANNI: So can we invite the other speakers to come to the table.
Thank you. Okay. So we are going to open it up for questions, and I
would ask you to please come to the microphone, and state your
questions, and then we will have our panel members answer the question,
or start some discussion. Don\'t be shy. Can you also state your name
and what your affiliation is.

MS. LEBER: There is no microphone here, but I can talk really loud
though. My name is Amy Leber, and I here from Quest Diagnostics, and
what I have not heard this morning yet is the world of clinical
laboratory. particularly in the development of SARS tests.

And I would be interested in the comments from Dr. Gutman in particular
in light of this from ASAR-3, because I think that some of my laboratory
\-- fellow laboratorians in laboratories across this country are
developing SARS tests independent of industry and the FDA/CDC.

DR. GUTMAN: Sure. The SRA rule allows for a fair amount of freedom for
our home brew tests, but there is a restriction that when the assay
becomes too high a profile to risk, that entraps the ability to be Class
I exempt and causes the ASAR to be regulatable.

The two \-- there is only two pathogens that were cited in that manner
at the time that it was written, because they were the only two that
were actually imagined to fit the bill were HIV and TB.

And the notion was frankly that those assays would have a powerful
impact on the person being diagnosed, but actually those assays or
mistakes in those assays might have impacts on people who might come
into contact as well.

And one example is where you have the incorrect or wrong diagnosis, and
you get on a plane and you infect not only yourself, but everybody else
traveling with you.

SARS seemed more like TB to us than like the usual Class I itself. and I
still say it is more like TB to us than the usual Class I exempt
products. So that does not preclude laboratories like Quest or any other
entrepreneurial lab from moving forward with the assay.

But it does require oversight that is not usual for the assay, and that
oversight would be at point where the assay is being credentialed and
would require an IDE, and at a point where the assay is being offered
without informed consent and IRB oversight that it would require a PMA.

A PMA, as my industry colleague put on, might be a very pragmatic one
that takes into account the unusual circumstances, and we dance around
sampling and labeling issues. But we would still want to have some
threshold of safety and effectiveness.

So for Quest or other labs that are interested in that, my suggestion
would be the same for any manufacturer, and for that matter any
government entity fielding a commercial assay, which is come in and talk
to us early, and have a dialogue with our group, and we will see what we
can do for you, and we will see what you can do for us.

MR. KRAFT: I am David Kraft from Walter Reed Army Medical Center. Maybe
the next step following Dr. Leber\'s question, no one has spoken from
the perspective of the user, the clinical laboratory.

I might be sending something to Quest on the issues of \-- can I get
people\'s informed consent before they run that, or they, but perhaps
also for Dr. Robertson as an LRN laboratory at Walter Reed from
receiving your protocol, and approved by your IRB, but not approved by
mine, and they come back and say, no, this doesn\'t fit our direction.

Perhaps Dr. Gutman could address how I get information to a reference
lab and perhaps Dr. Robertson could address, as part of the lessons
learned, how do us individual clinical laboratories transfer from the
CDC to our own review committees?

DR. GUTMAN: Well, your negotiation with reference to the lab is like
that for any particular assay, that as you are ordering a test or
understanding what the test requirements are, they may be a bit unusual
in this case, and that they may require more information being provided
to the health care provider or the user than would be the typical case
they might require.

But the issue of communication between someone using a reference lab and
the lab is not a new entity, because there are all kinds of unique
twists and turns about how to collect certain assays and what kind of
information is required.

This may be at the extreme end of it, but Quest or \-- well, I don\'t
mean to pick on Quest \-- Quest or whatever lab is offering this, but as
it is offering it has to offer it with the appropriate information so
that it can be properly collected, and in this case that might require
some kind of IRB.

MR. KRAFT: Because that part has never been a part. Everything up to the
last half-a-sentence I will agree with, but the piece of the IRB and
informed consent, as far as I know, has never been addressed
industry-wide. If it has, it has been simplified.

DR. GUTMAN: Well, with regard to that, I must say that this is the first
example of this particular problem that we have actually addressed. So
if you have imaginative ideas, put them on the table to help us address
it, we would be grateful.

DR. ROBERTSON: I\'ll pick up from there. As he said, this is the first
time that this has been addressed. And from a CDC perspective we tried
to have our IRB serve as a national IRB, and this was provided in a
health care \-- in a special letter that was sent out with all of the
documentation.

To be honest with you, we have had multiple questions from State labs
and from other LRN laboratories, and from hospitals now, relative to
local IRB, and the necessity for local IRB approval, and I don\'t have a
good answer for you. I mean, this is an issue that I think needs to be
resolved.

MR. BRAY: Hi. I am Kurt Bray from Beckman Coulter, and following up on
Dr. Gutman\'s and Dr. Koziarz\'s presentation, it seems like that from
what you said, Mr. Gutman, that the FDA is willing to be very flexible
in terms of what is needed in order to accomplish the goals that we are
all here interested in here today.

But at the same time you were sort of describing a pretty standard Class
III approval, and I am wondering to what extent is the FDA prepared or
contemplating adopting some of the things that Dr. Koziarz has talked
about.

Specifically, approving Class III indications for identification only
without a lot of clinical information, and also granting an approval
where the pivotal trials that use only banked samples, given that there
are no active infections that are ongoing.

DR. GUTMAN: Yes, I was trying to make the point that we have a clear
vision for safety and effectiveness \-- I actually spelled out the regs
for it \-- but it does need to get more or less clear than that.

But I was also trying to point out the fact that if you read the regs
that they also allow a fairly wide latitude in terms of the types of
evidence that are allowed. So I think that our review process is
underrated in terms of its flexibility.

Our review process is probably underrated in terms of the balance that
we might have between cautious labeling and narrowing intended uses, and
datasets, and of course the Modernization Act does give us an
opportunity to play around.

We don\'t have a lot of experience with the balance between pre-and-post
market data collection.

So I think \-- I can\'t be prescriptive. I can\'t tell you exactly what
path the group would follow, but we certainly would be very interested
in engaging in a dialogue to figure out what the right path is.

We have a number of people, frankly many who are in this room, who are
more familiar with this pathogen than I am, and who might be able to
provide advice on what the least burdensome thresholds would be
appropriate.

But we understand the public health exigency here, and so it is in all
of our best interests actually to sit down and have this dialogue test
by test, and company by company, and lab by lab, and see what we can do
to make the product available.

MS. SAUREN: Hi, my name is Nancy Sauren, and I am with RDD Consultants,
and one of the real particular logistic challenges that all of the
manufacturers looking to submit an IDE and PMA will have to face in this
particular circumstance is dealing both retrospectively and with samples
banked in foreign countries, where privacy issues may be handled
differently.

What are the Agency\'s thoughts on the requirement for gathering
currently informed consent for samples for which consent for research
use was not given at the time that the sample was obtained?

DR. GUTMAN: Well, the agency actually is addressing that not in this
specific manner. There is a lot of discussion frankly about a much more
mundane test than SARS, and the agency has not actually developed a
formal position yet on exactly how to sort through it.

It would be fair to say that the whole sensitivity of informed consent,
and the use of banked tissues and repository issues, and frankly of
taking material in and delinking and atomize, it is a higher sensitivity
than it was 3 to 5 years ago.

It would be fair to say that not to provide specific enforcement
discretion, but it is fair to say that we are anxious to work on helping
people get these assays available.

We are not willing to break the law, but we certainly are willing to
apply enforcement discretion or reasonable interpretations wherever
possible. And we do understand that internationally that there is a
heterogeneity of rules of behavior, and we again are willing to work
with companies to help them get products through.

So I can\'t give you a specific answer. I can indicate a willingness to
deal, a willingness to work, and an anxious and sincere interest on our
part in helping to bring these diagnostics through.

MS. SAUREN: Thank you.

MS. BRAY-WARD: I am Patricia Bray-Ward, and I am from Yale University
School of Medicine, and I would like to say that I sort of feel as if I
am almost the only academic in the room.

And while there has been a great deal of discussion about trying to
speed up the time table of the development of diagnostics and what not,
there is no rapid mechanism for bringing academic labs on board.

The grant process is a very slow process, and I have to say also that
much of my understanding of SARS comes from a historical, academically
derived data on the behavior of coronaviruses. And I do feel that the
academic community still has contributions to make. There is not a good
funding mechanism.

I mean, there is good funding mechanism, but we are looking at the
beginning or end of next year before labs can actually switch over in
real time. Our lab has been working since April, but in our spare time
as opposed to having a real project.

AUDIENCE: What is the question?

DR. ROBERTSON: I would say from a funder of technology development, you
know, I have to agree with you, that the time from sending in
applications, to getting it reviewed, to processing and then awarded, is
at this point nine months.

I mean, we are trying to speed up that process, but you are not seeing
it today. So we understand your comments.

MR. GORE: My name is Steve Gore, and I am the Health Advisor of the
(inaudible), which is the de facto of the Taiwan Embassy here in
Washington, D.C. I do have a question for Dr. Peiris of Hong Kong, but
first let me take this opportunity to thank the FDA to invite people
from Taiwan.

In fact, we have five persons from Taiwan who are attending this
meeting, including Doctor or Professor Wang, who is a professor at the
Taiwan University, and also persons from our CDC, and our National Labs,
and which are doing the SARS outbreak in Taiwan.

And we appreciate your invitation and we look forward to working with
the FDA. We have a good relationship with CDC. CDC has sent more than 25
health officers into Taiwan to help us out, and we really appreciate it,
and we look forward to that.

But my question is about the facilities that Dr. Peiris just mentioned,
that the second generation is as high as 96 percent. I just wondered do
you have any idea about the specificities, because in Taiwan, although
it is important to have a high sensitivity tasked in the low
specificity, but the problem of false positives is equally damaging and
hampering Taiwan, especially when Taiwan was regarded as affected areas,
and caused a lot of trouble.

So I just wondered when you said that the second generation of PCR is as
high as 60 percent of sensitivity, I don\'t know where this is a
possibility. Thank you very much.

DR. PEIRIS: Yes, thank you. The second generation data that I was
talking about is still in the process of being completed in essence, but
certainly we are in the process of testing those 15 (inaudible) and 10
or 12 stool samples, and yet we tested 50 negative specimens as well.

And in that situation, none of the negative samples came up positive. I
must say, however, that the sensitivity that we are getting, in order to
get this 90 odd percent sensitivity with specimens, you really do have
to push the system to its limits in relation to the PCR itself, but more
importantly in relation to the specimen extraction process.

And the question is if you have to apply this in a real time diagnostic
setting, I am quite \-- I realize quite well that specificity could well
be a problem when you are handling large numbers of specimens.

Just to put that in a context, during March and April our lab alone were
handling 200 to 300 specimens a day, and trying to do PCR with that type
of volume really does pose problems.

MR. HOUNG: I am Huo-shu Houng from Walter Reed. Before we come to this
number in general specificity or sensitivity, we must ensure that all
the lab GOP comply. I mean, that is the first essential.

And secondly depending on the sample type, and whether it is the early
stage of infection or in two weeks, or convalescing, you connect the
number as low as 10 to 15 percent, or to as high as 96 percent.

MR. LUCEY: Hi, I am Charles Lucey from CBER. There was some discussion
in the clinical literature about superspreaders, and I was wondering if
maybe your laboratory analysis had gone into looking at that question,
and whether certain patients could be identified as superspreaders.

DR. PEIRIS: Yes. We have looked at the index case for Hong Kong, and I
am sure that you are well aware with this patient, and we looked at
bioload in this patient to see if it was markedly higher than what we
normally see in patients, and that was not the case. But that is only
one patient really that we have looked at, at least in terms of bioload.

We looked in that patient to see if there was a multiplicity of
genotypes and in fact that patient does have at least two variants, if
you like, of virus in the protein.

I don\'t know what the significance of that is, but at the moment we are
looking at other patients to see whether there is a (inaudible) in
genetic sequence in other patients, but these are very early days as
yet.

In total, there are only a very small number of superspreaders in Hong
Kong, or for that matter in Singapore. And they are spread out over
major different hospitals, and even though we have a hospital authority
which theoretically controls everything, it is not possible to rapidly
get to all these specimens in an adequate period of time.

But that is something that is certainly that we are certainly looking
at.

DR. KOZIARZ: Okay. I would like to thank everyone who participated in
the morning session, and for Maria for being a wonderful co-moderator,
and for everyone for staying relatively on time. We would like to
stretch and now take a break, and exchange places with the next set.

OIDD does always like to have the last word in every session, and so I
would remind you that we have a process called a pre-IDE process, and in
which we are willing to talk to folks when they are in the protocol
phase, and when there is a twinkle in the eye feasibility phase.

So please don\'t hesitate to contact us to follow up on all of the
unfinished answers that I provided this morning.

(Whereupon, at 11:10 a.m., the meeting was recessed and resumed at 11:18
a.m.)

DR. BABB: Okay. Everybody be seated.

DR. GOLDBERGER: Good morning. I am Dr. Mark Goldberger, and I am the
moderator for Session II, Incorporating Diagnostic Testing into Clinical
Management of Patients and into Public Health Practice of Patients.

We have two speakers today. The first is Dr. Josh Metlay from the
University of Pennsylvania, who will be talking about clinical
management. The second is Dr. Stephen Ostroff from the Centers for
Disease Control, who will be talking about public health practice. Josh,
do you want to start?

DR. METLAY: Thank you, Mark. It is a pleasure to be here. I am going to
really try to change gears here quite a bit from what has been going on
in the morning, and try to talk about this issue from the perspective of
a physician in a primary care office or in an urgent care setting, or in
an emergency department, because I think that context really needs to
inform some of this discussion.

So I am going to talk in general about the clinical approach to the
diagnosis of acute respiratory tract infections, and I am going to talk
then a little bit about the diagnosis of pneumococcal pneumonia.

Now, that may seem like an odd choice from a transmissibility and from a
pathogenesis point of view, it has really little to do with SARS. On the
other hand, in terms of some of the treatment options in the clinical
presentation, not treatment options specifically, but treatment
benefits, it may be an interestingly relevant example. And it also has
the added advantage that I know something about pneumococcus, which is a
good thing for your speaker, I think, in general. And then I am just
going to conclude with some considerations of how these sort of lessons,
these epidemiological lessons for a physician, might apply to the
development and application of a SARS diagnostic test.

So, I am outlining here \-- and Steve will sort of elaborate on \-- the
sort of distinctions here between the physician and public health
perspectives. As a physician the issues really here is when a patient
comes in with an acute illness are determining the need for
anti-infective therapy, then targeting that therapy.

And in some such situations, risk-stratifying, based on the presumed
pathogens in terms of the site of care and some other management issues.
Those are the time-dependent issues that we are facing.

From a public health perspective we are talking about surveillance and
infection control, and having adequate samples or patients for clinical
research.

These are really distinct, and as a consequence some of the
considerations for what has got to be in a diagnostic test are
different, okay?

So that from a physician perspective, we are talking about something
that has to be rapid, and I have used the concept of bedside capability,
perhaps not literally that it has to be done at the bedside, but that it
has to be in real time and can provide information that can inform these
physician decisions.

And so some examples are that there are some things that could really be
done at the point of care, in contrast to what I have listed in some
sense time insensitive, although they are not completely time
insensitive, obviously, to the public health perspective, and the role
perhaps of some of the other kinds of diagnostics that we have heard
about.

So I am going to anchor my comments, which will not be that long,
because I really want to engage in discussion, around a model of
thinking about diagnostic tests used for physicians. This is only a way
to give it some kind of quantitative way to think about this problem.

It is certainly an imperfect model, but nonetheless a useful one, and it
was proposed over 20 years ago by Pauker and Kassirer, is what is called
the test treatment threshold model of how physicians would think about
using diagnostic tests.

And what they proposed and has been used in a lot of other settings,
although not much in the setting of acute respiratory tract infections,
in this concept that we think about the probability of any infectious
agent going from zero to a hundred percent when we see the patient.

And that there is a realm in which the probability of that pathogen \--
SARS in this case \-- is so low that there is really no point in
pursuing any further diagnostic testing.

On the other hand, there is another realm towards the right where the
probability is so high that we are going to empirically treat or
initiate management strategies that we think are SARS- appropriate, and
in between it the realm that we are going to apply the diagnostic test.

The thing that you should see from this is that we don\'t need to demand
a hundred percent positive predictive value, or zero percent negative
predictive value to be in those two extreme boxes. That will never be
the case.

So really the question is, where are those thresholds, because they are
not at zero and 100. If you wanted to quantitate this, and I think that
this starts to get a little bit into the two numerics and gets from the
art of medicine, one could actually quantitate where those thresholds
are, knowing the specificity and sensitivity of the tests, and the risks
and the benefits of the treatment that you are deciding on, assuming
that there are no risks of the tests. And we are leaving aside the
economic considerations.

So you can see that what starts to become important here obviously,
which has already been brought up, is some sense of what are the costs
of false negatives, missed opportunities to treat, and false positives
\-- treatment when it wasn\'t necessary.

So this would be the decision not to test, or to test, and then one can
calculate for the decision to test or to treat. So I am going to think
about this just as a patient coming in to see me with a productive cough
and the issue of whether they have pneumococcal pneumonia.

And so I have rewritten this now, just to consider the probability that
the underlying diagnosis is one of strep pneumonia. So the factors that
have to go into this decision from the clinical perspective then is some
consideration of what the pretest probability of the disease is,
something we haven\'t talked a lot about, but which is clearly key in
understanding the interpretation of any of these diagnostic tests.

We need to consider the test costs if they exist, and we need to
understand the operating characteristics of the tests, which we have
heard about. And then we need to talk about the treatment risks and
benefits, which we have not heard much about, of course, because this is
really a sort of a yet-to-be-done.

So what are our pretest probability? This is in some sense the part of
this exercise that really irritates a lot of physicians, particularly
physicians in training, because the implication is that your perfectly
calibrated test could yield a different answer in the hands of two
different physicians, if they used the test for different pretest
probabilities.

So it provides a kind of a movement to this interpretation of a test,
and there is no specific result here, that we just all have to get
comfortable with, because that is the reality of medicine.

So we begin usually with a population-based estimate of the probability
of the disease. In the case of a patient coming in with a cough illness,
we have done some of this work \-- many others have.

It turns out that only a very small percentage of the people who come
through the door with an acute respiratory illness have an underlying
pneumonia \-- we have given estimates there of about 4 percent \-- and
most of the other diagnoses are more upper respiratory tract types of
infections, or exacerbations of underlying lung disease typically
associated with viruses, which as Mark has mentioned used to mean no
need for therapy. So this is another place that we are starting to move
into new territory.

Obviously each patient is not exactly the same, so there are
characteristics of patients that help us focus in on the probabilities
of disease, once they come through the door, based on science and
symptoms, which lead us to think that they have pneumonia, and then
given that they have pneumonia, lead us to believe that they would have,
for example, pneumococcal pneumonia.

And others \-- and we have as well \-- published data to give you some
sense of, for different kinds of symptoms and signs, how should you
think about that patient differently in terms of their probability of
having a specific disease.

And I will summarize a lot of this by saying, the more they have
classical findings sort of suggestive of an underlying pneumonia, the
more you move to the right of your probability.

But you rarely get above 50 percent. You are at best sort of in the
middle, even in the classic presentation of a patient. And in a patient
who otherwise looks quite well, you probably can get your probability
down to the 2 to 5 percent range.

So that gives you a sense of what\'s the probability that a patient
would have pneumonia, and by that I mean something that we would confirm
with chest radiography. And then we want to ask, well, what is the
pathogen, and I will summarize a lot of what I think is somewhat
controversial work and say that, once the diagnosis of pneumonia is
established, the history and physical is of little value in targeting
antimicrobial therapy.

And both the IDSA and ATS guidelines, the front pages of which are
outside, advise against targeting therapy based on the history and
physical. So, although, and I will mention this at the end, we have
heard a lot about sort of some interesting patterns of clinical symptoms
and signs that go along or against SARS, I believe that we are not going
to see that those turn out to be particularly clinically useful in
making clinical treatment decisions.

So just some numbers then. We have to think about this in the context,
and in the U.S. at least, of 30 million visits to physicians in
emergency departments, urgent care centers, and primary care offices a
year for cough illness.

Five percent of those, as we\'ve said, perhaps will have underlying
pneumonia \-- anywhere from 30 to 50 percent of those probably have
pneumonia due to pneumococcus. So one might say that one percent of the
patients who are coming through the door have a pneumococcal pneumonia.

So one percent, which sounds small, is already log orders greater than
we would be considering now for a patient coming through the door in
terms of the probability of SARS.

So if we now move on to consider some of the other characteristics that
I mentioned \-- I will just put up here some test characteristics of
some tests on influenza, just to be provocative \-- and think about how
that might relate to some of what we have heard today.

But I am going to pick here on the low-lying fruit here and talk about
the gram stain, because that has been sort of the unfair whipping child
of this business.

And I will use the sensitivities and specificities that most people will
agree on. And I will argue that if we want to estimate the risks and
benefits of treatment, we don\'t have a lot of good data. And I
participated in an FDA conference last year that Mark held which really
tried to get at this issue of what are the real incremental benefits of
giving anti-infective therapy to people with respiratory tract
infections. And the answer is, to a large extent, we don\'t really know.

And risk is also in some sense even more nebulous, once we begin to
think about massive use of these drugs. So if you just do an exercise,
just looking at historical data and comparing the pre-antibiotic to the
post-antibiotic era, you might center into a feeling \-- if we look at
the second set of bars \-- that amongst all patients with pneumonia,
there has been about a 12 to 13 percent decline in mortality that could
perhaps be attributed to the use of anti-infective therapy. So 25
percent to about 12 or 13 percent mortality.

So a treatment benefit perhaps of 10 to 15 percent. A treatment risk out
of nowhere \-- I will just throw that out there to get us going \-- of
one percent. And that leads us to calculate, based on the formulas I
gave you already, a no-test threshold of 2 percent, and a test treatment
threshold of 14 percent.

So what that looks like now is that the patient coming through the door,
we are not going to pursue the diagnosis any further at a probability of
less than 2 percent, and we would empirically begin therapy if the
probability of pneumococcal pneumonia is greater than 14 percent.

Well, I already told you that probably no more than one percent of
patients coming through the door at any one time have pneumococcal
pneumonia. So for the average person coming through the door, no more
diagnostic testing is going to be warranted.

And then once the diagnosis of pneumonia is established, they are
probably in the 20 to 50 percent range probability to have pneumococcal
pneumonia. So you are comfortably in the range of empirical treatment.

So this is not the only explanation, believe me, but a good explanation
\-- if you will \-- of why nobody does diagnostic testing for
respiratory tract infections. Because they are always to the left or
right of that center box, which is actually relatively narrow.

And gram stains are not used, by and large, at all in the management of
respiratory tract infections these days, and this is at least one
explanation for why that is the case.

So, some lessons that I just want to sort of point out is that until the
pretest probability of the pathogen is much greater than one percent,
diagnostic testing is unlikely to be indicated in routine practice. We
need to keep that in mind.

I know that we are now in a situation in which we don\'t have new cases,
and we were in a situation in which we were really doing with sort of
localized epidemic situations. But one could imagine a situation in
which the pathogen became endemic, and which we would have to start to
think about pre-test probabilities if you are in Philadelphia, or Los
Angeles, or anywhere, and not just if you are in Toronto or in Hong
Kong.

Unless the diagnostic test has excellent operating characteristics, the
testing window will be narrow. And it could be considerably narrow,
especially if effective treatments exist, because they are going to
drive down that threshold quite a bit, and people are going to use
empirical therapy.

And I will just give you one graphic way that I like to think about this
problem in general. If we think about the pre-test probability that
someone has SARS, for example, ranging from zero to a hundred percent on
the X-axis, and we want to see the impact of the tests on the post-test
probability, the orange curve is giving us the result for most of the
tests that you are describing, in terms of how much it would increase
our probability if the tests were positive.

And the lower orange curve gives us the result if the test is negative.
And what you can see is that for any given probability before you do the
test, a positive test certainly raises the probability, and a negative
test certainly lowers the probability.

But unless you are in the middle where you get the most action for your
test, when you are at the margins, you don\'t get a lot of movement for
that test. So if you really have a high level of probability, the test
is not going to rule it out.

And if you have a very low suspicion, the test is never going to rule it
in, no matter what the operating characteristics are, unless they are
darn near perfect.

So I will just close by suggesting that the issue that we are really
thinking about is that kind of test for SARS in the middle there \--
whether it is a DNA amplification, or some kind of immunoassay \-- is
where are those thresholds going to operate for clinicians, to give you
some kind of guidance on what kind of tests should we put out there and
how should we label them.

We have case definitions which are largely now driven by epidemiological
factors and exposure history, but absent that, look a lot like a
pneumonic illness coming into a hospital. So as long as we still have
the second bullet, I think we are probably in okay shape, but as soon as
we start to lose that, all bets, I think, are going to be off.

And so I will just close by saying that we must emphasize the importance
of local surveillance in disease reporting. You need to know the
probabilities in your region, or you really can\'t use these tests
accurately.

If you don\'t have local cases, I think that diagnostic testing will not
be supportive without epidemiological exposure. I suspect that we would
agree to that now, but who knows how it will be a year from how.

And given competing reps for pathogens, it is unlikely in my opinion
that science and symptoms will further modify the pre-test probability.
So we will look very much to the use of diagnostic tests, but hopefully
they are going to be used in the appropriate situations.

Let me conclude there. Thank you very much.

(Applause.)

DR. OSTROFF: Thanks very much. I am just going to very briefly go
through a fair number of slides to give a little bit of a public health
perspective about SARS diagnostic testing from the standpoint of an
epidemiologist.

Before I do that, let me just take an opportunity from the CDC
perspective to thank FDA for both putting on this meeting, as well as
for taking a leadership role in moving forward with SARS diagnostic
tests.

Although Eddie Robinson said that sometimes CDC and FDA talk different
languages, I will point out that we are in the same department, and that
we are definitely partners, and I think that we are partners in the
truest sense of the word.

And I think from the standpoint of CDC, we are partners with FDA, we are
partners with the scientific community, and we are partners with the
industry, in terms of trying to meet the particular challenge of SARS
and all the other challenges that we have before us.

And I also listened very carefully to the comments from Dr. Koziarz
about the West Nile model, and I think the West Nile model was a very
good model, and he said that the industry rapidly rose to the challenge.

At least from my perspective, West Nile has been here since 1999, and
the challenge that was put before the diagnostic industry had to do with
screening of the blood supply in response to last year\'s major outbreak
that occurred. But certainly we would have liked to have had been a lot
further along than we actually were, when all of this hit us last year.

So if we are using that as the model, I don\'t want to be in the same
position four years from now without having the availability of the
types of diagnostic tests that we need.

What I am going to do, very briefly, is talk about the international and
domestic experience with SARS, although a lot of this has been covered,
and then talk about some of the public health imperatives for SARS
diagnostics.

It is always important, when you give a talk on epidemiology, that you
have some case definitions, and I think as you listen to the
presentations that occurred earlier in the day, it is important to look
at what the case definitions actually are for SARS diagnosis.

And these are the case definitions that are currently in use in the USA,
but they basically do mirror the approach that was taken by the World
Health Organization.

And that is that the case definition for SARS is a combination of
certain clinical features, being fever of greater than 38 degrees in
respiratory illness; radiologic findings, including pneumonia or
respiratory distress syndrome, for autopsy findings of the same type.

In addition to that epidemiologic criteria, which was a travel history
within 10 days to a SARS- affected area, or close contact with a known
or suspected SARS patient.

The laboratory criteria that were added, once the diagnostic tests were
available, were antibody to SARS coronavirus, acute or greater than 28
days convalescence, SARS coronavirus RNA by RT-PCR and the second PCR
assay, or virus isolation.

The case definitions for suspect were simply that clinical and
epidemiologic criteria for a probable case clinical and epidemiologic
criteria, plus radiologic or autopsy evidence of pneumonia or
respiratory distress syndrome. And for us, confirmed is to have a
positive laboratory test, which is the important reason that we need
good laboratory tests to be available.

This is the map from a week or two ago. It hasn\'t really changed since
then, as you all know, showing that this definitely was a global
problem. There were probable cases of SARS, and you will note here that
it only talked \-- that from the WHO perspective, they only counted
probable cases.

There were probable cases that were identified on all continents around
the world, with the exception of Antarctica down there on the bottom,
and so this was definitely a global problem, and there is a large need
out there for diagnostic tests, not only here in the United States, but
throughout the world.

In the United States, there were over 17,000 individual reports that we
received of potential individuals with this disease. Of these, 423
persons met the case definitions that I put up on the screen before.
Three hundred and forty-eight of these, or 80 percent, were identified
as suspected cases, and 20 percent of these were identified as probable
cases. This is just some demographics about those individuals \-- when
you are thinking about the development of diagnostic tests \-- 22
percent of them were in individuals less than 18 years of age.

The vast majority of them were in what I call young adults \-- and 64
looks younger to me all the time \-- about an equal male-to-female
ratio, and about 50 percent of these in Caucasians, and about 50 percent
of these in Asian-American individuals.

About 24 percent of the suspect cases were hospitalized for at least one
day, and 61 percent of the probable cases, being that these were
individuals with pneumonia for the most part.

This is an epicurve looking at the distribution of the occurrence of the
probable and suspect cases here in the United States. And I will point
out to you that we continue to get sporadic reports of potential cases.
And for all of you who heard the reports on CNN at the end of last week
about potentially some servicemen that came home to Texas last week
where this diagnosis was considered, we have ongoing needs in relation
to SARS, and while we are in a lull in the battle, now is the time to
catch our breath and look towards the future.

This was a national problem from one coast to the other, with the
largest number of probable cases being identified in California and in
New York, as one might anticipate.

Among the probable cases, 97 percent of these were individuals who
reported travel to areas with documented or suspected community
transmission.

One was in a health care worker caring for a SARS patient, and one was
in a household contact of a SARS patient.

So for the most part, we were looking at a circumstance from the public
health perspective, where we were looking at travelers coming home that
fulfilled the case definition to be considered a probable case of SARS.

As far as the laboratory is concerned \-- and these are data that were
timely provided to me by Bill Bellini from our laboratory \-- this is
the totals of specimens that were just received at CDC.

And I am not going to go through each of these categories, but suffice
it to say, down there at the bottom on the right, that we received a
total of over 5,000 specimens for diagnostics. They were a whole
menagerie of different types of specimens, ranging from autopsy
specimens to NP swabs to sputum, to stool, to urine, as I am sure was
similar to the experience in other parts of the world.

And in light of some of the comments that were made earlier about the
need to have specimens well characterized, it is important to point out
that for the nasal pharyngeal swabs, and for the serum, a substantial
proportion of them we don\'t quite even know whether they were acute or
convalescent, because they were just coming into the laboratory, and
were there for the testing.

In terms of the diagnostic findings, as far as the serologies looking at
2,742 specimens that were tested, we have had 188 of these, or 7 percent
of these, that were positive. I will point out that the vast majority of
these are specimens that were sent to us from outside the United States.
These are not domestic specimens.

As far as RT-PCR is concerned, there were 44 positives or 4 percent, and
I think that it is also relevant from the public health perspective to
also point out that among specimens that were tested for human
metapneuma virus, that there were also a substantial proportion of them
that were tested.

And this once again raises the issue of other agents possibly being
associated with SARS and the need to have assays that not only are
directed specifically against SARS, but can look at other pathogens as
well.

Domestically in the United States, as I am sure that all of you are
familiar with, we did not have a lot of individuals that were confirmed
as having SARS. There were 8 out of 45 probable cases in which we
currently have what we refer to as interpretable results, meaning that
we have a convalescent specimen at this point.

We have the same problem that was mentioned from our colleague in the
U.K., in terms of getting convalescent specimens from individuals. And
among the suspect cases that were mentioned earlier, so far none of them
have shown any evidence of being positive, and I believe that this
number more recently is up to about 160 of these individuals, in which
we have interpretable results.

Among those eight individuals, seven had a travel history; four to Hong
Kong, two to Toronto, and one would travel to both Singapore and Taiwan,
and one was the spouse of a lab-confirmed SARS patient who had also
traveled to Hong Kong.

So why do we need good SARS diagnostic tests for public health purposes?
And I think, similar to the previous speaker, as was pointed out, there
are a whole variety of reasons why we need good diagnostic tests.

And certainly from the public health perspective, it is also appropriate
for clinical management, both current clinical management, as well as
future clinical management, in terms of the availability of therapeutics
and prophylaxis.

And it is very, very important for disease surveillance, and SARS is
somewhat unique in that we do have \-- for surveillance purposes \-- we
do have needs for rapid diagnostic tests, and we also have needs for
less rapid diagnostic tests to be able to definitively characterize when
and where SARS is occurring.

When you think of the case definitions that were used for SARS, with the
requirements for a travel history to a SARS infected area, when you look
at respiratory tract infections in travelers, these are data from an
article that was published earlier this year in [Clinical Infectious
Diseases]{.underline}, more than 600 million persons travel annually.
Twenty-five percent of these individuals develop respiratory symptoms
during travel, and 10 percent following travel.

Ten to 20 percent of these individuals develop acute respiratory
infections, and among travelers seeking health care at a travel medicine
clinic, acute respiratory infections are the second leading complaint.

And so I think the bottom line, when you see data like this, is that we
are going to continue to have large numbers of individuals coming back
from areas that are at one time or another going to be considered SARS
diagnostic areas, or previously were SARS affected areas.

And somebody is going to want to have a test to be able to determine
whether or not the disease has resurfaced, or to be able to better
characterize the illness in these individuals.

From the public health perspective, there is also a great need for a
fairly rapid diagnostic test, because the diagnosis itself has
tremendous consequences from the standpoint of how to manage a patient
both in the hospital, as well as in the outpatient management setting.

And when you are doing things like this to patients that may have this
particular disease, such as putting them in negative pressure rooms and
having to have special wards and special hospitals designated as your
SARS care hospitals, you really do need to know whether or not these
individuals actually have the disease.

And so in terms of infection control management, which is a public
health responsibility, in addition to a clinical responsibility, we
really do need a very good rapid diagnostic test to be able to tell what
the appropriate management strategy is for the individual patient that
may be coming to the hospital.

There is also issues related to community-based isolation and
quarantine, and as all of you who followed the SARS saga along know,
there were certain things that were done to individuals who both had the
illness, as well as for individuals that were contacts of persons with
the illness, in terms of community isolation and community quarantine.

This is just a picture of what was done in Taiwan in terms of setting up
cordon sanitaires around particular neighborhoods. And if you are going
to be taking public health measures like this, you absolutely do need to
definitively know whether or not you are dealing with SARS or not
dealing with SARS, and so there are a lot of good public health reasons
for us to need very good diagnostic assays.

This is in reference to that recent situation in Texas. This is from
last Friday, and as you can see here, it says here the initial tests
results from the laboratory samples taken from eight Dyess Air Force
Base members that may have been exposed to SARS are negative for the
virus. And it also says, although the early samples are negative for
SARS coronavirus, more testing is being conducted to rule out infection.

Definitive results may not be in for another 2 to 3 weeks, and then if
you look at the bottom paragraph, it says all are currently stable or
improving as of this morning. They remain isolated in their homes and
have been instructed to stay there until released.

And so if you think about it, it would be nice to have more definitive
diagnostic tests that don\'t take 2 or 3 weeks to get the answers back,
so that you know how to appropriately handle these types of situations.

There are also a lot of other rationales as to why we will continue to
need good diagnostic tests for SARS now and in the future. There is the
issue of contact tracing and testing, as was mentioned earlier, when you
have circumstances on airplanes, where you have an individual with SARS,
and you have to go about trying to determine whether other people who
may have been on the same plane were exposed.

You need a good diagnostic test to be able to categorize those
individuals. There are a lot of epidemiologic investigations that were
done, certainly looking at the cohort of individuals who stayed at the
hotel in Hong Kong.

There is environmental sampling which requires diagnostic assays. There
is potentially product sampling that would need to be done. There is the
evaluation of issues related to viral shedding which requires
diagnostics.

And while I put on here blood supply and screening, if you think about
the West Nile situation, nobody really thought about the need for
screening of the blood supply for West Nile until we realized that there
was a problem, and it would be nice to think about it ahead of time so
that we are not once again caught in the same situation that we were
with West Nile \-- about realizing after the fact that we need these
diagnostic tests.

So it would be nice to do a little bit of work in that area before we
get into a situation where we realize that we should have been doing it
ahead of time.

The last thing that I will close with is that in addition to a good SARS
diagnostic assay, we also need good assays for the co-factors, and I
will point out that as far as the human metapneuma virus and the
chlamydia, folks were not wrong about those particular diagnosis. Those
organisms were also present in some substantial portion of patients.

And one of the problems that we have is that simply finding one of these
agents does not necessarily exclude the individual from also having
SARS, and an individual having SARS doesn\'t necessarily exclude the
possibility that they have one of these other agents as well.

It is very important for us to need to know whether or not the patient
has SARS. It is very important for us to know if the patient has
something else.

And the bottom line for us is that it would be very nice to have very
good multiplexed assays which look for the whole gamut of organisms that
we need to look at to be able to best characterize illness in these
particular patients.

And so I hope \-- if there is one message that I get across \-- is that
while we are all sitting here talking about SARS diagnostic assays, we
really need a multiplex of better assays to be better able to
definitively diagnose what people have.

That is important for clinical management, and it is important for
public health. So with that, I will stop, and thank you very much.

(Applause.)

DR. GOLDBERGER: Hopefully we have time for a few questions. Go ahead.
Please identify yourself.

MR. PRUDENT: I am Jim Prudent from EraGen Biosciences. I was curious.
You mentioned on a topic that we are extremely interested in, and that
is multiplexing a number of different targets besides the SARS virus for
respiratory disease.

Do you know where a good place or who has the best list, or the most
up-to-date list of what those would be?

DR. OSTROFF: Well, to me as an epidemiologist, or someone who is a
little closer to the world of respiratory pathogens, possibly you may
want to comment as well.

But from our perspective, when I talk about things from the public
health point of view, there are a number of respiratory organisms that
have great significance, in terms of their public health diagnosis,
whether it is Legionnaires\' disease, or whether it is microplasma, or
whether it is chlamydia, or whether it is SARS, or whatever it happens
to be, that might not necessarily have the same impact or consequences
from the clinical perspective.

So there is \-- you know, looking simply at the SARS circumstance, it
certainly would be nice to have a multiplexed assay that would allow you
to recognize some of these alternative diagnoses that were mentioned
here that were found in some of these SARS patients, as well as to be
able to identify SARS.

I don\'t have a definitive list of what I would like to see in a
multiplex, but I am sure probably Dr. Anderson this afternoon might want
to comment a little bit further.

DR. METLAY: Let me just add that the way that I would approach the
problem is that I would think about it in terms of what are the issues
relevant to treatment decisions. And I would be less epidemiological if
the perspective is more from the clinicians point of view.

So what are the pathogens whose absence would change therapy, or whose
presence would add therapy to it? And this is a tricky problem indeed,
because we know most of our current guidelines for the management of
lower respiratory tract infections are based on observational data,
which is not particularly linked to pathogens, but more to sort of
risk-stratifying patients into different disease groups. So we have a
disconnect here between an infectious disease, in which we would like to
have pathogen-directed therapy, and empirical therapy, which is in no
way really clearly pathogen-directed.

But I think in general if I were thinking about this, I would like to
know which other things I want to make sure are not there, because I
might, for example, not add a basal \-- might not add a macroite, if I
really didn\'t think that chlamydia was an issue here or pneumococcus
was an issue.

DR. GOLDBERGER: Does anyone else from the audience have any questions?
Let me just ask Josh, then, a quick question. The example that you used
for your model was pneumococcal pneumonia. How much, if at all, would
things change when we consider an illness like SARS, which is
potentially much more transmissible?

DR. METLAY: Well, I think that I tried to model it on the simpler way of
thinking about it, because from a therapy point of view, which had to do
with treatment, because then the consequences of not treating, I think,
have become a little bit clearer.

I don\'t know how to think about this. One would imagine that one would
have a very low threshold for isolating someone who had even a somewhat
elevated clinical suspicion for SARS.

The example that I can give you is that I know that in our own clinical
setting, in our own emergency department, that we had a period of time
in which, you know, masks were being put on virtually every patient who
came in with an acute respiratory tract infection.

I suspect if you went through the exercise I just did that it would be
hard to justify that, and yet in the context of what was going on, it
was hard to argue against that.

And I think that this is a little bit of what I alluded to, where sort
of the quantitative approach to this will only take you so far, and then
there is this sense of sort of the gestalt of what is really happening
before you, and how willing are you to be wrong here?

So I don\'t have a way \-- I don\'t think that is going to fall as
neatly to a way I have approached this, as a specifically therapeutic
decision that it would fall into.

DR. GOLDBERGER: All right. Last chance. Any other questions? Did you
want to give some direction with regards to the lunch hour? Something
that is always of great interest to the audience.

DR. BABB: For those audio participants, we will reconvene about one
o\'clock, and for the people here there are several places to eat within
walking distance, or there are restaurants here in the hotel. So we will
see everyone back at one o\'clock. Thank you.

(Whereupon, at 11:57 a.m., a luncheon recess was taken.)

A-F-T-E-R-N-O-O-N S-E-S-S-I-O-N

(1:20 p.m.)

DR. NICHOLSON: Welcome back from the morning session. We are ready to go
for Session III now, Specimen and Control Materials for Test Development
and Evaluation. We heard this morning about reports from some of the
affected areas and the laboratory testing that was done there, and about
the development of an IDE that was done in the United States.

We heard a little bit about some of the concerns with the manufacturers.
We heard something about plans at the NIH. And in this session, we are
going to talk specifically about those materials that will be needed for
the development, evaluation, validation, of diagnostic assays, and how
that could be done.

I am Jan Nicholson, and I am the associate director for laboratory
science in the National Center for Infectious Diseases at CDC, and we
have a great group of people up here to talk about a wide variety of
issues in this area.

We are going to start off with Cathy Roth from the WHO. She is the
project leader of Dangerous and New Pathogens for the Global Alert and
Response in CSR at WHO. Cathy?

DR. ROTH: Hello. I am going to talk about the WHO perspective on
diagnostic and laboratory needs, including sample banking. I realize
that this is a little different than what is on your agenda. The reason
for the deviation is that I think that we are not really at the point
where we can say precisely what the WHO agenda will be and I hope that
this meeting will be one aspect of the process of finalizing that
agenda.

So just to begin with the process for the detection and response to
SARS, as many of you may know, the response to SARS was characterized by
the very rapid convening of a virtual laboratory network, first to
determine the etiology, and then to try and develop some diagnostics.

This group was convened virtually over a weekend in mid-March. It
involved 13 laboratories in 9 countries, with daily telephone
conferences, and identification of the coronavirus was announced at a
face to face and also video meeting on the 16th of April, basically
within a month.

I think that this was really an unprecedented achievement. In addition
to the laboratory network and I am mentioning these because they will
have relevance to our approach for both diagnostic development and
sample and reagent banking and archiving, there was also a virtual
network of SARS clinicians, a virtual network of SARS epidemiologists,
the WHO partnership global alert and response network, and also fielded
lab scientists to teams sent to countries. And also there was a modeling
group, both virtual and actual, again from participants from 10
constitutions.

All of these groups had a secure website, and I think that we are
working now towards unifying these websites with specific areas so that
all the different groups can have access to the conclusions and the
possibility of discussion with the other disciplines whose thoughts
should inform their work.

The achievements of the lab network were: number one, its establishment
and development very rapidly of useful assays. We have heard about some
of the phases of the development earlier this morning.

The consultation was already mentioned, and it coordinated an
international scientific research program to understand antibody
kinetics, roots and parents of virus transmission, and excretion, very
rapidly published information about environmental stability of virus,
which was very, very important to the infection control measures in
hospitals, the main amplifiers of outbreaks, and also has initiated and
continued research to find and characterize the animal reservoir.

Also this group has accomplished and continues to accomplish
synchronizing the virus strains. It has already performed evaluations of
some of the diagnostic tests that have been developed.

It has prepared guidelines on the use of laboratory tests for diagnosis,
and it has developed procedures and guidance for the sampling of
patients and performance of tests for labs that may not have been
involved in the initial development phases. It has published the results
of research on the stability of the virus, and a number of other
scientific papers by the members of the group.

It has also already begun to conduct training courses in diagnosis. The
first one has been held in Beijing, and there are other courses planned.
The next one will be held for African labs in the late summer.

It has provided support to national reference labs, which were
identified by Ministries of Health, by direct nomination, or by WHO
regional offices.

It has produced and distributed various standards reagents, referenced
antigens, referenced sera, and it has also encouraged and is producing
reagents for participation in proficiency testing.

It is produced and distributed by the good graces of some of the
partners, including the Rober Koch Institute in Germany, gamma
irradiated whole virus standard, and also acute and convalescent sera
tested, validated, aliquotted, and realphalized (phonetic).

It has allowed other labs to have access to kits developed by its
members and it has already created one specimen bank in Hong Kong under
the aegis of Dr. Youlinda Lin.

In the middle of June, there was a global meeting of many of the
partners in countries who had participated in the response to SARS
either from having outbreaks in their countries, or having contributed
to laboratory, or clinical, or field teams.

This was held in Kuala Lampur, and in this conference there was both the
review of all the evidence so far, and an attempt to identify in various
breakout groups the topics that should be the basis for the next work on
SARS to be coordinated by WHO or other partners.

I have included here some slides that were the conclusions of the
breakout group for laboratory issues. They identified the major needs as
further work on animal models, for pathogenesis, to understand better
the evolution of disease, and for vaccine and anti-viral testing.

They have also encouraged the need for a priority for vaccine
development, evaluation of different vaccine constructs, epitome
mapping, other issues that they feel needed very careful attention, and
a fair amount of resource input were further work on strain diversity,
anti-viral drug screening, human monoclonal antibodies, diagnostic test
development, with an emphasis on timely and reliable tests.

They felt that there was a very strong need at this stage to emphasize
the need for standardization, and also the need for a well-pedigreed
panel of specimens to validate future diagnostic assays: blood, serum,
sputum, stool, urine, pathology samples.

And that these sample archives should be linked to clinical details and
that there also should be standard panels created of SARS strains. They
also emphasized the need for the development of reagents and reagent
banks.

That there should be a repositories of both reagents and isolates. The
WHO should have the leadership in establishing the repositories, but
they should function as a result of an international collaboration, and
that there was a need for both live and inactivated virus, and a need
for additional sequencing of SARS and non-SARS coronaviruses.

And there should be guidelines for the distribution of virus and that
the real priority was reliable tests for clinical triage. They
identified a time frame of positivity between 2 to 7 days after symptom
onset.

Well, our current priorities are in the process of being derived from
their conclusions, and what have been the events of the last few weeks,
and also of course what will be the events of the next few weeks, and
whether we will see renewed virus emergency there in the short or the
medium term.

I think our current priorities for WHO focused very much on those
aspects which are public health priorities, and particularly those
aspects for which there may not be any other incentive structure to
encourage people to perform the work.

And also to help coordinate work done in different centers that may
achieve full value when it is looked at in a collaborative manner. So I
think at the moment we would feel very much along with the breakout
group, and along with the views expressed by many of the speakers this
morning that we have a desperate need for a reliable, quite early,
perhaps day one to two, virus or antigen detection assay which is lab
based.

This will allow us to perform safe case management, conserve all these
resources that were mentioned by earlier speakers, and would be able to
act as confirmatory tests for another very clear need or a reliable
early near patient screening assay.

Now, I know that many people who work in labs will recoil in horror when
one talks about near patient assays, but I think the reality for many of
the countries where WHO works is that there is no easy access to a lab
and patients may have to pay for samples that are sent to a distant lab.

Clinicians do not even bother to consider the diagnosis in such cases if
they know that they are not going to be able to get confirmation. There
will be no diagnosis and there will be no surveillance. We need a near
patient test for screening, which can be confirmed by laboratories
either within the country or through a network of reference labs.

And I think that this is clearly a need for domestic isolations and
prevention of some of the terrible hospital-based outbreaks that we saw
in some of the countries where SARS was established in the last few
months.

We need a network of reference labs and the logistics to support the
transport of samples for countries without adequate lab infrastructure.
We need sensitive and specific antibody assays, preferably in several
different formats for confirmation, for complementarity, and also
because I think that it is going to be very important to have assays
which are going to be valid for the different population groups which
will have to be addressed.

And I think many people who have worked in the international field have
had the experience of having an assay which performed very, very well in
the European setting, and being absolutely useless, for example, in an
African setting.

So we need a variety of assays that will be appropriate for all the
populations at risk. And we need \-- I think \-- very, very, importantly
to link and analyze the epidemiological and clinical data, link it to
the lab data, to answer some key questions which are relevant both to
diagnostics development and to disease transmission.

Well, to achieve all these objectives, there is going to have to be a
process, and this is really what I hope we will be arriving at over the
next weeks. Our plans are to review and expand the current laboratory
network.

There are a number of partners now who were not members of the original
group who have much to contribute. Some of them are in this room, and
other labs, I think, can be brought in as time passes. And we intend
over the course of months to expand this from initially a SARS specific
viewpoint to take in the capacity to be a lab network in support of
other dangerous and new pathogens which are going to be the focus of our
group, currently and in the future.

We need to establish, I think, an expanded number of sample banks and
repositories. We need both sample archives and reagent archives. We must
agree on the number and localization. At the moment, there is only one.

But it certainly is our experience, based on our experience with
smallpox and other diseases, that it is probably unwise to have all of
your repository eggs in one basket.

Things can go wrong, and institutional priorities may change, and there
can be earthquakes. It is quite a good idea to have them distributed for
purely practical reasons like that.

But also because I think that the number of different sites where SARS
outbreaks were large and the number of other partners who were deeply
involved in the supporting process for diagnostics development \-- all
will have different aspects to contribute.

And there is no need for the repository to exist in one place at one
time. I think we also believe that there should be a panel of
coordinators for each repository, to ensure that all the needs of the
various partners on other sites can be addressed.

There is a need for a panel of specimens to validate future diagnostic
assays, and I think there is also a need for a database to be devised
that will cover all the repositories, linking not only the archive
material in the database, but also \-- as mentioned earlier \-- clinical
and epidemiological information.

I think these repositories also should be involved in facilitating
development and exchange of various reagents, expressed antigens,
polyclonal antiserum, monoclonal antibodies, and also the evaluation of
antigen and antibody tests.

One of the processes we are hoping to implement soon will be a process
for developing a multicenter international evaluation of the major
diagnostic assays now available.

We need to establish the test procedure, including standard reagents,
sample panels, have investigators on several sites reviewing some of the
same assays in different settings. And we need to analyze and publish
these results rapidly. And then we need to have some process for access
to and distribution of appropriate assays for any countries which may
require them.

In addition to this, we are currently working to develop international
quality assurance programs and the availability of standards. This has
been supported now not only by the Robert Cox Institute, but by the
Lyons Branch of our Department, which has been also supporting the
training, and is currently developing an international quality assurance
program for SARS.

But all these programs will require a fairly long term commitment of
resources to support he reagents, logistics, and the associated training
support, if there is a quality assurance program to support those labs
which are having problems or need strengthening.

I think there are a number of biocontainment issues which we will be
having to address and are addressing, and these will be, I think, very
different. If SARS does not re-emerge, we will have to come up with a
rather clear policy on biocontainment of virus in the labs in which it
is already knowingly or unknowingly present.

To all these ends, we are establishing a SARS Research Advisory
Committee. This is going to guide WHO on diagnostic laboratory,
clinical, epidemiological, and animal research issues, and also identify
which of those issues should be encouraged by WHO and coordinated by
WHO.

And this will be led by Professor John McKenzie \-- who I hope is
listening on the phone since he could not be here \-- a virologist from
Australia, who was in China and Hong Kong as a member of one of the
teams on the SARS responses, and also Dr. Katra Lightmeir in our
department at the moment. And this will focus on issues of relevance to
public health.

And there are some constraints and caveats to all this work. Obviously
much of this will take funding. The value of the network approach is
that it can help reduce the amount of direct funding required.

That is not going to be free, and there is going to have to be some
input to it. There are a number of legal issues still to be worked out,
in terms of international sample repositories and reagent exchange, and
we are working on those.

But this may take a bit of time, and also we will be very grateful for
the collaboration of all the laboratory partners in this. Another thing
to mention: that on the 21st of July WHO receives a new Director
General.

We are anticipating changes \-- we are not exactly certain what they are
yet. But of course this may also have some impact on some of these
activities. I hope a positive impact.

I just wanted to close by mentioning some of the multidisciplinary and
public health aspects of SARS research that are relevant to archiving
and diagnostic developments, and why I would like to see a much closer
link between the other networks mentioned at the start of this talk \--
the epidemiological, the clinical, the modeling.

These issues are all the ones that have been discussed this morning;
virus origins, stability, excretion, viral load, routes of transmission,
clinical presentation, the effects of treatment \-- all of these may
affect how we characterize our sample repositories, and what we try to
include in them.

The role of asymptomatic infected individuals certainly is key for
diagnostic tests, but also we have to ensure that these samples are
included in our archives, and that all the samples in the archives are
well characterized.

The role of products of human origin \-- we were thinking about the
safety of the blood issue after the experience of West Nile, but this
has to be something receiving continued attention. Pathogenicity,
identification and use of antiviral drugs, vaccine development, and
epidemic modeling. Thank you.

(Applause.)

DR. NICHOLSON: Okay. We are going to switch computers here. So our next
speaker is Larry Anderson. He is the Chief of the Respiratory
Enteroviruses Branch in the National Center for Infectious Diseases at
CDC. And we are hoping that this is working.

DR. ANDERSON: Thank you. I think this meeting is timely, important, and
is a next step in one of the things that has been very important in the
response to the SARS outbreak, and that is the cooperation and
collaboration that I think has served the response to this outbreak very
well. And although it has gone well, that it also illustrates the power
of it on the one hand and some of the difficulties when the cooperation
and collaboration is not at the level that it could and should be.

And I think that developing diagnostics is clearly an area where the
cooperation is going to be important if we are going to move quickly
forward to having access to good diagnostics commercially.

And then certainly WHO\'s central role in facilitating the cooperation
and collaboration really has been outstanding, and I think they deserve
a great deal of credit for that.

What I am going to do is talk about specimen access and how we deal with
specimens, and much of this really has already been discussed in part in
the course of the morning, and first discussions this afternoon.

But obviously access is important. IRB is an issue. Handling and storage
of the specimens, and deciding how you are going to characterize the
specimen, in terms of sensitivity and specificity, i.e., a gold standard
for saying this is SARS or not SARS, or some other agent is important.

And then how you manage access to the specimens that are available. Now,
we have had limited experience in developing specimen panels in our
group, and that is looking at B19.

And we developed a set of serum specimens, 128, some IgG positive and
IgM positive, and some control serum specimens, some of which were also
positive by PCR for B19, which a number of commercial groups have used
in evaluating their respective assays to B19.

And this just lists some of the data that we included in distributing
this panel of specimens, and I think this is part of what would be
needed in looking at SARS.

The kind of specimens that we have gotten related to SARS that could
potentially provide source for developing panels of serum and
respiratory, et cetera, specimens to assist in evaluating or developing
diagnostic assays came from specimens related to suspect and probable
cases in the United States, studies of the natural history of SARS, both
in cases and contacts.

We didn\'t have contacts for positive, so that actually did not provide
an additional source of specimens. And then a fair number of specimens
that were submitted to CDC as part of collaboration or referenced
diagnostic support in looking at SARS, and the epidemiology and clinical
characteristics of SARS.

In the United States, we did not have many cases of SARS coronavirus,
and this just illustrates this point. Steve Ostroff provided or showed
this data earlier, and it really makes two points.

In the United States, we did not have much SARS \-- it turned out to be
in probable cases only, unlike in the U.K. where they had some positive
in other categories \-- and therefore makes or reinforces the point that
Dr. Ostroff made that there is a lot of respiratory illness. It is one
of the more common diseases of man, acute respiratory infection, and
therefore there is a lot of background noise.

And SARS is \-- unless it is a huge outbreak, which I doubt will occur
\-- is going to be a really small part of the big picture, except in
certain circumstances. So what is the status of specimens that could
conceivably contribute to a panel that could be used for characterizing
assays?

Well, it is not particularly encouraging from our perspective. We\'ve
had 188 positive serum specimens \-- some of those are actually serum
and blood, and so they are actually duplicate specimens \-- and most of
these are from specimens submitted from other countries in which the
volume that we receive is small, and really does not represent an
opportunity for developing a panel of specimens that could be used in
evaluating assays.

We did get some units of blood from three positive patients so far, and
we are looking at getting some additional units which provide a larger
volume of serum that could be used not only in evaluating an assay, but
also in more of the development side, where a larger volume of serum
would probably be useful or helpful.

In respiratory specimens, we actually onlyl had one positive respiratory
specimen in the U.S., and that specimen has essentially been used up. So
we are not really going to be helpful there.

Stool specimens is another story. We have got a few, and some of those
are positive and could potentially be a source once we get through with
the other testing on these specimens to be used in evaluating assays.

And then we have some other specimens, autopsy material, that could
conceivably be used. And maybe the way to look at this at least is
multicenter standardly characterized specimens and handling, such that
you are not relying on one institution to provide the needed specimens,
although some institutions actually could do quite well.

Characterization of the specimens is actually going to be quite
important, and there again I think a standardized approach is probably
where we should be. So what do you want to know?

You want to know \-- for the respiratory or the PCR product \-- that it
is positive or negative, that you are fairly certain in terms of how the
specimen is handled that it is actually coming from the patient and not
contamination in the process of either handling or testing the specimen.

I think if there is sufficient virus that it would be important to
actually get sequences, or at least limited sequences, on that
particular isolate, such that you can address the issue of breadth of
reactivity against different strains of SARS coronavirus, so you
understand that side of it.

And possibly a test for other respiratory pathogens. In antibody
studies, those ELISA binding antibodies, I think that is going to be
part of a well-characterized serum specimen to have neutralization and
probably protein specific antibody results as well so that can be put in
the context of not only the viral lysate assays, but also looking at
protein specific assays.

And then of course the handling and storage such that we are confident
that the specimen has the same characteristic when it is tested or used
to evaluate an assay system that it had at the time that the initial
data was collected.

Now, one of the questions earlier today was what are some of the other
respiratory pathogens to deal with, and certainly the bacterial
respiratory pathogens, strep pneumonia, Legionnaires\' disease,
chlamydia, microplasm, are included in that group.

And it will vary to some extent to the age group of the patient that you
are looking at, and the time of the year, and the location.

The viral pathogens influenza of course is a biggy, and one of the major
pathogens that might confound the diagnosis of SARS. And you have the
RSV, the parent influenza viruses, and coronavirus, rhinovirus, and
adenovirus.

Now, one of the things to remember in the viral diagnostics, and I
won\'t address the bacterial because I am not quite so knowledgeable in
that area, is that the antigen detection assays in adults by and large
are not very good.

Certainly for RSV and parafluenza, they are probably not of help at all.
The sensitivity is too low and then you run into false positives and the
predictive value of positive and negative really are not where it is
useful.

So there we really need PCR-based assays, sensitive PCR-based assays,
and that is something that actually does need to be developed in the
future, because they are not readily available at this point in time.

At this point in time what we are going to do is continue putting
together panels that we can, which are limited, and make those
accessible, and work with WHO and others to expand that as new
specimens, if they become available, and facilitate their efforts to
develop panels that they can distribute as well.

The other thing is to make sure that in the future if SARS does return
that we are in a position to collect and appropriately handle and manage
specimens, and try to get the volume of specimen that can be helpful in
developing panels that can be used to evaluate these assays.

And as diagnostics move out from CDC, which they are doing, and which
they should be doing, it will be likely that this is going to be more of
a collaborative than a CDC-based effort to do this.

And try to build and ensure the kind of collaborations that larger
panels of specimens can be developed. And then the other thing that I
think is really important is to \-- and which I think is one of the
themes that was discussed this morning, is to have a clear strategy of
what you are looking for and why.

And how to creatively accomplish what in fact you need to accomplish.
And if you think about what part of what you need in evaluating an
assay, you want to be able to identify sensitivity for PCR of the assay
itself, and the extraction procedure that goes along with it, and this
can be done in terms of copies of RNA that you can detect.

You also want to make sure that the assay, in the context of PCR, the
primers will detect the range of strains that you might encounter. And
this can be done by looking at sequences, and developing a bank of
isolates that can be actually detected to make sure that in fact it
works as you predict it will work.

The other thing that you want to know is how does the assay perform in
the context of different clinical material, and there some of that can
be acquired by adding the appropriate RNA to a range of negative
clinical samples.

Now the other piece of that actually understanding the sensitivity of
the assay in the population that you want to use the assay, obviously
you have to use clinical specimens well defined with a gold standard to
understand who is infected and who is not.

So a lot of or some of the questions can be addressed creatively without
the primary clinical specimens. And I think I will stop there.

(Applause.)

DR. NICHOLSON: Our next presenter this afternoon is Patricia Somsel.
This is the Director of the Division of Infectious Diseases at the
Michigan Department of Community Health Laboratory.

DR. SOMSEL: Good afternoon, I am never very comfortable going on after
lunch because I know that is when I start getting sleepy. So we will try
to keep it fast and hopefully we can keep your attention.

First, I wanted to thank the organizers for inviting me to represent the
thoughts of the public health laboratories and the State laboratories.
And I also, because I have many years of experience in clinical
microbiology, want to pass on some concerns and issues that my former
clinical colleagues faced as they dealt with the SARS outbreak.

I think many of the points that I will make this afternoon have been
addressed this morning, but maybe I will put it in a little bit
different context. I think really what we faced with the SARS outbreak
was a challenge of knowledge gaps, certainly in epidemiology and
surveillance.

First of all, we had to establish what the organism is, and how it was
transmitted, and how infectious was it, and how dangerous was it, and
what were the risk factors for acquisition.

And those risk factors actually ended up being fairly important in our
case definitions. So those were significant things to establish. What
were we going to use as a case definition and that was something that we
found was a moving target.

Certainly for epidemiology and surveillance, it is important to
establish how long an organism might be shed and in what body tissues,
and when would antibodies be demonstrable, and importantly how could we
distinguish it from other diseases.

In the diagnostic realm, it is also important how long the agent is
shed, because it will determine what type of testing we are using.
Likewise, when our antibodies are going to be demonstrable, and how do
we distinguish it clinically from other diseases.

In the diagnostic realm, when we are talking about tests, we want to
know how stable the organism is going to be, because we are going to
want to know or need to know how to stabilize that specimen.

We need to look at both the sensitivity and specificity of tests. We
need to know how likely we are going to be to find a positive test when
we really have a case, and how much difficulty we are going to have with
cross-reactions.

And from the standpoint of prevention and safety, what are the risk
factors for acquisition, and how do we handle infected patients in a
health care setting, in the community, and context. Those are issues
that become very important in health care institutions.

And also important to health care institutions, how do we protect health
care workers. I am going to talk for just a couple of more moments about
those issues in the health care institutions, because infection control
is an issue that was very prominent with this outbreak, because many of
the cases were as a result of exposure in a health care institution.

So there was a great deal of concern about it, and because the main \--
one of the major tools that we used since we didn\'t have a mechanism of
treatment, was to quarantine patients and their contacts.

And that provided a significant impact on the lives of people who were
involved. So when you are talking with infection control practitioners,
they want to know how the agent is transmitted, and importantly how it
is inactivated in the health care setting.

What isolation precautions are appropriate for the patient, and what
personal protective equipment is necessary for health care workers. So
those may seem like very mundane issues to us in this room. Trust me
that they are not.

The issue of informed consent. Certainly we struggled with it when we
have talked in public health laboratories about the hurdles that this
presented. But I want you to realize that physicians are not used to
dealing with informed consent.

They typically do not order tests which require informed consent. A
nurse walks into a room and say pee in this cup, or spit in this cup. A
laboratorian walks in and draws blood.

It is never explained to a patient what they are being tested for, and
they rarely get a chance to see the results or any of the limitations,
and any of the interpretative data that goes along with that test
result.

So clinicians are not used to dealing with informed consent patients
certainly are not used to dealing with informed consents. And likewise
clinical laboratories are not either.

It is very confusing, and a patient who is not used to dealing with
these things and is faced with a three page consent is liable to say
that I don\'t understand any of this, and I am not signing anything.

A gentleman that I had lunch with talked about, well, it comes down to
the trust that the patient has of their physician and public health.
Unfortunately, sometimes public health represents government, and that
trust is not always there.

We were just involved in Michigan in an investigation of a salmonella
outbreak, and somewhere over 20 people, all of whom were exposed and
suffered the consequences of that exposure, certainly might have had an
interest in preventing the spread of the salmonella outbreak by
identifying the vehicle.

But there was a silence clamped down on this family, and nobody would
talk to public health. Why? Don\'t know. We talked about how important
getting the correct specimens are. We need to put that in the context of
the people who are going to be collecting and handling those specimens.

We have very busy clinical settings and certain in this day and age most
of the patients that we are going to be collecting samples on are
hospitalized. And we have a very busy nursing staff on the floor, and we
have to make sure that the appropriate information on what specimens are
required, and when it is to be collected, and how it is to be
maintained, all of this information has to be conveyed to the nursing
staff.

We in Michigan spent a good deal of our time surfing the web and getting
the most recent information on specimen collection and handling, and
faxing that to the clinical laboratories so that they could provide it
to their nursing staff, because trust me, the physicians don\'t have
time to go to the web for the most part and get a current update, and
find out what the appropriate specimens are.

One of the other things that we ran into is that health care workers may
not have the appropriate training for collecting and handling the
specimens that we require.

We found a couple of years ago when we started asking for nasal
aspirates to be submitted for bordatella pertussis, PCR, that nurses and
nursing staff on the floor were not prepared to collect those samples,
and did not have the equipment to do it.

And yet it is one of the best specimens for SARS. We had to provide
information and guidance on specimen collection and equipment for
patients on whom these specimens were requested.

I deal with the laboratory issues separately because there are some
other things going on in the laboratory that affect the way that
specimens are handled and transported that you need to be aware of.

And I put laboratory safety in big letters, and specimen integrity in
smaller letters, because that is the way that the laboratorians dealt
with it. They wanted to know what specimens that they were handling from
that clinical patients contain viable organisms, and that did not just
mean respirator samples.

They wanted to know if there was SARS in the urine, in that CBC sample
that they were going to process, in that serum sample that they were
going to run through the chemistry analyzer.

And we had laboratories in Michigan and I know other States that had the
same problem, laboratories who refused to handle specimens on patients.
They were not doing CBCs, and they were not doing blood chemistries.

They were trying to ship that all to the State laboratory. Part of that
is as a response to work force issues in clinical microbiology, where
experienced clinical microbiologists are draining out of the laboratory
and being replaced with generalists, or with chemists, or with
hematologists, who are not familiar with infectious diseases, who are
not familiar with handling biosafety issues, and who are not familiar
with the type of personal protective equipment that they need to choose
for a particular setting.

They are not comfortable with working in a biological safety cabinet,
and they are not comfortable handling these agents that they are afraid
of.

And they have very knowledge and are not interested in finding out how
they need to stabilize the specimen to ship it off to someone else for
testing.

This is not the way that clinical microbiologists typically are
comfortable working in the clinical laboratory. Another major hurdle
obstacle course to be negotiated has been added over the last few years.

The Department of Transportation Hazardous Materials Regulations and the
International Air Transport Association \-- I have to stop and think
what the acronyms stand for \-- Dangerous Goods Regs, had added an
additional complication to how we handle these specimens.

First of all, someone who is packaging has to decide is this a
diagnostic specimen, or is this an infectious substance, and it all
depends on how likely it is that that sample that they are handling
contains a viable organism.

If it is a sample on someone who is diagnosed with HIV and it is going
in a CB4 or CB8, then it has to be transmitted or transported as an
infectious substance.

You will get 50 different answers or opinions from clinical
laboratorians about how to handle a throat swab, anything that could
contain a viable organism.

It is complicated life for laboratorians who have to ship things, and in
addition to that, to choosing how they are going to transport something,
they must decide at what temperature to transmit it. Can it go at room
temperature, does it need to be refrigerated, does it need to be frozen.

And if it has to be frozen will frozen gel packs at negative 20 suffice,
or does it need to go at negative 70, and therefore needs dry ice, which
involves an overpack, and additional labeling, and these may seem like
minor choices, but this is an illustration that I pulled off the CDC
website of the complexity of packaging.

And this is for a sample that does not require any sort of refrigeration
while it is being shipped. The consequences of shipping regulations to
clinical laboratories, first of all, great expense.

These little packages cost anywhere from \$40 to \$60 to package and
transmit. That expense is not recoverable from any source. It not
reimbursed by anyone. Likewise, I will just put in a plug for some of
the other programs that public health is involved in.

The salmonella isolates, the shigella isolates, the listeria isolates,
on which public health both at the State and Federal level depend, there
is no reimbursement for clinical laboratories for any of the work that
they do on those samples.

Once they are reported out on a patient, their recoverable expenses are
done. If they subculture that, package it, report it, ship it, that is
all on their buck. And this is what our public health system depends
upon.

It is done out of the good will and knowledge of clinical
microbiologists who understand the importance of what they are doing. I
don\'t know if their bosses know the expense that they are running up.
That would be a good question.

Because of the expense, and because of the confusion, there is lack of
compliance for shipping regulations, and there is loss of specimens that
are shipped and are unacceptable for testing when they reach their
destination.

Just last week, I had to throw away four specimens on a SARS patient.
They were shipped by surface mail, unrefrigerated, in July. It took five
days to get to me. I threw them out.

And therefore there is a lack of data to support the diagnosis. And what
do we say to that patient? Oops? But we are going to keep you in
isolation for 3 weeks.

I think that it is important to understand that public health
laboratories do testing for two very different purposes. We test for
surveillance, and with some special things we test for a diagnostic
purpose.

And the way we handle those tests is very different. Because we do
diagnostic testing, we must be CLEA certified and it requires therefore
that those tests that are done for diagnostic purposes meet certain
standards that we have kind of brushed up against today.

Those are CLEA requirements that demand that tests be adequately
verified when they are brought into our laboratory and that we see how
they work in our hands that we have adequate controls, positive and
negative.

And that is a big issue that we have to deal with. I want to remind you
to think about the SARS testing in perspective of some of the other
diseases. Think where we were 50 years ago with syphilis testing versus
where we are now, and 15 or 20 years ago with HIV testing.

We have developed an algorithm for these testing of significant diseases
that utilizes a screening test, and a confirmation test, and our testing
has evolved.

Our current status with West Nile Virus is complex. It may be better
than last year, but we still \-- there are more assays getting out to
clinical laboratories or to commercial labs and clinical labs, and that
is great.

The difficulty is does a positive test meet the gold standard. If a
commercial laboratory gives us a positive IgM antibody in Michigan, and
we had West Nile Virus in Michigan last year, and so an IgM antibody
test is useless to us.

It doesn\'t meet our definition or the CDC\'s definition of what a West
Nile Virus case is. So it will not be recorded as a case until we
receive the sample and a paired convalescent serum for testing.

I put here where will we go with SARS to remind us as one speaker
suggested this morning, this year we have used the epidemiology as a
very useful took. Travel has been a significant risk factor.

Next year or two years from now, whenever SARS comes again, we are not
going to have that tool in all likelihood to help us separate SARS from
the other common respiratory viruses, and bacterial infections.

One last issue that I want to bring up is a question. When public health
laboratories don\'t do the testing will they get a report of the
positive test and what test was used, and will the result meet a case
definition that we have to use in public health.

And if that doesn\'t happen will the sample be forwarded to the public
health laboratory for a gold standard test if the result doesn\'t match
that case definition. I think that those are important issues for us to
grapple with.

Because, you see, each of us has only a part of the picture as the six
blind men with the elephant. We all have a piece of it, but we only have
the whole animal when we all work together.

I think that public health laboratories are an essential link, the State
labs, between clinical labs and commercial laboratories, and on the
other hand the Federal agencies that are recognizing new diseases.

The health of our citizens and our Nation will improve with our
cooperation. I think that public health labs and manufacturers should
collaborate to develop commercial diagnostic for emerging infectious
diseases, because we are all in this together. Thank you.

(Applause.)

DR. NICHOLSON: Our next speaker this afternoon is David Norwood. David
is the Chief of the Systems Development Branch in the Diagnostic Systems
Division at USAMRIID.

DR. NORWOOD: Well, I\'d certainly like to thank the organizers for
inviting me to come speak today, and what I would like to try and speak
to a little bit this afternoon is what we have done to try and adapt
some of the methodologies that we use for biological threat agent
detection and clinical samples to the SARS outbreak.

So specifically I am going to be speaking about some non-human primate
samples that we worked with and some human banked material. A brief
overview. I am going to talk just a little bit about assay design and
assay optimization, a small amount of data that we have done with
purified viral RNAs and then sort of get to the heart of the matter, the
clinical samples.

The gene target that we used for this was the RNA directed RNA
polymerase gene which had been spoken to earlier. The primers we used to
sequence that region were published in the May [New England Journal of
Medicine]{.underline} article referenced there.

And the region that we looked at corresponded to the region between
15,239 to 15,630 of the Urbani strain. We designed specific primers and
probes, and perhaps different than some of the folks had spoken to
earlier.

We are using Taqman MgB probes, and we have gotten significantly better
sensitivity results with those lately. This is just an alignment of the
region sequence that we used.

This is an alignment that shows some homology with some other
coronaviruses, and so we actually broke this region into two sections,
and developed assays to the five prime and three prime ends.

There was a hundred percent hetamology in this region across all of
these strains of SARS, and so we were pretty confident at least at that
point that we would be able to pick up the various strains.

Assay optimization was done with purified or strained RNA. Just to give
you an idea of the extent to the development that we did, we
down-selected 56 primer pairs from those two regions, and 13 of those
were selected for probe testing.

We then had 38 primer probe pairs that we tested for robustness and
found a single set that was superior to all others. This was a
sensitivity that we got with a purified viral RNA.

We were able to detect down to about a thousandth of a PFU per assay
input, which corresponds to about a tenth of the PFU per mil on purified
viral RNA.

The assay appears to be fairly quantitative, with an efficacy of
somewhere between 1.92 and 1.97. Where we really lack it seems and
perhaps a lot of other people are lacking as well, are additional
strains of SARS to test, although we have procured several others.

Other related coronaviruses and respiratory viruses, and bacteria, and
we virtually have done no specificity testing with purified viral RNAs
of any of these relatives to date.

As far as positive clinical or negative clinical samples, we virtually
had access to nothing when we started this work at the end of April. But
we did know that there was some work being done by Colonel Tim Indian
and his folks in the virology division at USAMRIID to determine whether
or not a non-human primate model of this disease was feasible.

So we decided to piggy back on their work. We also realized that
negative samples would be extremely important for specificity, and
decided that we thought that they should be from individuals of course
exhibiting similar clinical presentation \-- flu-like symptoms,
respiratory disease, et cetera.

We wanted them to be from a relevant clinical matrix such as throat or
nasal swabs, and in fact what we used were throat washes. And we wanted
them to be temporally separated from the SARS virus.

So I will speak to these two models of positive and negative samples.
For this particular study, three cynomologous macaques were challenged.
Monkey-1 and Monkey-2 received an intra-nasal challenge, and Monkey-3
received an intravenous challenge, mainly based on some work that had
been done with pox viruses by Dr. Peter Jarling at CDC.

And that is why the IV challenge was done, and the animals were
monitored with telemetry implants to monitor temperature, blood
pressure, et cetera. And the strain again used for this challenge was
the Urbani strain.

We collected urine and feces daily, and nasal swabs, throat swabs,
rectal swabs, and blood were collected every other day, beginning at day
zero. The animals were followed for 20 days post-challenge, and RNA was
extracted from all of these matrices using a standard Trizol extraction
method.

Before we actually started processing the non-human primate samples, we
did some spiking experiments with purified virus into urine media, which
is what the swabs were collected into, and blood, and found that we were
able to detect down to .4 pfu\'s per mill in those three matrices.

That corresponded well with what we had gotten in terms of the purified
viral RNA from cell supernatants. The LOD for feces \-- this is a typo
here, but we were actually a lot less sensitive. We were able to detect
4 pfu\'s per mil for feces.

Part of that was due to the \-- I think to the fact that with fecal
material on the non-human primates, we had to suspend those and
basically to a 10 percent solution and buffer, and that accounts for
some of the loss of detection of the assay.

As far as what were the results for the non-human primates \-- well,
non-human primates 1 and 2, which were challenged by IN really showed no
observed blood chemistry differences, or no disease by blood chemistry
work.

Non-human primate 2 appeared to have a mild pneumonia on day 6, which
did eventually resolve. Both of those monkeys fully recovered, and there
is still some reads going on of the x-rays on those two monkeys.

Non-human primate 3, which was injected by IV, developed a fever on day
5 and 6, and eventually died of a bacterial infection on day 16, which
kind of clouded some of these results.

The infection itself may have been from the telemetry implant. They are
still investigating that. There was clearly labored breathing during
this day 5 and day 6 period of time and the animal was clearly sick.

It developed a left-lower lobe pneumonia and that had resolved by the
time that the animal passed. Again, there was no disease observed by
blood chemistries.

When we looked at all the matrices on all three of these non-human
primates, we were unable to detect the virus by real time PCR in feces,
blood, or rectal swabs.

We were able to detect virus in nasal swabs, throat swabs, and urine.
These are the results that we saw with the throat swabs. Keep in mind
that non-human primate 1 and 2 were infected intranasally, and we
routinely saw results where we were able to detect the virus between day
2 and day 8.

We saw no detection of virus in the throat of the animal who actually
developed the most severe disease, if it was SARS related, on days 5 and
6, and that was non-human primate 3.

The other trend that we did see is the viral load in terms of the
quantitative aspect of the PCR going down as time progresses. This is
not \-- at least in terms of detecting the virus \-- a sustained
infection for a long period of time, but there does seem to be some
viral replication during this period of time.

The nasal swabs showed similar types of data, and in this case directly
before sickness in non-human primate 3, we were also able to detect the
SARS virus.

The same window of detection was seen in non-human primates 1 and 2 in
days 2 through 8 after infection.

Urine was a bit surprising to us. We really saw very, very sporadic
detection of this virus in the urine, and we saw no \-- we were unable
to detect the virus in the feces.

One of the published pieces of information which may explain why we were
able to detect this virus in the urine is that it has been shown that
the Urbani strain replicates very well in monkey kidney cells.

So we may be detecting some of that.

As far as negative samples, what we were able to do here was use Army
banked samples from CONUS military patients who had exhibits signs of
respiratory disease at the time of their examination.

They also exhibited at least a low grade fever at the same time. We
received a hundred samples processed and tested. They were throat washes
from these hundred individuals.

All samples from these patients were from examinations prior to the
introduction of SARS into the United States, and the question was would
other coronaviruses, infectious agents, respiratory diseases, which had
caused these patients to seek out medical care be detected by the assay
that we had developed.

And we found all 100 samples to be negative for the SARS assay. I should
also mention that any of the work that was done with purified virus in
our laboratory was carried at BSL 3 conditions, and all the non-human
primate samples were tested in triplicate. So those results are
confirmed in triplicate.

Additional work that we would like to do, we already have a plan to
challenge six more non-human primates in August. The plan is to do three
IN challenges, and three IV challenges.

We are currently looking at whether or not we should use a different
strain of SARS, or whether we should up the titer that is being used. We
are also trying desperately to obtain nasal panels for specificity as I
think everybody is at this point in time to include other strains of
SARS and other coronaviruses.

I would be remiss if I didn\'t acknowledge all the people who were
heavily involved in this. My group mainly works in the development of
nucleic acid based assays for the detection of biological threat agents.

Lieutenant Colonel Dave Kulesh and the group below him did all the assay
optimization and down selection of primers. Dr. George Ludwig and his
group was essential in growing the virus. They are currently purifying
the virus on gradients and producing immunological agents.

Dr. Melanie Ulrich, whose group prepared all of the samples by doing the
extractions of the RNA, and Colonel Endy\'s group, to include John
Huggins, and especially Jason, who was critical in actually infecting
the monkeys and providing us with the samples. And I thank you for
having me.

(Applause.)

DR. NICHOLSON: The last presenter in this session before the discussion
is opened up is Linda Lambert, who is program officer in influenza,
SARS, and related viral respiratory diseases at NIAID.

DR. LAMBERT: Thank you, Janet, and my sincerest thanks to the organizers
for giving me the opportunity this afternoon to tell you about some of
the research resources that NIAID has in place for SARS and, as well, is
developing.

Before I begin, I want \-- NIH is a really big place, and so I want to
just tell you that I am an extramural program officer, and that means
that I don\'t work in a lab.

It means that I have oversight responsibility for a number of
international and national grants and contracts. So when you see
requests for proposals, requests for applications from the NIH, it is a
program officer who is responsible for that.

For those of you who don\'t know your program officers, and you are
interested in getting NIH support, the program officer can be an
invaluable resource to you.

They can not only watch your grant as it goes through the review
process, but can also tell you in addition to SARS what are some of the
other resources that are available at NIH to help you do your work.

The very first \-- basically the very first sort of outline that I want
to present to you is what the need \-- as clearly as you have heard all
morning long and this afternoon, sharing information resources has
become the crux of moving SARS research forward and for diagnostic
tests.

We know that it is an important and often rate limiting step in basic
and translational research. It is the identification, procurement, and
distribution of state-of-the-arts reagents and technology.

And Dr. Giovanni talked to you this morning about some of the
technologies that are coming on-line. I also want to mention there will
be a number of SARS funding opportunities that are on the NIAID home
page.

So to address the need for moving some of these rate limiting steps
forward, the NIAID has a history of establishing a series of
repositories that serve as worldwide resources to facilitate both basic
research, as well as product development, for infectious diseases.

So what I am going to tell you in just the next few minutes \-- I am
going to give you two examples of several that the NIAID has in place
for repositories, the current infrastructure that we have for SARS that
exists now and that will exist in the future, and then finally end by
just mentioning some of the other research resources, in addition to
reagents.

So the history of some of these repositories the NIH has the capacity
and capability to develop really began in the early \'60s. There was a
vision, a need for a viral reagent program. So that program is now more
than 30 years old.

The vision was to be able to provide something to the community to
produce tests, globally distribute reagents, as well as viral reference
standards, that were really not available anywhere else, and certainly
not at an international level.

And the goal of this work was so that the individual laboratories could
test their working reagents against these standards, and the very first
virus that was used was actually the enteroviruses, and a respiratory
still exists today.

It has been greatly expanded. Other viruses and antigen seed materials,
antisera, these materials come from a variety of sources. They come from
contracts with industry. Sometimes they come from donations from
industry, non-profit research organizations, and many, many sources of
these materials come from academia.

We also have WHO standard human and animal reference, interferons,
control serum. As I said, it has been expanded, and I have a list with
me that shows you the breadth of the respiratory specimens.

It has been expanded to include influenza, rhinovirus, RSV, measles. The
list just goes on and on. And if you are interested in taking a look at
what is in that repository, the website is in front of you, as well as
in the handout.

And we have individual program staff who work with these repositories.
So for the one for this one, the project officer is Terry Greenfield in
our virology branch.

So now I am going to jump scale on you and tell you about probably the
largest repository that we have, and it is the AIDS reagent program. And
it was really established actually not that long ago. It was about 62
reagents from about 20 contributors in 1988.

This information is all on the website \-- you can go and look at some
of the latest figures. In 2003 there were more than 4,300 reagents in
the history, and this is a very, very large repository. It tracks just
about everything: who uses it, number of vials shipped \-- to date it
has been almost 140,000.

Again, take a look at this repository; it could serve as a model for
what we need to do with SARS. Certainly it is very, very large. So what
types of things are in stock in that AIDS repository? Proteins,
peptides, cell lines, recombinant clones, antibodies and viruses.

And as I said, this particular repository that we support tracks who
uses it. So you can see the primary user of this is the academic
component of the U.S., as well as \-- followed by the international
community, U.S. government, and also industry.

So again this repository \-- you can see, I am trying to set the stage
for what could be developed for SARS \-- it takes donations from
researchers, again private and public sectors, as well as contract
generated resources.

So you could imagine there is a need for some type of material, and
there is no one around to donate it \-- this repository has the capacity
to let a contractor or a subcontractor procure that to add it to the
repository as a resource.

It is all web-based systems. There are registration forms, again for the
different materials that you need, and it also provides a forum for
community feedback and needs.

So if you see something that you \-- if you are looking for something,
it\'s not there, these repositories can be responsive. So if they get
feedback from you, with a community, for meetings, individuals, there\'s
a need \-- they can go out and procure reagents.

International training courses. These repositories, both the AIDS
reagent program and the influenza repository, have supported
international training courses. So for the AIDS repository, it has
supported training in-country on immunoassays that the people who take
these courses can go back and use them in their own labs.

For the influenza reagent repository, it has used the reagents in that
repository to train for animal influenza surveillance at international
workshops. And that was actually sponsored by the WHO. The program
officer responsible for this, the project officer is Dr. Opendra Sharma,
and he is in our Division of AIDS.

So just to give you a framework of what information you need to supply
to us when you request something, these are the elements: the name, what
you want to do with it, where you are coming from, that you certify that
you are in compliance with all applicable safety standards, what you
want to do.

MTA elements, none of these reagents are available for human use. If you
are going to use them for animals, do you have the appropriate
assurances. One of the hallmarks of our repositories is that everything
is available for free. What you pay for is the shipping. And if there is
some problems with shipping, we can make other arrangements.

Reporting agreement. You need to tell us what \-- when you publish your
paper or you present your paper, it is always nice to credit wherever
these reagents come from. That\'s how we keep these going. We basically
get feedback from the community that they are a valuable commodity.

You have to sign the request, and it is not just the person who wants
it, but somebody who has authority at the institution, and then provide
some background; a biographical sketch, your experience, and your
relevant publications.

So now what I want to talk to you about for just the next couple of
minutes is the opportunities for SARS. So the NIAID, Division of
Microbiology and Infectious Diseases, is about to put online a
biodefense and emerging infectious diseases research resources program.

The request for proposal is a very large contract; the request for
proposals went out earlier this year. The contract proposals are being
evaluated and the awards are anticipated to be made in September or
October of this year.

The goal of these is to identify, acquire, and again biodefense and
emerging infectious diseases. So you can imagine that there is a lot of
resources in this, to identify, acquire, and produce, or expand and
clone organisms in reagents.

Pathogens, because it is emerging infectious diseases and not just
biodefense, it can include SARS. It has the scope to do genetically
manipulative cell lines, DNA libraries, clones. This particular
repository has a work scope for body fluids, cells, and tissues.

Proteins and synthetic peptides, monoclonal, polyclonals, antiviral
drugs, and therapeutics, it can procure them if it is needed; chemicals,
immunomodulates, and the list goes on and on, and also if needed
procurement of diagnostic tools and kits for detection and measurement.

And this repository also has built into it the capacity for quality
control. It also can handle materials, organisms that are BSL 3. It has
the capacity to handle GMP-produced materials. It must be in compliance
with Federal, State and local.

It will be a web-based system. And again, the project officer for this
when it comes online will be Dr. Ken Cremer in the Division of
Microbiology and Infectious Diseases.

And so while we have a brief gap between this one coming online, we are
currently using the reagent program in our Division of AIDS to meet some
of the SARS needs.

So the opportunities to develop SARS reagents is very clear. It is a
contribution that the NIH makes to the research community both in the
U.S. and worldwide.

And Dr. Giovanni also mentioned to you this morning that the SARS chips
are essentially in the virtual repository. They are able to be
distributed to you if you need them and request them. In process is the
development of T-cell epitope peptides for the entire SARS virus.

And then I just want to outline some of the challenges that we expect to
meet. We believe through the NIAID that we can complement what is being
done both on a national and international level. We are providing
essentially a capability to respond to the need for a prioritized list
of reagents for SARS diagnostics and development.

So out of meetings such as this, if there is a need \-- if we can
identify a need \-- we can go through contracts and procure them, and
put them in this repository, and make them available to you.

Capacity to receive aliquot, test, store and distribute materials,
clinical materials, develop or procure SARS research materials, again
international or interagency collaborations, and coordination. As
everyone who has said today, has talked to you today, has said is
critical.

Then I thought that there were a couple of important points to consider,
some of which have been echoed this morning and this afternoon. This
information is taken out of our Division of AIDS repository.

The AIDS reagent program largely exists because of donations, and donors
are asked to apply any restrictions on the commercial use of their
reagents.

So I am providing you with this example of how our Division of AIDS has
handled this, because the same issues may be raised for SARS related
materials.

So if you are a donator to this repository, you are essentially asked to
check one of four boxes. You agree that if you are the donator that the
people who want to use your reagent can use the reagent without any
agreement from the donor.

Or the recipient agrees to negotiate in good faith, and share resources
with the donor or the donor\'s institution. The recipient must sign an
agreement with the donor prior to receiving the reagents, and these are
again for commercial use.

Or the recipient must not use or incorporate the reagent for commercial
purposes. Now, I say this to you because I don\'t know if this will be
the case for what happens for SARS, but I know that the Division of AIDS
has grappled with this issue, and this is one of the ways that they
allow the resources to come into the repository, without hold up, for
commercial use.

As was mentioned again today, the renewable versus non-renewable
resources, if it is just expanding hyberdomas, we can do that ad
infinitum. If it is something that is a really limited material, I think
it is going to take some type of approval process, it is going to take
some type of international and interagency collaboration to make those
decisions.

And the last slide I just want to share with you, a slide from
diagnostics, some of the other activities that the NIAID is doing for
research resources for SARS.

There is an antiviral screening contract that has been in place. A lot
of that work that we have supported has been done by our colleagues at
USAMRIID. They have in vitro assays that are up and running, and I
can\'t remember, but the number of compounds they have tested has been
enormous.

Animal models are under development. Both the part of NIH that does
research on campus, as well as extramural contracts, are in the process
of developing animal models.

So we anticipate, when those become available. we will have antiviral
screening contracts that will be available to the research community.

Now, again I want to emphasize that this is a service, and so if you are
a pharmaceutical company, or an academic institution, you provide your
antiviral to us, and you don\'t even have to tell us what it is if it is
something that is secret, and we will test it either in vitro or in
vivo, and provide the results back to you.

Again, what we are trying to do is facilitate product development, and
also research and development contracts, contracts that have the
capacity to develop immunoassays, as well as basic and mechanistic, and
pathogenic studies.

So I want to close by saying in addition to the types of research
opportunities that Dr. Giovanni talked about, which really largely, as
someone mentioned, targeted the private sector, funding opportunities
for SARS on the NIAID website, there are a number of grants initiatives.
There are R21s, which are small 2 year grants, \$200,000 direct costs
per year, 15 page application, limited preliminary data.

There are RO3s that don\'t require any preliminary data \-- sort of high
risk, high payoff. And then a number of standard RO1s or cooperative
agreements.

So I encourage you if you are interested in funding opportunities for
SARS, as well as any of these repositories, in addition to just work on
SARS, to look at the website and contact the project officer. Thank you.

(Applause.)

DR. NICHOLSON: Well, I would like to thank the speakers this afternoon,
and their contributions to the SARS specimens, and the repository
opportunities that exist or will exist in the near future.

This is the time that we have set aside for open discussion about these
issues and perhaps anything that you have on your mind that may relate
to not only the issues that we talked about this afternoon, perhaps how
that also links with some of the talks that we had this morning.

MR. WINSLOW: Dean Winslow, Bayer Diagnostics. A question for Dr.
Norwood. Why do you think the polygene assay that you all developed at
USAMRIID appear to be, you know, more sensitive than the polygene assay
that was talked about by Dr. Peiris earlier today?

DR. NORWOOD: I am not sure that that is the case. I believe that the
detection limit discussed earlier was about .1 pfu. Now, I don\'t know
if that was pfu per mil or pfu input. But we have seen a similar limited
detection in terms of pfu\'s per mil.

We do know that there is \-- or at least in conversations that I have
had \-- others believe that there is a high number of virus particles
per platform and unit.

One of the things that we have noticed is about a log increase in
sensitivity with a minor group binder probes, and for anyone who is
interested and who may not have explored those for Taqman-based assays,
I would be happy to discuss those issues with them one on one.

MR. WINSLOW: Thanks.

MR. HUANG: Huo-shu Huang, Walter Reed. To answer the question for the
sensitivity, I think that you have presented your amplification
efficacy. I mean, per cycle, it was an increment of PCR, a part of 1.92,
or 1. something. It is really the max.

You could theoretically reach 2.0, but then again, signal-to-noise ratio
starts with \--

DR. NORWOOD: Yes, and then you start to see a preponderance of potential
false-positives and noise down at the limited detection area.

MR. HUANG: But then again, everybody\'s sample is different \--

DR. NORWOOD: Right.

MR. HUANG: \-- But on your own I would suggest that everybody who
developed this assay that you just quickly evaluate your amplification
efficacy, even though you reach 1.8 it\'s not good enough. Imagine that
.8, .9 \-- I mean 80 percent efficacy with a power of 40, then your
efficacy is down to about 3 to 4 log minus.

DR. NORWOOD: I would agree with that, especially if you plan on using
the assay in a quantitative manner.

MR. HUANG: A quick question, Dave. What is your challenge dose, I mean
the one you use for the monkeys?

DR. NORWOOD: I believe \-- you know what? I don\'t know the answer to
that. I would have to check with Jason. I think it was somewhere around
10 to the 5 pfu\'s per mil, but I am not sure how much of that they were
actually dosed with. So I could certainly give you that answer off-line.

MR. HUANG: Okay. Once again, it is pfu \-- I don\'t know whether
everybody agrees \-- based on my estimate, should we present 1,000 or
more per particle. Is that a correct estimate?

DR. NORWOOD: I would agree, and one of the things that we just finished
doing was in vitro transcribing the segment of the amplification product
for this particular assay.

So that we can do determination gene copy number, in terms of limited
detection. One of the other things that we are also addressing \-- since
you sort of brought up the issue of quantification \-- the issue of PCR
inhibitors.

We developed a novel inhibition assay for real time PCR, which we have
used for standard amplification technologies. The problem with that is
that it doesn\'t take into account the reverse transcription step. So we
have now taken that clone and in vitro transcribed that into RNA as
well, so that we can have a whole one-two RTPCR inhibition assay as
well.

MR. GUPTA: Khalid Gupta from NIAID. My question is again to Dr. Norwood.
You said that you wanted to change the strain for SARS for this
non-human primates model. What is the rationale behind that? Why do you
need to change this strain?

DR. NORWOOD: What is leading us to \--

MR. GUPTA: Change the strain of SARS to be \--

DR. NORWOOD: Change the strain? I am not sure of the specifics of that,
but we have \-- or Jason\'s group, the virology group \-- has been
looking at some of the other strains of SARS that we have now been able
to procure, and look at how they grow in cultured, non-human primate
cells.

So there may be some data to suggest that at least in non-human
primates, not necessarily humans, but in a non-human primate model, some
other strains maybe replicate better.

MR. GUPTA: So if you are not sure which strain to use, would it not be a
better approach to mix all of those strains and then try it out on
whether you can get the same or similar kind of \--

DR. NORWOOD: Well, the idea is to try and find a system which produces
disease in the non-human primate to the greatest extent possible, in
order to mimic the human disease.

I mean, there was a tremendous amount of work on the orthopox viruses
before a non-human primate model of smallpox, for instance, was
developed.

DR. NICHOLSON: Okay. We will take one more question, but then we are
going to take a break so that we can start the open discussion at three
o\'clock.

AUDIENCE: I was curious to know that we have had this morning some
discussion about probable versus confirmed cases of SARS, and some of
the difficulties that that entails from a clinical trial viewpoint, and
this afternoon we talked about repositories.

Where do the panelists think the science is going to in test evaluation,
of using clinical trials versus repositories, and it doesn\'t matter
whether it is an established infection like HIV or a new infection like
SARS as you evaluate a test.

DR. NICHOLSON: You know what I think? Why don\'t you bring that question
up again, the first question this afternoon after the break, because I
think that is a great question that has got many facets to it. Okay. We
are going to take a break.

DR. BABB: Let\'s take about a 15 minute break.

(Whereupon, at 2:50 p.m., the meeting was recessed and resumed at 3:03
p.m.)

DR. BABB: We have a very brief presentation from Dr. Chen from the
National Taiwan University Hospital, and you can come on up. You are
ready to go. After that, we will have the general discussion session.

DR. CHEN: I just want to thank you, the organizers to squeeze the
schedule. I promise that my presentation will be very short. After
discussion, we think maybe Taiwan\'s experience in the coronavirus
infection, especially for the sample collection and the diagnostic
study, may be helpful to this group.

So this is an epidemiology curve of all the coronavirus infections, SARS
coronavirus infections in Taiwan. We can divide it into two stages. The
first stage is from early to late February to the middle of April. This
is stage one.

There is only for limited cases, and 30 cases is the number that has
been filed, and all the cases have clearly contact or a travel history,
and afterward in the middle of April, there was an outbreak from one \--
from the Taipei Municipal Hospital, and because this is an outbreak,
then there is a greater subsequent spreading to the entire island.

So this is a very serious, much larger epidemic. So we have the two
stages. So we have this experience and we take this chance for the
Taiwan CDC to collect a lot of the specimens for the investigation.

So far, the Taiwan CDC collected about 6,000 cell swabs, and 5,000
blood, urine and stool sample, and about 1,500 urine, and also the stool
and the sputum specimens for the investigation.

And this sample can be very useful. For example, we know that it was
started, or the origin was the SARS coronavirus infection origin of the
Taiwan outbreak.

We did a full antigenome sequencing from the virus isolates, all
directed from the cell swabs. We used a 25 paired primer to sequence \--
to cover the entire SARS coronavirus genome, and by this full gene
sequence we can easily move to the more academic study to identify the
origin and also the phylokinetic relationship between the viruses in
Taiwan. Okay.

And I just put a long story short. The most important is that the
sporadic cases from the stage one are related to the same strain from
Hong Kong, and also the thousand SARS in Quan Do and the second stage
outbreak, and this is a much serious outbreak.

We received about 80 viruses from this outbreak, and they all belong to
the same genealogy, and so it is very likely that the infection is
spreading through this same origin.

So this is just a document that is useful and also simple to trace the
virus, to understand its epidemiology. And this is our detection for the
coronavirus infection by the RTPCR, and also the viral reason for the
probable cases and the suspected SARS cases, and also the other excluded
cases.

And you can look at this data, and it is quite clearly for the probable
SARS cases, the PGR positive rate is close to 36 percent. But for the
suspected cases, the positive rate \-- it is only about 3 percent, and
in the other two categories it is even fewer.

And in addition to the nucleic acid test, we also developed the lysate
test, and just as Mary did it before, we expressed the virus nuclear
capsule protein and also the spiked protein for the ELISA. And this is
just the conventional standard ELISA, and in our hands we found that it
is a serum dilution close to three to six thousand is probably the best.
And now we are evaluating this indirect ELISA in about 500 to 1,000
cases to see there, to determine the specificity and the sensitivity.

And we also expressed a virus spike protein for the antigen, but in our
hands it does not work so good as the nuclear capsular protein. So we
probably focused on this for the right diagnosis.

And all this diagnosis method, for the nucleic acid or for the antibody,
are quite conventional. It takes a long time, at least about one day, or
ten hours. So we developed another method. Another method is the
so-called immunochromatography test, or the immunochromate test.

This is like a pregnancy test, and it works very quickly. In about 30
minutes, you can get the result. For example, the reagent looks like a
cassette. You drop about 20 microliter of serum or blood into this well,
and as I said, with 30 microliters the results are possible.

And you can read the result in 20 minutes, and this is the control. And
this is a 5 cm sample from the same patient, and a sampling at a
different date. In the early days, there is no reaction, and there is no
antibody, but five days later, you see the antibody, and the data shows
that the antibody \-- the reaction is quite or becomes stronger, and
easily readable.

So this is quite useful to detect the antibody in the field, especially
like in the emergency service room or in other outbreak site. You can
help the medical profession to understand and decide immediately whether
the patient is infected by the SARS coronavirus.

In addition to this, now recently we have prepared an antibody, and this
is a polyclonal antibody from the rabbit, and recognize the virus
nucleic capsule protein. With this antibody, we can try to detect the
virus infecting the cell from the patient\'s cell swab, or from the oral
gurgling.

This is one example we prospectively followed, and the oral gurgling
cell from a few patients, and we just spread a cell in the cover slide,
and it detects the virus antigen by the rabbit polyclonal antibody. And
this reaction is also very quick. It just takes about one or two hours.

You can read the infected cell quite clear. In fact \-- actually this
method has been used to detect the many respiratory tract infection
virus cell, and when we have SARS we can use the same method. So now we
are in a stage to evaluating whether this new rapid diagnosis can be
useful.

So finally, I just summarize my presentation. This is for the
conventional method, and that uses the nucleic acid test, or the ELISA.
And this is quite a useful \-- probably very useful for the diagnosis,
or for the confirmation. But somehow we need a rapider one.

So we need a better way or a faster way to detect if it is the virus RNA
or the antigen, or even the antibody, and we are heading towards this
direction.

And secondly we need a second panel, a sample or specimen panel that is
clear in the clinical information, and also the collaboration on the
development and the validation for a new diagnostic test.

And Taiwan has a commitment on the SARS diagnosis, because we really are
the victim of this SARS epidemic. So the Taiwan government, with the
approval of the Congress, we set up a special funding, and also set up a
task force to deal with this situation.

And this group will be led by Professor Michael Li. He has been working
on the coronavirus for about 30 years. And he already returned to
Taiwan, at the date of this task force, and also he would be very happy
to have conversation with others around the world. I will stop here.
Thank you for your attention.

(Applause.)

DR. BABB: We have one more brief presentation from Karen Young. I will
let you introduce yourself.

DR. YOUNG: Thank you. I am Karen Young, and I am from Roche Molecular
Diagnostics. And I would like to thank you for giving me this chance to
give a very, very quick summary of what we at Roche are doing about the
SARS outbreak.

And it was brought out very clearly in all the presentations, a lot of
the presentations today, there is a real need for well standardized
diagnostic tests for the detection and diagnosis of SARS.

And there is definitely a role for industry in this, and as was brought
up very clearly today, there is a lot of technical \-- there are a lot
of issues that have to be addressed in order to very rapidly deploy a
diagnostic test, especially one that has to have all of the bells and
whistles, and are easy to use.

And a lot of these points have been brought out today, and so what I
want to do is very quickly go over these points. There are lots of
logistical challenges that are involved.

The nature of the epidemic is still not very well understood. Is it
seasonal? Is it going to come back, or is it a flash-in-the-pan sort of
phenomenon, and we won\'t probably be seeing the infection again. What
kind of reservoir is there for the virus?

In order for a diagnostic assay to be introduced rapidly, there is a
need to mobilize resources very quickly. One of the lessons that we have
learned from the West Nile epidemic and the need for screening the blood
supply is that the resources that were required for us to launch the
West Nile assay for testing blood under IND was tremendous.

So there needs to be quite a commitment from industry in order to do
that. So we need to have a very strong partnership with regulatory
agencies in order to accomplish that.

And another critical issue is sample acquisition. That was brought up, I
think, time and time again. Without a good source of well-characterized
samples, it is very difficult to develop good diagnostic tests.

And the IP landscape is another issue. With every new pathogen that is
discovered, all the \-- I think researchers are now very savvy in the
area of intellectual properties, and so without a clear idea of what the
IP landscape looks like, and if we don\'t have a good idea that we will
have freedom of operation, it is a very risky proposition, I think, for
industry to go into some of the areas.

In addition, there are technical challenges. What is the optimal sample
type? Blood, serum, and plasma are much easier to obtain than some of
the respiratory samples, but are the viruses found there? And would they
be appropriate samples for testing?

Stool and urine are easy to obtain, but for amplification techniques,
there are inhibitors that may be present that can interfere with the
performance of the assay.

There is also issues of how efficiently can the virus be lysed. How well
\-- how stable are the RNA, once they are extracted from the samples?
There is also a question of viral heterogeneity: as with most RNA
viruses, there is a lot of sequence heterogeneity between isolates; how
is that going to affect performance of the assay?

And coronaviruses are known to recombine, so is that going to be an
issue? And then of course there is going to be a need for
standardization of assays, and the availability of good reference
materials.

The \-- Roche\'s response to the SARS outbreak has been to rapidly
develop a research assay that can be put out there for the research
community to use. The assay that we have developed is a quantitative
real-time PCR assay that is run on the LightCycler, and the sample
preparation is defined by the user.

Now, from data that we were able to gather, we feel that an IVD assay is
warranted, then we are going to need a lot of help and guidance from the
regulatory agencies to establish performance requirements. What we will
try to do is then apply the lessons that we learned from the research
assay in the development of an IVD assay.

The assay will likely have an automated sample preparation, a Taqman
PCR. We want \-- these two issues, I think, are very important. One of
the important issues to deal with in the commercial assay is that you
need to be able to trust the results.

False positive results are certainly a real possibility with all
amplification assays. So if you can have an automated closed system that
certainly reduces the chance of having a false positive result due to
contaminations.

So an automated sample preparation and a Taqman assay, which is a closed
system, will go a long way towards that. And of course there would also
be required to have a full process control so that each part of the
process can be monitored.

So our current status of our research assay is that again we have a
LightCycler assay that is quantitative, using an external calibration
standards. The assay contains an internal control molecule that monitors
the presence of inhibitors.

Again, user-defined sample preparation. We just completed an in-house
evaluation of a panel of positive clinical samples, and a worldwide
trial at beta sites is ongoing.

In our in-house evaluation, we looked at 40 samples from Hong Kong. The
sample types included nasal pharyngeal aspirates, stool, urine, and
throat swabs.

And this is just a very, very broad summary of what we have found. Here
you can see that these are PCR results from the Queen Mary Hospital.
This is our PCR result \-- this is a qualitative yes or no answer. And
then here it shows the titer range.

As you can see, the respiratory specimens and the stool set specimens
tend to give us the best results. Urine gave us a much lower hit rate
than the other specimens, and you can see though that the viral titer
really is very variable.

It goes from its lowest of fewer than 10 copies, to all the way up to
greater than 10 to the 7th copies, per reaction. So that is certainly a
consideration when thinking about what kind of assay and what kind of
performance we need to ask from our assay.

So I just wanted to close by reiterating the challenges that we are
faced with in the SARS diagnosis. There are many unknowns. We don\'t
really know what the nature of the epidemic is, or we have very little
information.

We don\'t have a whole lot of information on the natural history of the
infection. And we are now starting to get some data on the most
appropriate sample types. And then also, what is the optimal way of
handling the samples?

And then, of course, to effect a rapid introduction of the diagnostic
assay, we need to devote very dedicated resources to the project, and we
need to have a lot of help from regulatory and public health agencies to
define the assay performance, to standardize how the performance of
assays is to be assessed.

We need to have made available reference standards, and also clinical
samples for development and evaluation of the assays. Thank you.

(Applause.)

DR. BABB: Thank you, Karen. If we could have the speakers to come up to
the table now, and we will start our final session, the open discussion.

Our moderators for this session is Dr. David Feigal, the Director for
the Center for Devices and Radiological Health at the FDA, and Dr.
Murray Lumpkin, the Principal Associate Commissioner.

DR. FEIGAL: One of the intents of this meeting today was to really be
able to respond to some of the requests that industry made. Dr.
McClellan mentioned this morning the industry that Secretary Thompson
asked for, when a number of people from the Device Industry and talked
about what they would need to do that, to develop effective tests in
this area.

And so one of the things we need to focus on this afternoon is to come
back to that point, and this is an opportunity really to get people from
around the world, from all the different parts of the puzzle together,
and to talk about this kind of an issue.

One of the things that I will do is actually start some questions off,
and let me actually encourage the panel, even though you can\'t see each
other, to feel free to ask questions to each other about the issue.

But let me start in a very nitty-gritty area, where there was a fair
amount of discussion before, and that was on the issue of: how do we get
sharing of specimens? Should the specimens be from clinical collections?
Can there be a repository? What exactly will move this forward.

And let me please invite the people in the audience, particularly from
industry, to actually comment on some of the issues that you have had,
the issues of obtaining specimens, and what your needs are at this
point.

But let me ask from the panel if we could actually have a discussion
about the human specimens for developing an in-vitro diagnostic. What
are some of the logistics?

DR. ROTH: To start with, just to reiterate what I said in my talk, that
there is one repository that has already been established in Dr. Lin\'s
lab in Hong Kong. We are hoping to expand this, perhaps with the
addition of some other sites, but the logistics \-- and indeed the legal
and operational arrangements for this \-- are yet to be worked out.

DR. FEIGAL: Could you say a little more about the practicality, the
shipping of specimens, how many specimens are really available, are
these specimens that are able to be expanded, or in fact are we dealing
with a scarce resource at this point in time?

DR. ROTH: At this point, we are dealing with a scarce resource. These
are clinical samples, and clearly this is one of the very big issues for
the planning of such sample repositories for the future.

And there are mechanisms set up to monitor the use and the demand, and
what we do if samples, particularly from some particular geographical
site, are becoming depleted, and how to ensure that any renewables are
kept renewed.

So I think these issues are actually going to be our immediate concern
over the next few weeks and months. But some of them are actually going
to be fairly problematic.

There are also some issues about shipping and transporting, including
paying the costs of this. But some of them are more basic issues to do
with transporting clinical material and potentially infectious material,
also in the context of development of new regulations and guidance, both
from WHO, and regulations from the airline and other transport agencies
about transporting such samples.

So I think that this is going to have to be a very well coordinated set
of plans for these different repositories.

DR. FEIGAL: And your comment?

DR. ZAMBON: Just a basic comment about the difficulties really. I think
that many of the laboratories that have the specimens are still
incredibly busy trying to sort things out related to the SARS epidemic.

Getting samples organized for a repository isn\'t actually a
no-cost/no-time piece of work. And it might seem like all you have to do
is pull out 10 specimens out of the freezer and send them somewhere, but
actually it turns out to be half-a-day or a day when you don\'t really
have the time to do it.

So I think that, in many ways, is one of the major problems about
getting free access to samples. It is not really even the sample
material. It is the person resources to get that material organized.

And if there was a way of finding some person resources for the labs
that actually have the specimens, to facilitate the shipping, that would
be one way of opening out the resource internationally, because it is a
big mistake to think that, oh, I only want so many samples; they can
easily do that for me.

It is a big mistake to think that that is not a trivial thing for the
\-- or that that is a trivial thing for the sending laboratory.

DR. ROTH: Can I just add one thing to Maria\'s comment on that point?

DR. FEIGAL: Sure. Can you pull the mike over a little closer?

DR. ROTH: Just to add one further point to that comment, which is that
\-- in addition to all that, there is still a great deal of work to be
done for these samples to be optimally useful in terms of characterizing
them epidemiologically, clinically, and indeed still virologically.

And so until that work is a bit more advanced, I think the usage of this
repository should be limited.

DR. FEIGAL: Did you want to make a comment from the industry
perspective, or call on your colleagues in the audience? We can name
names out there, if you want to do that.

DR. KOZIARZ: What I just wanted to mention was that, in keeping with \--
I think \-- the spirit of your question, when the coronavirus was
identified as the culprit as it were, here \-- I am speaking
specifically for us \-- we actively went out and tried to source samples
ourselves.

And obviously that had a lot of \-- it was time consuming. We distracted
researchers and clinicians in a lot of places in the world to work out
the details of doing that.

But essentially it was every person for themselves, when that occurs. It
is a question of who is going to go out and aggressively do that. And
while it may have some advantages early on, I think if we look at this
from the standpoint of really putting together a system that will allow
us in the future to react quickly and react well to these, there are a
couple of drawbacks to that.

The first one is: we have a set of samples that maybe someone else
doesn\'t, so how do we ever compare what we are doing here? And I think
what we saw this morning, also with respect to the sample types, where
in the course of the disease the sample was taken.

There are a lot of things there that I think this type of a strategy
just begs for some \-- you know, it is almost like the analogy to a HIV
sero conversion panel, where we all test our reagents against them, and
we all know where we are when we stand there.

So I think we are sort of building in, maybe inadvertently though, I
think some difficulty for the regulatory bodies, because they are going
to have to somehow find a way to compare a performance here.

And I don\'t think I am answering your question, though, on who is going
to put this panel together and store it. But I think that it is
something that we have to do.

And I agree wholeheartedly with the first two comments that this is a
lot of work, and it is nothing to be entered into lightheartedly. We are
going to have to make sure that we really have the right specimens in
place.

Now, who does it and how we all share in it, I think is something that
we have to consider in the future. But for samples like this, and I
think for instances like this, we really need some type of a yardstick
that we can all measure ourselves against.

DR. FEIGAL: Is there anyone from the audience, from industry, that would
like to comment on your experience with samples and trying to obtain
samples, or not succeeding in getting samples? You don\'t look like you
are from a company here.

MR. SHOEMAKER: No, I am definitely not from a company.

DR. FEIGAL: Unless Abbott has a snappy new uniform here.

MR. SHOEMAKER: No, but I would like to make a comment. I\'m Dave
Shoemaker, U.S. Army microbiologist. One of the critical problems that
we have all really addressed here is simply the volume of samples that
we get from patients, and the very small volume that we have, so that
you can\'t give the same sample to 10, or 20, or 30, or 50 different
companies out there to test their assays.

Dr. Dave Norwood brought up the non-human primate challenge studies,
which would give you potentially the opportunity to get larger volumes
of samples so that you could get the same samples out to a variety of
people.

My question is: how does the FDA \-- how would they view the data
obtained from animal samples, which is not human samples, per se. How
would they view those data in an application for a SARS diagnostic
assay?

DR. FEIGAL: Well, shall we put Dr. Gutman on the spot here? There is, of
course, the animal testing rule that has been developed for drugs and
biologics, but I don\'t think we have had a device version of that. Are
there precedents on that?

DR. GUTMAN: There are no precedents, so the question is broader. If FDA
wants to do things that are scientifically plausible and reasonable for
a particular circumstance, so the question is from the standpoint of the
scientific community, and from the standpoint of this panel, is that a
reasonable surrogate?

It certainly strikes me that it would be a reasonable surrogate to
provide some information. The question is, is it enough information for
us to consider it an investigational device? Is it enough to actually
carry it over to a provisional approval? Or is it enough to actually
say, gee, that\'s all you have got, and it is an approval.

I don\'t know the answer, and I don\'t know if David or anybody else on
the panel would venture an answer. I guess what I would suggest is that
at the point where somebody has got that data \-- and I would guess even
getting that information is not all that easy.

You do have to go through the work of identifying the animals and
infecting them. The sponsor would need to negotiate with us, and we
would turn to CDC and NIH, and the parties involved in this room, and
ask them: is this enough?

DR. FEIGAL: The primate studies aren\'t cheap, and if I recall, were
there three animals involved in that series?

DR. NORWOOD: Yes. Yes.

DR. FEIGAL: What was the rough cost of doing that? Just curious.

DR. NORWOOD: Well, each animal approaches a hundred thousand dollars.

DR. FEIGAL: So it is an expensive way to do that. But one of the
questions that has come up, and perhaps to ask the panel, is the
feasibility of getting started with a diagnostic assay with artificial
samples \-- animal samples has been another proposal \-- but something
that would be controllable, so that you would not have to work on the
serendipidity of being able to get the access. Anyone like to comment on
the feasibility of that kind of an approach? Do you want to start?

DR. NORWOOD: Actually, I was going to add that the conversation that
kind of started here on clinical samples, but I think that there is a
much easier bank of reagents that could be immediately prepared that
would allow the comparison of assays from a variety of sources.

And that is, it\'s not a huge undertaking to isolate significant amounts
of RNA from all of these strains and from nearest-neighbor panels and
have a central location for that material where people can test their
assays against other assays.

And based on that information and that data, then reasonably informed
decisions can be made about which assays are worth testing on clinical
samples that are available.

DR. ZAMBON: I would like to say that I think it is a very pragmatic
start, to use panels of negative clinical materials spiked with either
RNA or with virus, and hone in then so that you do save the very
valuable clinical material for \-- as has just been stated \-- things
that are worth actually testing.

And you could, I think, make large panels of clinical spiked material
available for large numbers of people if required. And that is
particularly relevant in things like fecal material, where you may need
to work through a lot of processes of inhibition and extraction in order
to be sure of what you are getting analytically. So I think that may be
a first, better approach.

DR. KOZIARZ: David?

DR. FEIGAL: Yes.

DR. KOZIARZ: I was just going to say that that does, though \-- I think
that is a plausible way to go forward, but it does imply that maybe the
first step on one of these assays then is the demonstration of
analytical sensitivity, as opposed to clinical sensitivity.

DR. FEIGAL: Gee, I think we have heard that proposal somewhere, didn\'t
we?

DR. KOZIARZ: I think you did.

DR. ANDERSON: One of the things that I think is important to get back to
is: what is the question that you are trying to address? And they are
different. One is the analytical sensitivity, which you can define that
with spiked samples or whatever, and you can define variation in
clinical samples with a given test that way.

The other piece is: what is the sensitivity, and how do you interpret
the results in a clinical setting? And there you need kind of the
clinical parameters, the gold standard, but you don\'t have to do that
with each assay.

And I think once you define the questions, then you can break it down
and put together \-- approach it in a creative way that can get you
where you need to go.

DR. FEIGAL: So if I understand your suggestion, your approach is to
develop reliable and accurate diagnostics that work on spiked samples,
and then link that to what is known about the biology of the response in
the infected patient of what you are trying to detect, so that you
don\'t require that \-- is that basically what you are proposing?

That each person does not have to go back and find, and characterize the
clinical specimens as where they are in the course of infection?

DR. ANDERSON: Well, I think that is one way to get there, because we
don\'t see to have enough specimens for everybody to test the full range
of possible settings. So I am not sure that we have a choice, other than
something along that lines.

DR. PEIRIS: Just to address this issue about samples and distributing
samples. I think \-- I\'d just like to echo something that Maria Zambon
mentioned.

It is just only recently that we have been able to put together the
epidemiological correlates of many of the hundreds of samples that we
had. I mean, the majority of samples we got is rubbish, you know. When I
said that we tested 300 samples a day, I mean much of that was totally
useless.

Even those that were positive, it is really not much use, because you
can see that the time codes of the illness is critical. I mean, we are
trying to establish the validity of the assay. So we really need to have
a date of onset in relation to sample, and that type of data is only now
beginning to come together, because you are getting samples from all
over Hong Kong.

One other point is that these original clinical samples are not just
important for diagnostics. They are important to understand molecule
epidemiology; they are important for pathogenesis; and, just as an
example of molecule epidemiology, we are interested in genotyping these
viruses in relation to transmission linkages.

Now, that information is only beginning to get put together. So I am
just trying to convey to you some of the issues that we need to keep in
mind before we lose all these samples by distributing them worldwide.

DR. YOUCHAN: Yes. With the SARS outbreak occurring in China, most of the
people think that the Chinese will be likely to worry more and that a
sample should be easy, but it is not true. In fact, we need the Army; a
lot are worrying about those samples. So it is very difficult to get
this kind of samples.

So in summary we want to have cooperation with international
organizations. We want to set the international laboratory reference and
then we distribute them to the panels and to the different laboratories.

But it is quite difficult to get the large warning samples, so we
already start to these workers, to get these valuable samples. We also
want to use the artificial samples. For example, we have introduced the
virus into the monkeys or something, some animals, where we can get the
virus. However, we can get the serum, and we maybe use that as part of
that kind of samples as a reference.

So in China many manufacturers have already developed the assays, but
they didn\'t get enough valuable samples. So they can\'t do evaluations
for the assays in clinical trials, and so they didn\'t apply for the
license. So I think that is still a problem, some difficulty, to come
back to the samples in China.

DR. FEIGAL: One of the things that was mentioned a few moments ago is
the usefulness of reference panels for HIV screening for blood. And as I
understand it, part of the importance of those panels is to be able to
track viral drift over time, as the viral population we are seeing in
the blood supply changes over time.

Does anyone have any comments about how we would tackle the problem of a
potentially variable virus and develop a diagnostic at the same time, if
we don\'t have an ongoing way of collecting clinical specimens and
tracking the genome and the viruses that are beginning to appear?

DR. ZAMBON: Well, perhaps I can start the discussion. In many ways, the
problems of the SARS corona-virus there that you just elaborated on are
not very different from those of influenza. It requires that you do
constant sampling, and we can call it surveillance if you like.

You do a lot of sequencing, and you relate your immune responses to the
strain variation that you get. So that means looking not only at ELISA
type antibody responses, but functional antibody responses by
neutralization or by other functional antibody assays.

And that is maybe a different question to diagnostics, but I don\'t
think it is undoable. It requires that you have in place mechanisms to
capture a virus and mechanisms for looking at functional antibodies.

DR. FEIGAL: But I think it sounds to me like what your point is \-- that
instead of tracking this for the purposes of developing changing needs
in altering a vaccine, it could be done for tracking the changing needs
in diagnostics.

DR. ZAMBON: Oh, absolutely, because you would want to do a number of
years of \-- well, let\'s assume that the thing continues to circulate.
You would want to be sampling regularly and to be sure that you are not
drifting from where you are diagnostically. Until you are sure about the
extent and rapidity of evolution, you are committed to having to do
that, while it continues.

DR. ANDERSON: I think that is one of the reasons for using more than one
primer set. You have got a couple primer sets that you are using, it is
unlikely that change would occur in both at the same time. So if you see
discorement, then that\'s an isolate you want to go back and look at.

You know, one being the possibility of different sensitivity at the
site, but the other being change. So I think to pick that up when you
are doing diagnostics, one way to do it is to make sure that you have
got a couple of primer sets.

MR. HOUNG: Huo-shu Houng from Walter Reed. My laboratory is heavily
involved with another IRD disease called adenovirus Type 4, and normally
the gold standard that we use is a viral isolation, and actually I
believe that based on the present data, and coronavirus and adenovirus
are very similar.

The virus shedding can last as long as three weeks, but then again
during the early stages to the peak of the infection, you could easily
isolate the virus. But to the later parts, the neutral antibody came out
and you would not neutralize the virus.

So the PCL would come up positive and viral isolation come up negative.
So I just want to caution everybody how to correlate it with clinical
symptoms.

DR. FEIGAL: Well, in fact we have been talking about two things. One of
them is tracking the virus in a clinically relevant virus, and the other
is trying to diagnose patients in the different stages of a clinical
infection, and the goals are related but somewhat different.

Do we have in fact the infrastructure in place now to do this kind of
routine collection of SARS? It has been very impressive, the
mobilization against the infection. But if it comes back in force in
another country, or in this country six months or twelve months from
now, the question that will be reasonable to ask is: what has been done
to prepare, and what are the steps that are needed, and what kinds of
pieces should people be applying to the NIH to get funds for? Jim.

DR. PRUDENT: I just want to make mention that without \--

DR. FEIGAL: Could you just identify yourself?

DR. PRUDENT: Dr. James Prudent, EraGen Biosciences. One of the
interesting aspects of SARS now becoming important is that it is opening
people\'s eyes up to the whole idea of molecular diagnostics and what
the future is going to allow.

Because this is \-- infectious diagnostics is one piece, but there is
also a genetic testing in general. And last March I was asked to
contribute at a roundtahle at NIST, which is the National Institute of
Standards and Technology.

And they are very interested in participating, even though they said a
number of times that they are not a regulatory industry or a regulatory
agency. But their interest is this. They provide samples and standards
for all types of other industries.

They would like to get involved in this. I don\'t know if there is a
proposal on the table in front of Tommy Thompson or someone else in the
Administration, where we could not only look at infectious disease, but
genetic testing in general.

Because, for example, cystic fibrosis \-- one of the largest genetic
testing targets out there today \-- it is very difficult to get all the
mutations that one needs to build a diagnostic test and assay it and put
it through the standards of clinical testing.

There is going to be a meeting in September at the CDC to talk about
that issue. I am wondering if the two groups \-- does it make sense for
the two groups to get together and actually build an agency or build
some sort of a group that can build models like David Norwood said.

It is not all that hard to clone these sequences, and to get
standardized RNA for the SARS virus. It just takes someone willing to do
it and the money to do it. That\'s all I have to say.

DR. FEIGAL: Well, I was going to say that at one time I wanted to be a
psychiatrist, and I can tolerate long pauses, and that makes you feel
uncomfortable and you feel like you have to go to the mike, and you just
have to go to the mike and ask a question. Just remember that.

Well, if we were in fact to take your \-- and you\'ve made one
suggestion, which is to take some of the themes across genetic testing
and some of the commonalities that are developing in different
diagnostics, and to combine some of those efforts.

But let me turn your question another way back to the panel, or anyone
from the audience who would like to comment. How \-- what should we
recommend, as a workshop today, in terms of what is needed in terms of a
viral repository?

I think we have heard that the specimens from the epidemic that has just
gone by us like a freight train has some things that are useful, some
things which would take some work to make them useful.

But what are the recommendations? What would be the priorities? What
would be your priorities in terms of getting specimens, either viral
specimens or clinical specimens, ready so that we are in a better
position to be ready for a recurrence of this, if that should happen?

DR. ZAMBON: Again, perhaps I can start. I think we need a repository of
virus strains, and preferably as broad as possible. But within that
repository a clear identification of a number of strains which are not
subject to material transfer agreements, which can be made freely
available for academics and for industry, for commercialization or
development of diagnostics.

Because I think there is a problem with accessibility of strains at the
moment, and I think we do need that, preferably in more than one place
in the world, too.

DR. FEIGAL: And what would be the practical logistics of getting those
strains? Do they need to come from clinical specimens? Do we find them
in animal reservoirs? Where do we get the strains?

DR. ZAMBON: I don\'t know.

DR. FEIGAL: Not from the Patent Office, you\'re saying.

DR. ZAMBON: That is a question that I can\'t provide the answer to.

DR. ANDERSON: Well, I mean, I think to be able to have sufficient virus
that you can distribute and be useful, you are talking about isolates.
And you are going to go to the people who have isolates, which a number
of people have, and then you want to look at the range of genetic
variation within that to make sure that you are representing what is
available.

DR. FEIGAL: And how many isolates do you think are currently in the
laboratories around?

DR. ANDERSON: Well, we have got six.

DR. FEIGAL: You have got six here. We will do this by auction here.

DR. ZAMBON: We have got two.

DR. FEIGAL: You have got two, and so we are up to eight. Do I hear nine?

DR. ANDERSON: Most are going to be in China and Hong Kong.

DR. PEIRIS: We have 20 or thereabouts.

DR. FEIGAL: And in China or others, are there other isolates? Taiwan?

AUDIENCE: We have about five.

DR. FEIGAL: You have about five. So it sounds like \-- in terms of
clinical isolates from this epidemic \-- that there is probably less
than 50 isolates around. It sounds more like perhaps even 25 or 30.

DR. ZAMBON: But the question is, how many of them come without any
strings?

DR. FEIGAL: Yes. Well, there\'s all sorts of strings. Intellectual
property\'s been mentioned. Earlier in the day, we also had discussion
in the context of collecting specimens under investigational device
exemptions of having informed consent.

And there are different practices around the world about informed
consent for diagnostic testing. So there are probably some interesting
issues there that are different than intellectual property, but still
can create some \-- at a minimum, lengthy discussions, and at worst,
barriers. Were there some comments down this side, on the top?

If we were to actually, though, envision pulling together the repository
\-- well, actually, let me turn the question back. Are there known
strings attached to some of these samples? Are there patents or anything
that apply to your samples, for example?

DR. PEIRIS: Yes. I mean, we would have to discuss with the university
about the IP issues, but the initial strain is under RNA, but I am not
really sure if the other strains can be sent out without that, but I can
explore that with our university.

I mean, I don\'t think there should be a major problem making viral
strains available.

DR. FEIGAL: I think probably one of the proposals would be that the
strains be collected and established in a common place if possible, and
who would do that.

DR. PEIRIS: And I think, in that regard, it would be certainly much
easier if an international agency, whether it be WHO, or NIH, or in
combination, were to host such a repository rather than \-- I think that
would make life much easier for all of us.

DR. FEIGAL: Any comments in terms of presenting the NIAID\'s resources?
Are there analogies here that you could point to that would suggest a
way to go?

DR. LAMBERT: Say that again? Analogies?

DR. FEIGAL: Analogies to some of the HIV repositories. Are there strains
available? Are there ways that \--

DR. LAMBERT: There are wide varieties of \-- the list of those HIV
reagents that have been built up over a number of years is enormous. And
I use that as an example as sort of an internationally recognized
repository that has really contributed greatly to research worldwide.

So we see that as sort of an option, a way, a path forward. Some of the
groundwork has been done to sort of deal with some of the
commercialization issues. A framework for maybe one approach.

I think that frankly that the success of that repository has depended
greatly \-- as I said \-- on donors, people who are willing to provide
materials. If they do have strings attached, that repository has figured
out a way of dealing with them.

DR. FEIGAL: Donors meaning the HIV infected patients?

DR. LAMBERT: Not necessarily.

DR. FEIGAL: Not necessarily? The clinicians who have collected the
specimens?

DR. LAMBERT: The people who have isolated viruses, the people who have
developed research resources who now want to make them available to the
community through the NIAID repository, because frankly they can\'t
distribute them on the level, or on the diverse level that people want
them. They just can\'t do that in their own labs any more.

So there is also a capacity issue that these reagent repositories fill a
really good niche for.

DR. FEIGAL: Could you \-- and I am sorry if I missed it from your
presentation earlier, could you remind us of physically how that works?
Are these all in one place, or is this a virtual repository?

DR. LAMBERT: Let me see. Is Opendra still here or did he leave? I think
he is gone. It is predominantly in the same repository. We have a GMP
repository, and it is actually housed up in Rockville, Maryland. It is
called KcKesson BioSciences.

They are the ones \-- and they actually run some of the other
repositories as well for the Institute. But they have the freezers, and
they have the cell culture facilities, and they have the GMP.

And a lot of what they do is also subcontracted out. So if there is a
particular need that someone has, we can go through the repository
contract, procure what it is that the need is, and pull it back into the
repository and make it available.

So I present it as sort of a model about the impact that that repository
has had on research.

DR. FEIGAL: Now, did that start as an initiative from NIAID, or was that
a proposal from a group of investigators? I imagine that was a
contractor.

DR. LAMBERT: That is a great question. In 1988, I know that there was a
need from the extramural community \-- that means the part that receives
funding and does research \-- to try to centralize this. I think they
dealt with the same issues that you all are grappling with, which is how
do we deal with standardization? How do we deal with quality control?

We need to present a unified front, and we need to sort or prioritize
what limited resources are available. So I know that there were only 20
or some donors in the very beginning, which sort of was a critical mass
that allowed it to come together as a repository.

And the NIAID then said, okay, well, we have got 20 different types of
material and now we are going to let contract to manage it for us. And
that\'s \--

DR. ANDERSON: I think one of the things to think about is actually not
say that it has to be \"no strings attached.\" I think it is quite
appropriate to respect the individual investigator or university,
institution, whatever, and develop the kind of repository that NIH
presently has the capability, with different levels of strings, MTAs or
whatever, to respect.

And that way I think you are more likely to get the broad range of
isolates that will actually be useful, and then the groups can look at
how they want to use it, whether it is appropriate for them or not.

DR. FEIGAL: No, that is a good comment. That is a good comment. Yes?

MR. WINSLOW: David, Dean Winslow, Bayer Diagnostics. First of all, I am
just going to warn you and put you on the spot, and try to address very
briefly a fundamental issue I think is of concern to industry.

First of all, I was gratified to hear Dr. Gutman propose that SARS
diagnostics be classed as Class III devices, both as I guess IVDs, as
well as, I heard him say, as Class III ASRs.

Just a little bit of preface. My former position before I joined Bayer,
I was Vice President of Regulatory and Clinical at a company called
Visible Genetics, and we had the first integrated system for HIV-1
genotyping for drug resistance testing. And by the way, I just want to
also say that I have the highest regard for the FDA, and I think that
the relationship that we developed and the wonderful assistance that we
got from CBER was just great.

So I am not bashing the FDA. But I think a real concern though is that
if the compliance division of the FDA does not enforce the regulations
on ASRs being Class III devices and subject to PMA, that I can\'t see
any of the major companies devoting the resources to developing a SARS
diagnostic as either an in-vitro diagnostic device or even as an ASR
type reagent.

And again just the reality of it is for many of those in the audience is
that there are three large reference laboratories that because of their
exclusive contracts with insurance companies, control about 85 percent
of the nucleic acid testing in this company.

And it is obviously cheaper for them to develop a laboratory developed
assay \-- you know, a home-brew assay \-- that is not subject, as
opposed to an industry that has to put all the quality systems
regulations into a product.

For example, we spent about \$50 million and five years, filed an IDE
and everything, and eventually because we could not compete with home
brew, because the FDA did not exercise its enforcement against the home
brews, that we basically had to fold up shop.

So, just again as a precautionary tale, and a challenge I think to the
FDA, that if you are going to regulate this as a Class III device that
you have to put some teeth in it on the enforcement side.

DR. FEIGAL: Thanks for that comment. One of the \-- let me continue the
discussion and sort of getting ready. I think that \-- well, actually,
let me just ask one final follow-up question to our colleague from
NIAID.

What would be the mechanism of getting a repository or getting SARS
specimens added to the resources that you already have? Does that need a
proposal from someone, or would this be something that NIAID would be
willing to issue as a contract to provide a repository for specimens?

Could that be piggybacked on to the work that is being done for HIV?

DR. LAMBERT: In terms of a mechanism, I really think the way that we see
this as \-- is a piggyback on to the biodefense research resources
program. I mean, that is ready to go live, probably September or
October.

And that has an incredible \-- that actually has unprecedented capacity.
As you can imagine, we are building something for biodefense, and it is
broader than biodefense. It is biodefense and emerging infectious
diseases, which means that it has teeth to outride whatever this
biodefense thing looks like.

So the infrastructure, the dollars, the resources, are in that contract
that we expect to award within the next several months. And as I think I
mentioned, the Division of AIDS contract is actually filling a little
niche until that one goes on-line.

So I guess what I heard someone say earlier is \-- and maybe it was you,
Maria \-- you know, we could go out and we could talk to these folks,
and we could say that we have this capability, we will take your
specimens, we will work with international partners. We will attribute
your donation to this repository and give you and your institution
credit, if that is what you need. We will put agreements in place with
people who want to withdraw materials that you have provided.

I mean, I think all of that is on the table, is something that this can
do, as probably as other places in the world can as well. But if
resources is pulling things out of the freezer and it takes money, and
if the Canadians say that we have these banked resources, or the folks
in Taiwan say we have them, but we need resources to get them out of the
freezer and to categorize them and expand the isolates, I don\'t think
that is off the table.

I think that is something that as part of its contributions to this
project that we could talk about. Does that answer what you were \--

DR. FEIGAL: Yes. Did you want to comment?

DR. NICHOLSON: Yes, this is Jan Nicholson. NCID. To follow on that and
the comment that we heard about the HIV panels, I guess those are
antibody panels.

Is there a proposal then on the table to provide or put together panels
of, let\'s say, RNA or viruses, or antibodies, for SARS coronavirus,
that would be available for industry to use, so that everybody would be
measuring their assay against the same materials? Have you thought that
far ahead?

DR. LAMBERT: So are you asking, has the NIAID put out requests for
proposals to do this to the academic or private sector? Is that what you
are asking?

DR. NICHOLSON: Well, I am asking \-- in this repository that you are
talking about for coronavirus, is it envisioned that you would put
together panels of specimens that could be used as evaluation panels,
basically?

DR. LAMBERT: Absolutely. Absolutely. Yes. And I will be honest with you.
I personally know very, very little to nothing about standardizing
antibody and RNA panels, and we would have to pull in experts who have
dealt with that for other infectious diseases and been able to advise us
on how to do that, or work with international colleagues.

DR. FEIGAL: Let me pick on \--

DR. LAMBERT: Sure.

DR. ROTH: Let me just say that from the WHO point of view. This is
something that we are very definitely trying to pull together quite
soon, in order to perform some multi-center \-- as I was saying earlier
\-- multi-center evaluations of the current major candidate assays.

But also, they have already been producing and distributed to many
countries panels of reference sera and standard sera, and obviously this
needs to be something that is continued and expanded in terms of
availability.

DR. FEIGAL: Did you want to comment?

MS. KODSI: I am Xiuli Chen from BBI Biotech, based in Boston,
Massachusetts. We are a panel manufacturing company. Actually we
manufacture the HIV and HPV, and recently just finished the West Nile
virus for the Panel 1 and 2.

The main issue is, I think, for the panel manufacturing, for our company
right now we are trying to get virus from any source that we can get,
but I really feel that it is really difficult. One question that I
wanted to ask the panel is that we just are talking about animal models,
and the patient specimens to get the viruses.

What is the steps for coronavirus culture, for the staph culture?
Because I know for the West Nile virus that we can culture the virus up
to 10 to 9th or 10 to 10th copy per mil.

But can we culture such virus? And if we can culture, what the titer can
be? And which laboratories is doing this, and how can we get this virus
culture?

DR. FEIGAL: Do you have a comment?

DR. NORWOOD: I believe that we have been culturing them in Viral 6
cells. Our titers have been somewhere around 10 to the 6th or 10 to the
7th pfu\'s per mil \-- we don\'t get much higher than that. And the
first passages usually are not that high. They tend to be somewhere
around 10 to the 5.

MS. KODSI: Okay. That is very good, but I wondered if we can get some
from you.

DR. FEIGAL: Well, this is an interesting question. Do we need the virus?
Is having the sequence adequate enough? But for the manufacturers, do
you actually need to have the virus and the capability to produce the
virus? And is this \-- what kind of BSL level are we talking about,
developing this?

DR. NORWOOD: All our cultures are being down at BSL 3. with appropriate
personal protective equipment. We don\'t transfer anything to BSL 2 for
RNA isolation until it has been put in trizol.

I am sure that perhaps not everyone is working under those
circumstances, but that is what we have been told from our safety
people, that \-- the way we need to work with it.

DR. ROBERTSON: And those are the recommendations from CDC also, and also
from WHO.

DR. ANDERSON: There are a number of groups that have live virus,
including CDC, that are distributing it on request, and with signing an
MTA.

MS. CHEN: You know, from West Nile Virus panel experience, we first heat
activated the West Nile virus. So for the SARS virus, from my knowledge,
it is sensitive to heating. So if we can get the virus, I think maybe we
can first heat the virus in the BSL 3 laboratory, and then in this case
the downstream process should be easy, and it should be easy for all
industry and the public health departments to work on these panels.

DR. NORWOOD: I think it depends what you want to do with the virus. If
you are interested in immunological-based assays and antibody
generation, or things of that nature, any sort of heat denaturation is
going to affect the epitopes on your proteins.

If you are just talking about using the virus for the RNA and nucleic
acid components, then that is probably true. The way that we typically
inactivate our agents is by gamma radiation.

We have not done any of that testing with SARS to date, though.

MS. CHEN: Okay. Thanks.

DR. FEIGAL: Now at this point, we have been talking about the virus and
viral specimens, and collections of viruses, and it looks like we have a
path forward of developing a repository of those kinds of specimens. Can
we turn to talking about the host response, and specimens reflect the
host response. This was sort of mentioned briefly, that some of the
panels that are available for some diagnostics are antibody response
panels.

How are we going to build that kind of \-- well, what do manufacturers
need? How can the public health networks be helpful in this kind of a
setting with a new infection?

DR. ZAMBON: If I could just start off and say that I think that it might
be easier to make antibody panels, because you can to a certain extent
ask individuals if they are prepared to donate larger volumes of blood
when they are recovered. What you don\'t cover with that approach is the
acute phase antibody diagnostics, which are \-- those are usually the
sera which are in limitation.

So again, exactly the same problems with acute phase antibody diagnosis
as exists for acute phase nucleic acid diagnosis. But in principle
detection of antibody responses ought to be fairly straight forward,
because there are enough SARS infected patients who can be followed up
and get large volumes of blood to get those. So I don\'t think those
would be difficult.

DR. FEIGAL: Has anybody started collecting those? Yes?

DR. ZAMBON: We have.

DR. FEIGAL: You have. Anybody else working on \-- ?

DR. ZAMBON: But bear in mind that we have very few patients.

DR. FEIGAL: But you don\'t have very many patients.

AUDIENCE: Well, one thing I might say that would be useful for measuring
the immune response from an industrial perspective would be for academic
institutions and hospitals, and anyone else dealing with SARS, should it
come back, would be to start saving PDMCs.

Dr. Anderson briefly touched on it in one of his slides, but for the
most part we have been focused entirely on the humeral arm, and I think
there is a lot of information on the cellular arm that can be derived as
well.

DR. ZAMBON: Okay. And I think to answer that immediately, it is a
question of resource. The labs are overwhelmed with providing diagnosis
\-- don\'t have the time to do T-cell separations that are required, or
prep your cells in such a way that they can be used later, and that\'s
really \-- it\'s a resource issue again.

DR. FEIGAL: Could we get a comment from \-- I was going to pick on
Indira Hewlett, since I can still see you in the back. Could you comment
a little bit on the experience of developing panels for blood testing,
and some of the mechanics of how that works, and who actually \-- where
the panels physically are, and how the manufacturers get them, and how
are they produced?

Are there things that we can learn from those systems, as we look
forward to this?

MS. HEWLETT: Thank you, David. Obviously in CBER, we do lot release
testing - tests that are used to screen the blood supply, and to support
that function, we have actually engaged in developing panels.

Some of the panels that we have are those for HIV, and we also have
panels for hepatitis. And more recently we have been involved in
developing panels for West Nile. And actually some of the issues that we
have been talking about are very reminiscent of the discussions that we
have had in regard to West Nile virus test validation.

Where in fact there are very few specimens that are available for
validation, and one of the strategies that we have taken is to develop
panels in-house at the FDA.

So we have in fact acquired some virus isolates from patients and
cultured them in the laboratory. And we are in the process of actually
doing collaborative studies to look at the performance of these panels.

We are also, in the case of West Nile, trying to acquire specimens from
various clinical laboratories and public health labs, where cases have
been identified, and to create a repository in-house in our laboratories
at the FDA.

The repositories are actually stored at a contract facility, actually at
the Bratton Biotech, Boston Biomedical Laboratory, and you just heard
some comments from an individual from that laboratory.

The way it works is we actually perform some testing on the different
panel members to characterize them, to make sure that they are
pedigreed. We also look at the performance of different tests on these
panels, and at that point they are sent off to the contract facility
that actually manufactures them under GMP conditions.

And when it comes time for a manufacturer to actually develop a test, or
when it comes time to licensure, they acquire these panels from us and
they perform testing as part of the qualification and validation of the
test.

So that is sort of the approach that we have taken in CBER. It does
involve some efforts in the laboratory, and we have BSL 3 facilities on
campus, the NIH campus, which allows us to do some of this activity
ourselves, within the FDA. But hopefully that is something to think
about.

Obviously in the case of SARS, it has not yet surfaced as a blood issue
in terms of transmissibility by blood, but we are looking ahead and also
beginning to look for specimens. And obviously this discussion here is
very useful for us as well.

But one of the approaches, obviously, would be to create some type of
repository, and perhaps working through NIH and working through our
laboratories in-house may be a way to move forward here.

DR. FEIGAL: Thank you very much. Does anybody have any questions for Dr.
Hewlett? Comments?

We sort of had three different models that have been suggested. One is
the blood model, and another is the influenza model, and \-- I have
already forgotten the third one, but we had a third one a moment ago.

But the question is sort of what strategy \-- well, the HIV and the
NIAID was the third one that I was thinking of. So there are different
types of resources.

Let me actually put the panel on the spot and \-- well, actually, let me
take one different tack, and then I am going to put you on the spot to
ask you what we need to do to be prepared, if in fact we were to have a
major outbreak, and bring it to this country.

What if we had a major outbreak in this country? But let me ask first
about a different strategy. We have talked a fair amount about the
virus, a little bit about the host response, and we have talked about it
from the perspective of collecting resource materials that someone \--
separate from responding to the epidemic \-- could deal with as
developing assays to respond.

And these materials could be used either by someone trying to develop a
reference central laboratory, a home brew type of approach, or they
could be used to develop a commercial finished kit.

But the other possibility that could be raised is whether or not there
is the possibility to actually bring experimental diagnostics to the
public health response.

Historically \-- and we have seen a pretty effective response to this by
CDC, WHO, by the health departments in the countries affected \-- that
testing was put in place pretty rapidly once the organism was
identified.

But if this becomes a cyclical pattern or if we are dealing with new
types of agents, is it possible in fact to begin to test commercial
assays in development, alongside with the public health response?

And we have heard already about how busy the public health response is,
and how hard that is to keep up. But is it possible to find a way to get
the extra resources, and would that be another mechanism forward, and
would that be something that would be attractive to industry? So if you
can follow that run-on question, I would ask if there are some comments
for that.

DR. PRUDENT: I would like to make just a quick comment. We actually were
working with the CDC, and I don\'t want to say who, but there were a
number of individuals there that said, we would love to have a company
take over the responsibility of putting out some of these early
diagnostics and sending them out, because we are swamped.

So that was a response that we had from a few people there.

DR. FEIGAL: And one proposal that has sort of been made is that people
have sat around and kicked this around, saying that if you had multiple
companies even developing multiple analytes or multiple diagnostic
strategies, would there be a way to rapidly call for these and identify
these at the same time?

The idea a little bit is that the public health system response can
handle an epidemic of a certain proportion, but once it gets to the
magnitude that you need to have the testing in every hospital in a large
country, you may well overwhelm and swamp that kind of a system.

So is there a way to rapidly put commercial development in place
alongside a public health response \-- and particularly as we look at
how to respond to new emerging threats \-- would that be a worthwhile
investment to sort of build that sort of infrastructure?

DR. ROBERTSON: I am going to take a stab at this. I am not sure that I
am the best qualified person to answer this, but in the midst of the
outbreak, as difficult as it was, at least we were dealing with assays
that we had experience with in-house.

I guess one of my concerns is if we had multiple commercial assays out
there, how would we compare them one to another? And perhaps Rosemary or
somebody from the state public health labs would like to speak to this,
because one of the things that has come across quite strongly to me is,
at least we have \-- every lab is technically following the same
procedures, and so hopefully we are comparing apples to apples.

DR. FEIGAL: I think the idea would be \-- and since you actually had the
experience of putting together an IDE, working through the U.S. approach
to consumer protection and informed consent \-- would be to say that
rather than each commercial company having to do that independently \--
find its own hospitals, find its own sites \-- in fact, to pick on you,
a company could come to you and say, could I be an amendment to your
IDE? Could I have a test that you run alongside with yours?

So that they would all have their apples \-- they would still be running
their apples and running your tests \-- but in addition there would be
other tests, and some of you could modify the informed consent slightly,
modify the IDE \--

DR. ROBERTSON: And we have run into the people and space issue.

DR. FEIGAL: Well, that is the question that I am asking. Is this
logistically feasible, or is this a good idea that just can\'t possibly
work?

DR. ANDERSON: I think that one of the problems that we worry about at
CDC doing that, is if we do it for one company, we are obligated to do
it for all companies.

And we really because of that shied away from getting involved in
evaluating tests at CDC, because we would get overwhelmed very quickly,
and I think it would divert our resources from the public health
response perspective.

The idea of panels of specimens that then can be sent to the respective
commercial company or whoever wants it, works much better for us,
because it is easier to treat everybody the same. If you have got panels
of specimens that we can send out \-- organized by whomever \-- that we
can deal with.

Bringing in a variety of different assays that we are going to be
running in parallel with us, we just can\'t do it. And it kind of
diverts us from the public health response that is really our first
responsibility.

DR. FEIGAL: Is there a possibility of saying that your assays are this
and comparing it with that?

DR. ANDERSON: Oh, absolutely. That is not a problem. And the other thing
is that if we do it for one company, we really have to do it for
everybody. And it is a real slippery road, and we can\'t go there.

DR. GIOVANNI: Actually, I was going to make a comment on basically what
Larry was saying. I think the sheer volume of what the CDC would have
knocking on their door would be overwhelming, and then also choosing \--
if the volume is so high \-- and then choosing among the companies to
decide which ones you are going to actually going to partner with, I
think that it would be very hard to do, in terms of the staff.

And just making it an even playing field for everybody who wanted
access.

DR. ANDERSON: And they are for vaccines. They are doing it for vaccines.

DR. GIOVANNI: Can you be more specific?

DR. ANDERSON: Having an outsource for a small

amount \--

DR. GIOVANNI: Well, actually I can tell you within NIAID that a lot of
the things that we do are through a peer review mechanism of people. Is
that what you mean?

DR. LAMBERT: You had a specific example though, right?

DR. ANDERSON: Well, the smallpox vaccine was outsourced to a company,
and I am curious to see if they can do that, can they do diagnostic
tests as well?

DR. FEIGAL: Well, outsourcing would be one thing, but what we are
looking for is sort of the mechanism to develop commercial tests. What
one of the fears would be is that, if you have an effective public
health response that can deal with the problem of a certain size, what
happens if that problem expands beyond that, and overwhelms the public
health response?

And are we in danger of having the public health response actually blunt
the incentives to develop a commercial response, so that there isn\'t a
commercial backup. If you needed this test for hundreds of people in
every hospital in the United States, I am assuming that would be a
stretch for the CDC.

AUDIENCE: I think Dr. Peiris had a comment.

DR. FEIGAL: Sure.

DR. PEIRIS: The same issue that I think that CDC was addressing about
maybe a company coming over to our lab and evaluating their test
on-site. We would have less problems I guess than CDC, where they would
have to be equally open to every company. I think we would certainly
welcome that.

Obviously we can\'t all host more than one or two people at the same
time, but that is certainly possible from our point of view.

DR. ZAMBON: I think it is important to remember, in the public sector
your priorities are to ensure public health virology, and you have got
to be absolutely clear when you are working with industry that, if you
do, you work where interests coincide. You cannot be driven by the
imperatives of industry in any way, shape, or form.

And I think the CDC view is similar to that taken by the U.K.
government. We don\'t \-- we try to adopt a very even-handed approach in
whatever we do with companies. And that in practice may mean that we
don\'t do anything very much with any company, because we just don\'t
have the resource, the people or the space for it to be done.

DR. ROBERTSON: And that is not to demean the company\'s interest in
public health, either. It is just because we have limited resources.

DR. FEIGAL: Let me ask the companies that are here if you are willing to
speculate, but is there anybody who feels that they would have a
commercial test available for hospitals this fall?

DR. KOZIARZ: Well, speaking for Abbott here, David, we are with our
partner, ARTIS, we are preparing an IDE, and we will be coming in very
soon, and so I guess depending on the regulatory cycle \--

DR. FEIGAL: So you are preparing to do an IDE, but of course you will
have \-- you need to have another outbreak of disease in order to study
the test under an IDE.

DR. KOZIARZ: Depending on again how we would position a first generation
test here in the United States, and be ready, your answer is yes. But
again, we are looking toward the possibility that there will be a need
for a commercial test, that the industry\'s ability to scale and to
distribute would be important in a situation like that, and so we are
taking those steps.

Now, yes, we are sort of stuck \-- if you will \-- by the seasonality or
the finality of the outbreak, but that is something that we are just
going to have to address as we go forward. And I think it is part of a
discussion of the IDE with the agency, as to how we would proceed.

DR. ZAMBON: I think the question of how diagnostics are rolled out is
one that probably \-- well, we have thought about, but that we have not
solved. And maybe, like CDC, we would consider how to roll out
diagnostics to particular laboratories in the United Kingdom.

Because it is a question that we keep being asked: how would we cope if
the thing explodes again? And if the thing explodes again tomorrow and
it explodes again in Europe, let\'s say, then we will be faced with a
situation where we have a very central laboratory capacity, which is not
ideal.

But the next immediate move would be \-- in the absence of a licensed
commercial test \-- is to roll out PCRs that we know work, that we can
specify exactly what goes in them, to certain designated laboratories in
the U.K. And that would be the way that we would go.

It would not be dependent on commercial PCRs, and it may be that we have
less of a regulatory framework in the U.K., where we could actually
envision that happening fairly quickly.

And I think it would be our preferred outcome that there were a clearly
definable confirmatory strategy, because it is not only the ability to
test a sample. It is also to confirm it, because there are an awful lot
of public health actions consequent on a positive sample which you need
to have in place, and that is the thing that is difficult to achieve.

It is simply not doing the testing, but it is having a confirmatory
strategy.

DR. FEIGAL: And is the confirmatory strategy usually involve the host
response?

DR. ZAMBON: No, by that timing, that if you get a PCR positive, you
should have the capacity to seek what is immediately your product,
let\'s say, or do another PCR, using a different target with a different
strategy.

And for us in practice in the U.K., there are very few labs that have
that capacity. So there are lots of labs clamoring for diagnostics, but
when you actually home in and ask the question: well, how are you going
to confirm? That is where you have the difficulties.

MS. HYMNS: I am Rosemary Hymns with the Association of Public Health
Labs, and I think that Betty Robertson made the point that the testing
that CDC develops and then transfers out to the state public health labs
is really critical in the public health response.

State epidemiologists are making decisions about quarantine, isolation,
control, and certainly with West Nile, and with all the decisions about
whether or not to spray or not to spray, and when unvalidated tests are
maybe being done in the private sector, it is very difficult to use
those test results to put public health control measures into place.

And for our public health labs, that has been a great advantage of the
technology transfer out of CDC. Those tests are developed and
standardized. Training, reagents, standardized methods are deployed to
the state public health labs. And it allows for a much more controlled
and effective public health response.

DR. FEIGAL: What would happen \-- what State are you from?

MS. HYMNS: I am from the Association of Public Health Labs, where we
work with all \--

DR. FEIGAL: I know that you are all around the place, but I was just
going to pick on whatever State you are in. But if whatever State you
are from, and we can leave that confidential information here, but if
whatever State you are from, what would happen if you had a Hong Kong
sized outbreak, in terms of your laboratory network responding to that?

MS. HYMNS: You are absolutely right. It is a huge burden to the public
health labs. We saw it last summer with the West Nile. There were two
impacts of that. One was the burden to CDC to produce adequate reagents
to supply the public health labs, and the other was for the public
health labs to keep up with the volume of testing.

So testing did move into the private sector. I think there is two
differences. One is, we are talking about a public health response. Once
a disease is endemic in an area, the public health response is in place,
and testing in the private sector has less impact on public health
response.

Then it becomes more of an individual case management situation, where
you might be relying on a non-validated test, but the clinician is
making decisions based on clinical presentation, exposure history, all
of those sorts of things.

And in those cases then, those test results can move into the public
sector to be confirmed, but then you are talking about delay, certainly.

DR. KOZIARZ: Can I ask a question?

DR. FEIGAL: Yes.

DR. KOZIARZ: I am curious as to why you are discerning the CDC test as
being validated and an industrial test as being unvalidated. Could you
help me out on that?

MS. HYMNS: It depends on how you define validated, and believe me we
spend a lot of time talking about that.

DR. KOZIARZ: It depends on how you would define a lot of things, but I
am just curious as to how you got to that distinction?

MS. HYMNS: By validated, we mean that CDC has run this assay against
known positives. There is at least some demonstrable performance
criteria that has been set. You are right \-- it has not met a broad
definition of evaluation and validation, and I think that is the
challenge anytime there is a new disease \-- is how do you develop a
test?

Where the benefit is, is that we have certainly something that has been
standardized. And in a new disease that is probably the best that we can
do.

DR. KOZIARZ: It could very well be that any company in industry could
come to you and probably show you more data than perhaps you are seeing
with the CDC test. Would you consider that more validated than the CDC
test?

MS. HYMNS: I think that this is part of the whole issue of public health
response. It is not any one person\'s decision. It is a decision about
how you are going to respond based on a test.

DR. KOZIARZ: I am just curious \-- again, I am outright being defensive
\-- on why the industrial test would be unvalidated just escapes me.

MS. HYMNS: Unvalidated is a difficult word to define in the context of a
new disease. It is not like an HIV test, where you have standardized
validation panels. The public health sector is relying on CDC to develop
a test and validate it, using the best materials that are available.
Maybe Betty or Larry can address this better than I can.

DR. KOZIARZ: The CDC is providing that to you under an IDE.

MS. HYMNS: In the case of SARS, yes.

DR. KOZIARZ: Okay, yes.

DR. FEIGAL: I mean, one of the real challenges \-- it is the diversity
of the way that laboratory and diagnostics come to market now \-- is
that there certainly are tests that are developed at single
laboratories, a university laboratory perhaps, or another, and you never
really do know what the access was for it to clinical specimens, or
other types of issues.

And that is even an issue for any central lab with a home brew. It is
one of the things that gets blurred because of the lack of \-- or the
fact that the CLIA process doesn\'t or isn\'t designed to pay any
attention to whether a test is investigational or not.

And so the tests have to be offered for the first time when it is
offered in a home brew format, and historically I suspect a great
majority of those have never had any informed consent, have never been
presented as investigational tests.

Probably, in the setting of genetic tests, because the confidence that
the laboratory has in their ability to measure genetic material with the
use of their analytes.

But I think that is some of the challenge, is that there is a great
range of diagnostic tests that are made available, and there is
currently not a standardized review.

DR. ANDERSON: And I think \-- to me, one of the things that could well
come out of this meeting is the issues, but then some cooperation and
collaboration among interested parties, including the FDA, in terms of
guidance.

You know, what is the requirements? What can we actually do to make sure
that we have got specimens characterized in the way that they should be,
to meet FDA requirements, that we have done the best job possible in
getting the numbers and types of specimens there, such that we can
actually get there in an efficient fashion.

And I really think, as a follow-up to this, that it would be really
useful to have a little more detailed dialogue, to actually have a plan
for being prepared, rather than: \"We need to be prepared. We need more
specimens. We need a specimen bank.\"

That just is not enough detail to get us there in an efficient fashion.
And we need FDA\'s help on this.

MR. SCHOCHETMAN: Hi. Gerry Schochetman, Abbott Labs. Just sort of
listening to this about sample collection, I mean, we sort of have two
issues. We have the retrospective issue and the perspective or possible
perspective issue. Retrospectively the epidemic has occurred \--
whatever samples were collected were collected. And one could put out
RFPs or do whatever is necessary to collect those specimens.

But then we are talking about \-- what if the epidemic comes back? And
the question then becomes: what are we going to be collecting? We are
talking about funding repositories and putting things in repositories,
but have we defined what it is that we want to collect and what is
necessary?

Have we defined what the ultimate uses are going to be? Are they going
to be for regulatory submissions? Are they going to be for research
purposes? Are they going to be for a combination of things?

And I think what may be useful, and I think what Larry was just trying
to touch on, was for the future is to define what the true needs are,
and consider preparing the appropriate funding mechanisms to deal with
those once the \-- or if the epidemic comes back so that we are ready to
move to the right source, the right sites, and collect the appropriate
specimens, so that we don\'t have this whatever-is-available kind of
thing and we sort of do it as an afterthought.

DR. FEIGAL: I think that comment is right to the mark of what this
conference is, and if today we can identify the kinds of questions that
can lead us into a follow-up to put together the process to answer
those, then perhaps we can make some progress.

It is interesting to think about what some of the different incentives
are. If in fact you have a blood-borne pathogen like West Nile, then FDA
is in the unusual position of both evaluating and approving the test,
and also requiring that blood banks in the United States apply that to
the 14 million units of blood that are drawn.

And so it doesn\'t matter if West Nile doesn\'t come back. Once FDA
requires it, you have got your commercial incentive, you have got your
market for doing that. One of the questions is: How do we build the
commercial incentives? Or how do we build the incentives for the
development of tests, as a way of supplementing having a highly
competent public health response that can quickly mobilize for a new
threat?

So far we have been sort of developing the theme that we get an
effective public health response, and then we look for how to make the
handoff between the public health response and the commercial
development.

Another idea which was touched on this morning was the idea of
multiplexing, or developing tests for multiple purposes. And let me put
Dr. Gutman on the spot \-- since I have made somebody from CBER stand up
once already, it is only fair to ask Steve to stand up.

Steve, how would we develop a multiplex task. if someone were actually
trying to develop a good diagnostic to use during the flu season that
would look for influenza, that would look for pneumococcal pneumonia,
look for macroplasm, look for the common things, but also might have
tucked in there an experimental assay for an emerging pathogen \-- like
SARS \-- that would almost be a surveillance network, if you were, but
serve the much more useful function on a day-to-day basis of getting
more accurate diagnosis for the common pathogens that still kill more
people than SARS?

DR. GUTMAN: Oh, it would actually be quite easy. I don\'t mean to
suggest that we don\'t actually understand the route of looking at
whether it is the most plebeian or whether it is the most sophisticated
product in looking at products.

The problem is that we have a very traditional approach towards
products, and so we constantly look at products and we compare them
either to a predicate \-- if it is a 5-10K \-- or to some established
laboratory algorithm or clinical algorithm, that we can cast \-- if not
true sensitivity and specificity, then at least present agreements so
that we can label a product and people can use it intelligently.

So my answer to you would be that it would be easy to look at a
multiplex, and it would not matter whether there is five signals or 500
thousand signals. What drives us is the claim. If the claim is
influenza, then we are going to look at it against an influenza culture.

If the claim is RSV, we are going to look at culture. If the claim is
SARS, we are going to call it an investigational device, and we are
going to ask people to collect data.

And that is the essence of the issue here, is that we are very
comfortable when you are not quite at this cutting edge, and you are not
throwing it at us simulated samples, and you are not throwing at us
animal models, but when you are throwing at us real end points, we are
really good at this.

And in fact I think that Dr. Anderson has put a beguiling issue on the
table, and it may be more than the panel can handle this late in the
afternoon, but in fact the agency, as brilliant as we are, is not the
custodians of all knowledge. And particularly in the area of SARS, we
are tremendously dwarfed by that end of the room, or maybe even that end
of the room, because we don\'t have a lot of on-line experience dealing
with SARS in a research setting and a clinical setting and a statistical
setting.

So the issue is, it would be very easy for me \-- following the
traditional mantra \-- to say that the simulated studies are great, the
animal studies are great, and five samples from Hong Kong are great, and
we have a great IDE, and run with it, and we will help you get it out.

But if you want to push further and if you want a commercial product,
and you want to push us further, then we are looking for partners to
help us make a rational decision, one that passes the laugh test, and is
credible to say that it is not an investigational device.

There is enough information to carry it over the threshold and give it
some status of provisional approval or total approval. And if that\'s
\-- you know, I don\'t know if I can put it back on the shoulders of the
panel to address where they think the threshold is, or maybe that is
really too much, we need to set up some kind of working group that is
interagency or that involves industry in some way.

We can write guidance; we can write a draft guidance. I don\'t know that
we would get it right, and the whole purpose of having either this
dialogue or a dialogue is to try and get it as right as we can.

DR. FEIGAL: That didn\'t answer my question, but that is all right. I
will just graze it as a speculation to think about. Wouldn\'t it be
interesting to use the capability of multiplexing to simultaneously
provide the clinical community with tests that are established and
useful, but at the same time provide the investigational parts of
diagnostic companies, performance data, on experimental tests.

And perhaps you would have two formats of a multiplex test that you
could offer a patient to participate in, and one that they don\'t need
informed consent, and it has got the usual suspects, and another one you
put in place that has others.

I don\'t know how often this occurs, but we are told with certain types
of pacemakers, for example, that there are sometimes features embedded
in pacemakers that are not turned on, because the indication is not
approved yet, and the pacemaker already has approved functions, and
those are put in the patient.

But if the approved functions every prove themselves, then you can go
back and turn them on. And thinking back to the early days of HIV, there
were anonymized specimens, there were a whole number of things that went
on.

Could you in fact do public health surveillance, even looking at things
that would not be very be very helpful to the clinician \-- like
serotypes and other kinds of things \-- with the ability to do 255 or
10,000 tests at a time?

Do we need to change our whole way of thinking about diagnostics to
actually take advantage of the future, instead of the \-- is it E.F.
Hutton that does one customer at a time, the old fashioned way? And
that, I think, is what you were saying, that we do pathogens the old
fashioned way, one organism at a time.

DR. GUTMAN: Well, I actually think that there are models. My guess is
that a lot of companies, certainly if they listen to what I tell them,
will come in with narrow claims on a product, and while in fact it may
not be quite as fancy as a microray or a multiplex, but they will take
the limited claim and they will run with it, and frankly it will be used
off-lbel.

As I understand it, that is perfectly legitimate and legal, as long as
they don\'t promote it for that use. And frankly they can certainly use
it to accumulate data, hopefully, depending on the way that the data is
collected, either under an IDE, an abbreviated IDE, or a very deliberate
exemption from the ID because of the way that the data is not presumably
not being used \-- although it would still require human subject
protection.

So I think the model might actually exist now, and maybe we can dust it
off and refine it.

DR. FEIGAL: We are getting close to 5:00. What I would like to do is to
come down the panel in order, so that you get the last word. Unusual for
the FDA ever to cede that, but we will do that in this case.

And I would like to ask each of you: If you could recommend a single
thing that would be the most important thing to do if the infection
comes back, to be prepared for it in the diagnostic realm, what would
your recommendation be?

Here you have together public health organizations, you have the
regulatory bodies, you have many manufacturers. You have many
researchers. What would be your recommendation? What do we need to do,
in case this comes back?

DR. PEIRIS: In relation to diagnostics, obviously we need to have
validated diagnostics that will help us to diagnose patients early and
accurately, but in addition to that there aren\'t many other things that
\-- say from sitting in Hong Kong we would like to know, for example,
there have been so many antivirals that have been screened. Which of
those are effective? I mean, we have not heard any such information
coming back in.

DR. ROTH: From our point of view, it was mentioned from the WHO\'s point
of view, and obviously the same needs that have just been described and
the needs for rapid diagnostic tests that can be used early in the
course of disease.

But I would say that our absolute priority at the moment is to take the
good candidates\' assays, which have already been developed, and which
have been used quite widely in different centers and perform an
evaluation of them so that we will be prepared, if it comes back, to
pick out of these tests the best tests that can be most appropriately
applied in a given situation and be ready to go with those.

And these may require further development at this stage in order to be
prepared, or they may simply require adequate production. But I think we
won\'t know that until we perform this evaluation, and I think it should
be performed soon.

DR. LAMBERT: Until you threw diagnostics in there I would have said
vaccines. I agree with what - maybe it was Larry \-- Someone said we
have what we have now because things were so busy. I think frankly the
most important thing \-- I don\'t know if we will have a diagnostic that
can widely distributed and something that can be widely available in an
implemented hospital. I just don\'t know.

But I think what we do need to be is all on the same page about what \--
if we get another crack at this, which some of us hope we probably never
do, and some of us hope that we might, we have to be organized,
coordinated, and we need to know what we are collecting, and it needs to
be \-- you know, blood specimens, BALs, whatever it is I think that
that\'s the most critical.

And as Maria said, if it happens tomorrow or it happens a few weeks from
now, the diagnostics are probably not going to be on line and so let\'s
not be in the same situation we are now six months from now or a year
from now.

DR. ROBERTSON: I am going to follow up with that from the diagnostics
perspective initially and then I have another comment that I would like
to make. I think that to plan ahead like you said, and to know what kind
of samples we want to collect and when to collect them, and to do
proactive and prospective planning as Jerry mentioned would be very
valuable.

In the midst of the outbreak, it was extremely difficult because you had
10 million things in your head at one time, and I know that Malik
appreciates that more, as do the people from Taiwan.

The other comment that I would like to make is I think that from a basic
perspective, I think one of the most important things that we still need
to figure out is what was the source of this transmission, so that if we
can prevent that in the future, we don\'t have to worry about this
disease again.

DR. GIOVANNI: So this is again NIAID. I think when we look at what we
want to actually do in the area of diagnostic and technology
development, I think one of the most important things that we see ahead
of us is really looking out into the future and actually partnering with
the research community, industry, and government agencies so we can
actually look into the future and see not the diagnostics of today, but
the diagnostics of a couple of years from now so that we are really
looking into the future.

Because what we support today in making decisions today will really have
an impact in where we are going. So I think we look for partners to
actually help us as we plan ahead in our agenda for technology
development.

I think what we are also hearing from the research community and the
scientific community is just well documented specimens that they can
actually get their hands on to do research, to do technology
development, and characterizing the specimens is actually what we see as
being really important so that we can get samples that we can actually
give to people.

DR. ZAMBON: I have got three things on my wish list. Number one is a
better database infrastructure, and in particular the use of web-based
databases so that you can link the clinician and his sample taking with
the epidemiologist and his desire to know about demographics with the
laboratory and what they get in samples and what they get in results.

And you want that as a single unified database, and so that is a
bioinformatic approach. The second thing that I would like to see on the
wish list is a better understanding of how to deploy the nucleic acid
diagnosis strategy so that it is not down to one test, but combinations
of tests and an understanding of how they can be used to give good rapid
confirmation very fast.

And the third thing is along those lines good serological screening
strategies which allow for high throughputs - rapid data delivery, and
again that goes to the database. If you have got a good database, you
can feed that information out to whoever needs to know it immediately,
and that makes your information capture and your linkage of information
easier. So those are my three objectives for the next few months.

DR. YOUCHAN: I think the public health authorities have a lot of
experience of the epidemiologies of the infectious diseases. They know
what kind of assays that the pubic has needed, and they also can connect
through many samples from the different societies. The manufacturers
have a lot of experience to make the documents to submit to the FDA.

They also have a lot of the experience of the standardization of those
assays. If the public has this, and the manufacturers join together so
they can make the assays pass or meet the requirements of the FDA, it
will go faster. So let\'s make the assays become available much more
quickly so that they can be used to help the public health. And this
should be - passing should be the better way.

DR. ANDERSON: I guess I will concur with the things that have been said
so far, because I think it lists some of the really key and important
factors that we need to do and just highlights the power and the
importance of cooperation and collaboration. I think it is going to be
important not to let that fall by the wayside, but continue the dialogue
that was begun today and at other times, and make sure that we actually
follow through and get these things done.

DR. KOZIARZ: I would just concur with your concurrence, but also I would
say that if the issue here is that the virus is going to reoccur, and
this type of outbreak is going to reoccur, then I would hope that we
would be in a position to deploy the diagnostic testing as quickly as we
can and that we sort of get past some of the complexity that we talked
about today, because we can sort of plan ourselves into a corner where
we won\'t be able to move forward.

And I would really like to see the flexibility that if the need is there
that tests that are currently potentially available and could be
deployed are somehow \-- that if we have a plan in place then we can get
those to the right place, because again we can talk alot about getting a
great sample base, but if that becomes a pacing item to being able to
deploy the assay, we may find ourselves in a potential crisis.

So I guess my wish list is to understand and accept the situation as we
have it today, and still find if there is a way for us to get safe and
effective assays on to the marketplace.

DR. NORWOOD: Well, there is not much left to say. I am not going to
concur. I am going to reiterate what I said earlier. I think that the
need for well-defined standards for widespread use, and to do
comparisons of assays and technologies from a wide variety of sources is
a necessity for moving forward. Thank you.

DR. FEIGAL: Well, we have reached our time. Mac, you have had a tough
time today as my co-moderator here, and we were afraid that there was
not enough room up here and so Mac allowed me to lead the discussion.
But let me thank all the panelists and all of those who participated
earlier.

I think that we have accomplished an important objective today, which
was to get some discussion of the different aspects that would really
focus on in being prepared for probably the thunderstorm, and we can
look out and see what it will be like when the lights go off.

But I think that the iterative nature of the development of diagnostic
products and the iterative nature of science should give us some of the
tools that we need to be able to deal with the next outbreak if it
comes. And if not perfectly, we should at least be able to say that we
are better prepared and that we have more in place than we had this last
time.

Not forgetting for a moment actually how effective the public health
response was to this and the tremendous number of hours and hard work
that was put into being able to say that there have been no new cases.
So may we learn from this episode, and may this help us prepare not just
for this agent, but for other things as well, and let me wish those of
you who have come from far distances safe travel back home, and thank
you all.

(Applause.)

(Whereupon, the workshop was concluded at 5:05 p.m.)