TRAINING CURRICULUM For Asia Regional Training Program (ARTP) on MODS, NRA and CRI

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1 TRAINING CURRICULUM For Asia Regional Training Program (ARTP) on MODS, NRA and CRI AT TB LABORATORY Division of Clinical Microbiology Deparmen of Laboraory Medicine All India Insiue of Medical Sciences, New Delhi, India For and in associaion wih he STOP TB Parnership New Diagnosic Working Group Organized By: PROF. SARMAN SINGH, MD, FRSTMH, FAMS Course Direcor, ARTP Head, Division of Clinical Microbiology Deparmen of Laboraory Medicine All India Insiue of Medical Sciences, New Delhi India

2 Inroducion Mulidrug-resisan uberculosis is an increasing public healh concern in many pars of he world, especially in low-income counries, where mos cases occur. Tradiional drug suscepibiliy esing is eiher imeconsuming, such as he proporion mehod on solid media, or expensive, such as he BACTEC 460 sysem. Commercial liquid culure sysems and seleced molecular assays have been endorsed by he World Healh Organizaion (WHO) as gold sandards for rapid deecion of mulidrugresisan uberculosis (MDR-TB); however, due o echnical complexiy excep Xper TB MTB/RIF, cos and he need for sophisicaed laboraory infrasrucure, upake of hese echnologies has been limied in many resource-consrained seings. WHO sill recommends he use of phenoypic assays o monior reamen progress and o deec resisance o drugs oher han Rifampicin. Therefore, several non-commercial culure and DST mehods have been developed a he same ime, aimed a use in laboraories ha lack access o more sophisicaed infrasrucure and echniques. Among hese, he following mehods were recenly assessed by WHO (WHO policy saemen, July 2011). m m m m Microscopic Observaion Drug Suscepibiliy Assay (MODS): A microcolony direc mehod in liquid culure, based on inoculaion of specimens o drug-free and drug-conaining media followed by microscopic examinaion of early growh. Nirae Reducase Assay (NRA): A direc and/or indirec mehod based on he abiliy of M. uberculosis o reduce nirae, which is deeced by a coloured reacion. Colorimeric Redox Indicaor (CRI) Mehods: Indirec esing mehods based on he reducion of a coloured indicaor added o liquid culure medium in a microire plae afer in viro exposure of M. uberculosis srains o ani-tb drugs. Thin Layer Agar (TLA): A microcolony direc mehod on solid culure, based on inoculaion of specimens o drug-free and drugconaining media followed by microscopic examinaion of early growh.

3 m Phage-based Assays: Assays which uses baceriophages o infec and deec he presence of viable M. uberculosis in clinical specimens and culure isolaes. CRI mehods, MODS and NRA were subsequenly judged o have sufficien evidence o consider heir use in laboraories ha lack access o more sophisicaed infrasrucure. WHO has recommended he selecive use of one or more of he following non-commercial culure and DST mehods, in reference laboraories, and under sric laboraory proocols, and as an inerim soluion while capaciy for genoypic and/or auomaed liquid culure and DST are being developed. MODS, as direc or indirec ess, for rapid screening of paiens suspeced of having MDR-TB. NRA, as direc or indirec ess, for screening of paiens suspeced of having MDRTB, and acknowledging ha ime o deecion of MDR- TB in indirec applicaion would no be faser han convenional DST mehods using solid culure. CRI mehods, as indirec ess on M. uberculosis isolaes from paiens suspeced of having MDR-TB, and acknowledging ha ime o deecion of MDR-TB would no be faser (bu less expensive) han convenional DST mehods using commercial liquid culure or molecular line probe assays. To achieve he above goal he culure subgroup of he STOP TB Parnership NDWG (NDWG-CSG) recommends our laboraory seup (TB Laboraory, Division of Clinical Microbiology, Deparmen of Laboraory Medicine, AIIMS, New Delhi , India) as a referral raining cenre for hese newly endorsed non-commercial TB diagnosics and Drug Suscepibiliy Tesing in Asia region. On behalf of he NDWG-CSG recommendaion, we organize a raining o full fill he above global goal.

4 Purpose of he Training This raining has been designed o aware he applicaion and implemenaion of he NRA, MODS and CRI echniques for simple, rapid and inexpensive deecion mehods of M. uberculosis in lowresource laboraories/ developing counries. The goal of he programme is rain he mycobaceriologiss, and echnicians working in Naional TB Programmes (NTP) from Asian counries who afer his raining course will be able o carry ou high qualiy pracice in he field, managemen of MDR-TB in heir represenaive counries and will be able o rain ohers in hese mehods based on experience gained during he raining course. Wha is Included in he Training? In his advanced raining he paricipans will learn he principles behind uberculosis diagnosics and various exising mehods for TB diagnosis. The raining curriculum has wo secions. Basically, firs par will be based on heory and i will help paricipans o undersand he nex session. Paricipans will receive Sandard Operaing Proocols and documenaion for laboraory biosafey. The second main par will involve he basic mycobacerial laboraory exposures and much of pracical exposures on NRA, MODS and CRI mehods. Paricipans will have direc, hands-on experience on hese mehods. Principle and hands on workshop on NRA. Principle and hands on workshop on MODS. Principle and hands on workshop on CRI mehod. Principle and hands on workshop on firs and second line DST by MGIT-960. Observaions and inerpreaions of es resuls.

5 Who should paricipae in he Training? The raining will be bes for Clinical Microbiologiss, Mycobaceriologiss, and Laboraory echnicians who are engaged in uberculosis diagnosis. This raining will help paricipans, o acquire he necessary heoreical knowledge and pracical skills on rapid diagnosis of uberculosis and MDR-TB wih he NRA, MODS and CRI mehods. Number of Paricipans Maximum 10 o 12 paricipans will be seleced/ called o aend he raining programme per round. More number of paricipans can hinder he opporuniy for each member o have adequae ime o share and hands-on exposure. When is he Training Conduced? Quarerly Quarer 1 Quarer 2 Quarer 3 Quarer 4 Monhs March June Sepember December How o apply? For applicaion and inquiries please conac PROF. SARMAN SINGH Division of Clinical Microbiology, Deparmen of Laboraory Medicine, AIIMS, New Delhi , India. Phone: (91-11) , Fax: (91-11) , You can also download he form from hp://

6 Training Agenda LABORATORY TRAINING ON Idenificaion and Drug Suscepibiliy Tesing of Mycobacerium uberculosis Reference Training Cenre for Asia region in associaion wih culure subgroup of he STOP TB Parnership NDWG (NDWG-CSG) Tuberculosis Laboraory, Deparmen of Laboraory Medicine, New Delhi, AIIMS TRAINING SUMMARY DAYS SESSION TITLE Day-1 (Monday) Day-2 (Tuesday) Day-3 (Wednesday) Day-4 (Thursday) Day-5 (Friday) Day-6 (Saurday) Day-7, (Sunday) Inroducion and opening he raining Basic conceps and Biosafey pracices Principles and preparaion of MODS and NRA Demonsraion of specimens processing of MODS and NRA Pracice of MODS processing Pracice of NRA processing s Pracice of CRI assay-1 line drugs DST nd Pracice of CRI assay-2 line drugs DST s Demonsraion of 1 line DST by MGIT-SIRE ki Pracice of MODS processing. nd Demonsraion of 2 line DST by MGIT Free Free day Day-8 (Monday) Day-9 (Tuesday) MODS reading and inerpreaion* NRA reading and inerpreaion * CRI reading and inerpreaion * Open quesions and general review Day-10 Wednesday) Day-11 (Thursday) Day-12 (Friday) MODS reading and inerpreaion NRA reading and inerpreaion CRI reading and inerpreaion Theoric es of key conceps MGIT, MODS, and NRA reading Final review and raining closing *Readings MODS, NRA and CRI of es prepared previously (a week early) for he raining.

7 Day 1, Monday Opening and Basic Conceps 1 Welcome and opening of he course am Inroducion of paricipans Inroducion o TB diagnosis and raining programme Day 2, Tuesday Principles and preparaion of NRA and MODS implemens, and demonsraion of he process 1 Inroducion and principle of NRA and MODS am Provide copies of specimen processing Sandard Operaing Procedure manual for NRA and MODS - Required equipmens, supplies, reagens and serilizaion of maerials o be used. Biosafey and working area Preparaion of maerials and reagens Preparaion of drugs Drug poencies am 10: am Preparaion of anibioics socks soluions am Sorage of drug sock soluions Preparaion of Middle-brook 7H9 media Preparaion of he media (describe) Preparaion of egg-based media Löwensein-Jensen (LJ) media wihou drugs pm Preparaion of egg-based media Löwensein-Jensen (LJ) pm media conaining drugs 7H11 media 2 Demonsraion of specimen processing: MODS, NRA pm Sorage of deconaminaion samples of NRA and MODS as a back-up am pm 2 Biosafey pracice in he laboraory (General and BSL2 & 3) pm Inroducion wih essenial equipmens: uses and rouine mainenance Inroducion o Liquid culure handling: Skill Assessmen, pipeing, aped work areas, pouring ec) Overview of Paricipan Experiences and Basic Conceps pm pm pm pm

8 Day 3, Wednesday Pracice of MODS and NRA procedures 1 2 Pracice MODS Preparaion of media aliquo for: Specimens, negaive and posiive conrols and anibioic working soluions. Deconaminaion of specimens Preparaion of final sample suspension and back-up. Final MODS plae preparaion Plaing ou he posiive inernal qualiy conrol srains Day 4, Thursday Demonsraion and inoculaion of CRI assay for firs and second line ani-uberculosis drugs suscepibiliy esing am am am am * Plae reading for MODS pm Pracice NRA Preparaion of McFarland 1.0 inoculums: Inoculum from growh on solid media Inoculum from a liquid media Diluion of he inoculums Inoculaion and incubaion of NRA ubes *Reading NRA ubes *Readings MODS, NRA and CRI of es prepared previously (a week early) for he raining :30pm 3:30 4:00pm 4:00 5:00pm 1 Inroducion and principle of CRI assay am Provide copies of specimen processing Sandard Operaing Procedure manual for CRI Serilizaion of maerials o be used, biosafey and working area Preparaion of working drug soluions 9:30-10:00am am Preparaion of inoculums: Inoculum from solid medium pm Inoculum from liquid medium Demonsraion and inoculaion of he CRI (REMA/MTT/Alamar Blue) plae For firs-line drugs: STR, INH, RIF, EMB pm 2 Demonsraion and inoculaion of he CRI pm (REMA/MTT/Almar Blue) plae For second-line drugs: PAS, ETH, KAN, OFLO, CAP

9 Day 5, Friday Demonsraion of firs line DST by MGIT-960 ki and pracice of MODS processing 1 Inroducion and principle of he DST by SIRE ki am Provide copies of specimen processing Sandard Operaing Procedure manual for SIRE - Preparaion of reagens and maerials Serilizaion of maerials o be used, biosafey and working area Preparaion of drugs Drugs reconsiuion Performance of DST (SIRE) am pm pm pm 2 Pracice of MODS processing pm Day 6, Saurday Demonsraion of second line DST by MGIT 1 Inroducion and principle of he second line DST by MGIT am Provide copies of specimen processing Sandard Operaing Procedure manual Preparaion of reagens and maerials Serilizaion of maerials o be used, biosafey and working area am am Preparaion of drugs Drugs reconsiuion am Performance of DST (ETH, OFL, KAN,AMK,CPM) pm

10 Day 7, Sunday, Free Day Day 8, Monday Reading and inerpreaion of NRA and MODS resuls 1 Reading of MODS plaes * Afer 7 days of incubaion, will be repeaed a 9:00 12:00am day 9 or 11 days if required. Inerpreaion of resuls 12:00-1:00pm 2 Reading of NRA ubes * Afer 7 days of incubaion If no color change occurs, he procedure will be repeaed a :00pm day 10 or 14 days if required. Inerpreaion of resuls 3:00 4:00pm *Readings MODS, NRA and CRI of es prepared previously (a week early) for he raining. Day 9, Tuesday Reading and inerpreaion of CRI / Open quesions and review 1 Reading and Inerpreaion of CRI resuls * 10.00am-12.00am Quesions 12.00am-1.00pm 2 Open quesions and general review pm. Reading and inerpreaion of CRI / Open quesions and review *Readings MODS, NRA and CRI of es prepared previously (a week early) for he raining. Day10, Wednesday Reading and inerpreaion of NRA and MODS resuls 1 Reading and inerpreaion of MODS 10.00am-12.00am Quesions 12.00am-1.00pm 2 Reading and inerpreaion of NRA pm. Quesions pm. *Readings MODS, NRA and CRI of es prepared previously (a week early) for he raining.

11 Day 11, Thursday Reading and inerpreaion of CRI and Theoric Tes 1 Reading of CRI plaes 10.00am-12.00am Resuls and inerpreaion - Quesions 12.00am-1.00pm 2 Theoric es of key conceps (NRA, CRI, MODS) pm. Quesions pm. Day12, Friday Reading, inerpreaions of MGIT, MODS, NRA resuls and closing he raining. 1 Reading of MGIT DST Resul 9.00am-9.30am Inerpreaion of resuls 9.30am-10.00am 2 Observaion of MODS plae and NRA ubes 10.00am-12.00pm Inerpreaion of resuls 12:30 1:00pm 3 Final review and closing 2.00pm-5.00pm Reviewed he key conceps of he raining Pos-raining Quarries Knowledge exchange: principles of implemenaion research, collecing evidence for scale-up, cos-effeciveness analyses and modeling sudies in TB diagnosics and pracice of diagnosic research focused on accuracy of ess. Implemenaion of curren pipeline of TB diagnosics mehods and WHO policies on new diagnosic

12 PROF. SARMAN SINGH, MD, FRSTMH, FAMS Course Direcor, ARTP Head, Division of Clinical Microbiology Deparmen of Laboraory Medicine, All India Insiue of Medical Sciences, New Delhi, India

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