>> DELIGHTED TO HAVE YOU HARD CORE SCIENTISTS HERE TO HAVE YOU TALK ON TB DIAGNOSTICS. TB DIAGNOSE STATISTICS UNTIL RECENTLY HADN'T CHANGED FOR A HUNDRED YEARS SINCE THE DISCOVERY OF THE BUG. IT'S BEEN AN IMPEDIMENT IN THE DIAGNOSE, TREATMENT AND RAPID UNDERSTANDING OF THIS DISEASE, MORE SO THAN MANY OTHER DISEASES, AND PARTICULARLY IMPORTANT BECAUSE THIS IS SUCH A HUGE BURDEN OF DISEASE DUE TO TUBERCULOSIS. THE DEVELOPMENT OF DIAGNOSTICS HAS REALLY BEEN CHAMPIONED BY THE GATES FOUNDATION THROUGH THEIR PDP, THE DEVELOPMENT PROGRAMS, PROJECT DEVELOPMENT PROGRAMS. AND TB HAS BEEN IN SOME WAYS ONE OF THE STARS AND FIND THE FOUNDATION FOR INNOVATIVE DIAGNOSTICS, IT IS ONE OF THEM. SO I'M PARTICULARLY DELIGHTED TO HAVE MARK HERE TODAY WHO IS THE SCIENTIFIC OFFICER TO SPEAK TO US ABOUT HIS WITH FINDS ON TB DIAGNOSTICS AND AN INCREDIBLE INNOVATION AND RAPID DETECTION. MARK IS NO NEWCOMER TO NIH. HE TRAINED IN PEDIATRICS AT VANDERBILT, WAS CHIEF RESIDENT OF PEDESTRIAN TRACKS AND CAME TO NIH WHERE HE FOCUSED ON RESPIRATORY VIRUS INFECTIONS AND VACCINES, INFLUENZA. RETURNED TO DUKE TO VANDERBILT FOR FELLOWSHIP IN INFECTIOUS DISEASES AND WAS THE FIRST SENIOR FELLOW IN CLINICAL MICROBIOLOGY IN DUKE AND A FACULTY MEMBER AT BOARD CERTIFIED INTERNAL MEDICINE, PEDIATRICS, INFECTIOUS DISEASE, CLINICAL BIOLOGY AND TROPICAL MEDICINE. HE THEN JOINED THE TB PROGRAM AT WHO IN 1998, TDR, WHERE THE GROUP FOCUSED ON MANY TROPICAL DISEASES. AND THEN IN 2001, FUNDING FROM GATES TO THE TB PROGRAM LED TO WHOLE WHAT'S BEEN A TREMENDOUS EFFORT TO DEVELOP TB DIAGNOSTICS WITH NOVEL METHODS. POINT OF CARE DIAGNOSIS BEING ABSOLUTELY CRITICAL TO THE LONG TERM SOLUTION TO THE TB PROBLEM. MARK IS WITH US TODAY TO TELL US ABOUT THE HE -- EXCITEMENT AND NEW DIAGNOSTIC TEST FOR TB, APPLICATIONS, ITS STRENGTHS, WEAKNESSES AND CHALLENGES FOR THE FUTURE. THIS IS REALLY A REMARKABLE CHANGE IN DIAGNOSTICS THAT WE REALLY HAVE TO LISTEN TO AND SEE HOW WE CAN APPLY. MARK, IT'S A DELIGHT FOR ALL OF US TO WELCOME YOU BACK TO THE N IT H CAMPUS TO UPDATE US WHAT YOU'RE DOING ON TB DIAGNOSTICS. THANK YOU. >> THANK YOU ROGER FOR THAT INTRODUCTION. I WAS WALKING UP TO THE STAGE -- REMEMBER MY BRIEF TENURE THERE WHERE I SPENT AS MUCH TIME AS I COULD TRYING TO REINFORCE THE STEREOTYPE THAT SHOULDN'T BE LESS LOOSE IN THE LABORATORY WITHOUT SUPERVISION. I'M GOING TO TALK TODAY ABOUT TUBERCULOSIS AND SPECIFICALLY RAPID ASSAY DEVELOPED OVER THE LAST SEVERAL YEARS IN PARTNERSHIP WITH A COMPANY IN CALIFORNIA. I WANT TO PUT THAT TALK IN THE CONTEXT OF WHERE WE ARE WITH TB CONTROL AND ON SOME OF THE CHANGES AND EVOLUTIONS WE'RE THINKING ON TB AND THE ROLES SPECIFICALLY OF DIAGNOSIS OVER THE LAST TEN AND REALLY THE ASSAYS WE'VE BEEN DEVELOPING LATELY WOULD NOT HAVE MADE SENSE BEFORE THESE RECENT CHANGES IN THINKING HOW TB SHOULD BE CARED FOR HAPPENED. IN 1993, WORLD HEALTH ORGANIZATION THROUGH THE WORLD HEALTH ASSEMBLY CALLED SET UP -- DO YOU MIND IF I WALK AROUND. THAT STRATEGY IS CALLED THE DOT STRATEGY, VERY STRAIGHTFORWARD DIRECTLY OBSERVED TREATMENT SHORT COURSE THERAPY, SHORT COURSE FOR TB FOR SIX MONTHS. DIAGNOSIS MICROSCOPY. AND THAT STRATEGY WAS INTENDED TO INCREASE CURE RATES, INCREASE DETECTION RATES AND TRANSMISSION IDEALLY WILL SAVE LIVES, IT WAS ENFORCED OR INTRODUCE WITH VIGOR IN THE WORLD HEALTH ORGANIZATION AND IT'S PARTNERS AND THE PARTNER COUNTRIES. AND WAS HELD TO BE A GREAT SUCCESS AND I'LL SHOW YOU THAT INFORMATION. WHAT I WANT TO TALK ABOUT IN THIS DISCUSSION IS REALLY WHAT WAS THE ROLE OF DIAGNOSTICS THERE, WHAT WAS THE ROLE OF MICROSCOPY AND WHERE WE NEED TO [INDISCERNIBLE] TEACH EARN. THERE WAS CORE THINKING ABOUT THE STRATEGY AT LEAST WITH DIAGNOSTICS IN USING MICROSCOPY. THIS IS A PICTURE OF ROBERT -- STILL USED IN 18 -- WHERE HE WAS INTERESTED NOT SO MUCH IN THE DISEASES THAT WERE BOTHERING THE PATIENTS -- WISHED HE WOULD SO HE WOULD HAVE HIRE INCOME BUT HE WAS ALWAYS IN THE LAB LOOKING FOR PATHOGENS. ONE THAT WAS INTERESTED WAS THAT -- POPULATION, LOCAL -- ANTHRAX -- TO SEE ANTHRAX IN THE MICROSCOPE AND OF COURSE APPROVED -- WHICH WAS YET NEWLY FORMED. THIS MICROSCOPE THEN CAME INTO USE SIX YEARS LATER IN 1982 WHEN HE HAD MOVED TO BERLIN AND FOUND AS WE KNOW NOW THE CAUSE OF TUBERCULOSIS. THAT EVENT TURNED OVER NIGHT FROM HAVING MICROSCOPES TURNED INTO CLINICAL DIAGNOSTIC TOOLS WHICH WAS A COMPLETELY NEW IDEA AND HAS TURNED OUT TO BE FUNDAMENTAL EVER SENSE. TUBERCULOSIS DIAGNOSTICS WAS ESTABLISHED AS A MICROSCOPY SERVICE AS EARLY AS THE 19TH CENTURY, AND THAT REALLY HAS BEEN IN FACT THE PRIMARY TOOL FOR ALL DEVELOPING COUNTRIES ALMOST EVER SINCE. I'VE USED THIS SLIDE MANY TIMES IN THE PAST TO ILLUSTRATE REALLY WHY THE FIND WAS ESTABLISHED, THAT IS TO FIX A MARKET FAILURE OF THE COMMERCIAL SECTOR TO DEVELOP DIAGNOSTICS FOR DISEASES DUE TO POVERTY -- THE FIRST DISEASE TO BE WORKED ON. WE WORKED ON SEVERAL IDEAS. HOW TO DEVELOP DIAGNOSTICS FEASIBLY DEVELOPED IN COUNTRIES AND OUTPERFORM THOSE THAT E SIST. HOW DO HE REPLACE A 20 YEAR OLD DIAGNOSTIC WITH SOMETHING BETTER. SO THE FIRST OF THE THREE LESSONS OF INFORMED DIAGNOSTICS STRATEGY WAS THAT MICROSCOPY IS DOABLE. YOU CAN GET PEOPLE AND -- SEE THE ORGANIZISMS. THIS IS A PATHOLOGICAL FINDING ESSENTIALLY 100% SPECIFIC AT LEAST AT THE TIME OR LONGER THAT WE'LL TALK ABOUT LATER. THE SECOND FINDING CAME AS PEOPLE STARTED TO USE MICROSCOPES AND THEY USED THEM IN THE FIRST WHAT WERE EARLY OPERATIONAL RESEARCH CENTERS WHICH HAD BEEN POPPING UP ALL OVER NORTH AMERICA AND EUROPE SINCE THE BEGINNING OF THE 1800'S. THE SANTORUM WAS FILLED WITH INDIVIDUALS WHO GENERALLY HAD CHRONIC TUBERCULOSIS AND WERE ILL WERE MANY MONTHS, SOMETIMES MANY YEARS BEFORE YOU ENTERED THE SANTORUM. AS THEY BEGAN TO EXAMINE THE SANTORUM PATIENTS, THEY PRODUCED A PHENOMENA THAT PEOPLE TENDED TO FALL INTO TWO CLASSES. THOSE WHO WERE MICROSCOPY POSITIVE WHO HAD HIGH LEVELS OF THE SPUTUM AND THOSE WHO DIDN'T HAVE ANY VISIBLE TB IN THEIR SPUTEM. THEY WEREN'T ALWAYS DISSTINT SUBCOHORTS. WE DEVELOPED THEM OVER YEARS, CAREFULLY GRAFTED THE TUBERCULOSIS -- GO AWAY FOR A FEW MONTHS AND DO IT AGAIN. SO PEOPLE WOULD JUMP -- BASICALLY 50% MORTALITY. IF YOU GET INTO NEGATIVE TUBERCULOSIS PROBABLY MORTALITY ADAPTED AROUND 15%. THESE SEEMED TO BE DIFFERENT DISEASE CLASSES, THEY HAVE A DIFFERENT PATHOGENESIS, OR AT LEAST DIFFERENT BIOLOGY. THAT MEANT THAT NOT ONLY COULD YOU SEE THEM WITH THE MICROSCOPE AND THAT'S A DIAGNOSTIC FINDING, BUT ALSO THOSE WHO DETECT AND THOSE WHO ARE MOST LIKELY TO DIE. THAT SEEMED TO HAVE IMPORTANT IMPACT AS WELL. AND THE THIRD FINDING UNDER THE DIAGNOSTIC STRATEGY WAS ONE THAT'S BEEN REPLICATED IN MANY STUDIES SENSE. THIS IS IN THE -- AND YOU CAN SEE HERE THAT THESE ARE CHILDREN, THE INFECTION RATE AMONG CHILDREN WHO LIVED WITH A PARENT WHO IS EITHER SMEAR POSITIVE OR SMEAR NEGATIVE OR IE CULTURE NEGATIVE IE AND NON-TUBERCULOSIS. IF YOU LIVED IN THE HOUSEHOLD, YOU'RE MUCH MORE LIKELY TO BE INFECTED THAN IF YOU LIVE IN THE HOUSEHOLD WITH SOMEONE WITH A NEGATIVE DISEASE. FROM THOSE THREE PIECES OF INFORMATION THE WHO REASONABLY CONCLUDED WHAT WE HAVE TO DO IS MICROSCOPY WIDELY BECAUSE IT DETECTS FATAL DISEASE AND DETECTS DISEASE IN THOSE PATIENTS MOST CONTAGIOUS THEN WE CAN HAVE DISEASE CONTROL. IT WAS IMPLEMENTED TO GREAT EFFECT. THIS IS DATA FROM SOUTH INDIA BUT THERE ARE DATA FROM MANY PLACES IN THE WORLD THAT WERE LIKE THIS. WHEN I FIRST CAME TO W.H.O., WE WERE SENT AROUND TO DEVELOP THIS DATA TO CONFIRM WHAT WE USE WHICH IS IT'S WORKING. SO THESE STUDIES WERE TO THIS CONCLUSION BUT NONETHELESS THE DATA SEEMED QUITE CLEAR IF YOU GO FROM IN THE SETTINGS WHO WERE EXISTING IN SOUTH INDIA AND IMPLEMENT DOTS PUT EVERYONE'S RECORDS UP THERE FOR SIX MONTHS AND DETECT THOSE WHO WERE POSITIVE YOU GET DRAMATIC FALLS ANNUAL 10 TO 15% IN THE INSTANCE OF TUBERCULOSIS. NOW IT'S IMPORTANT TO REMEMBER WHAT KIND OF SETTINGS THESE ARE. THESE ARE SETTINGS WHERE PATIENTS ARE NOT GETTING REASONABLE TREATMENT, THEY'RE GETTING MONO THERAPY, THEY'RE GETTING NON-ANTIBIOTIC THERAPY, THEY'RE GETTING HOMEOPATHY. THEY'RE BEING DIAGNOSED BY X-RAY, THEY'RE BEING DIAGNOSED BY COMPETITION OS CULLATION, ETCETERA. THIS IS A MASSIVE IMPROVEMENT. THE PRIMARY IMPROVEMENT WAS IN MORTALITY. CURE RATES WENT UP, MORTALITY WENT DOWN AND CLEARLY DOTS WAS WORKING. IT WAS HALED AS ONE OF THE MOST COST EFFECTIVE HEALTH INTERVENTIONS ON THE PLANET FOLLOWED AFTER NEEDLES VACCINATION AND IT WAS RAPIDLY SCALED AROUND THE WORLD. SO FAR SO GOOD. AND THEN THAT WAS REALLY UP TO JUST ABOUT 10-15 YEARS AGO. AND THEN CHEATS BEGAN TO APPEAR. SOME COMPLAINTS FROM THE FIELD ABOUT PHYSICAL DOTS WAS IMPLEMENTED AND SOME CONCERN ABOUT WHETHER OR NOT IT WAS COMPLETELY EFFECTIVE GIVEN WHAT WE WANTED TO HAPPEN. SOME OF THE EARLY DATA MADE YOU WORRY A LITTLE BIT WAS THIS IS THE NUMBER OF COUNTRIES IN WHICH DOTS WAS SCALED UP. AND THIS IS A CASE DETECTION RATE. AND EVERYONE IMAGINED THAT AS YOU SCALE THE DOTS AND MAKE SURE THERE WAS MICROSCOPY CENTERS ALL OVER THE CASE SO DETECTION RATES WOULD GO UP, YOU WOULD BE DETECTING THEM EARLIER AND MORE THERAPY AND TRANSMISSION. IN THAT CASE THE RATES DIDN'T GO UP FOR A VARIETY OF REASONS. BUT THE IMPORTANT POINT, ONE OF WHICH IS PEOPLE WERE USING NON-MICROSCOPY METHODS -- THE OTHER THAT MANY CASES THAT ARE DETECTED ARE NOT NOTIFIED. THESE ARE NOTIFIED CASES. W.H.O. KEEPS, IF YOU WILL, A GIANT DATABASE FOR NATIONAL PROGRAMS. THAT'S HOW IT WAS REPORTED. THIS IS THE FIRST ANXIETY. MORE CLEAR DATA CAME FROM COUNTRIES THAT STARTED DOING DOTS VERY AGGRESSIVELY AND VERY WELL. SO THIS IS DATA FROM PERU WHERE WE DID A VERY LARGE AMOUNT OF WORK. THIS IS DATA LOOKING AT THE CASE DETECTION RATES, MORBIDITY AND INCIDENCE AND MORBIDITY AND POSITIVE. OVER TIME FROM THE EARLY 90'S UNTIL THE MID THOUSANDS. AS YOU CAN SEE, AS DOTS WAS INTRODUCED IN 1990, IT WAS AN IMMEDIATE BUMP AND CASE FINDING AS MICROSCOPY CENTERS WERE SET UP. AND THEN ABOUT A 6% DECLINE IN INCIDENCE YEARLY. AND THIS WAS THEN PUBLISHED AROUND 2002 AS AN EXAMPLE AGAIN CONFIRMING THE IMPORTANCE AND CRITICALITY REALLY OF DOTS IMPLEMENTATION TO CONTROL TUBERCULOSIS. THEN WE FOLLOWED THIS OVER TIME AFTER THE PUBLICATION AND FOUND IT INCLUDES A PLATEAU IN THIS INCIDENCE IN MORTALITY NUMBERS. WONDERED WHY THIS WAS. TRY TO CORRELATE THIS A LITTLE BIT WITH THE DELIVERY OF MICROSCOPY SERVICES. MAKE MICROSCOPY SERVICES HAS FALLEN OFF. WHAT'S REMARKABLE HERE YOU CAN SEE IN FACT THE PROGRAM, NATIONAL PROGRAM VERY HAPPY WITH THESE DOTS FIGURES -- MASSIVELY SCALING UP IN THOSE PARTICIPATING IN DOTS. YOU CAN SEE THE NUMBER OF SMEARS PERFORMED WENT UP DRAMATICALLY. SO HERE WE HAVE A SITUATION WHICH MICROSCOPY SERVICES ARE DELIVERED. THESE ARE AS WELL AS POSSIBLE, THEY'RE DOING THOUSANDS OF SLIDES. AT THIS POINT BY 2004, FOR EXAMPLE THEY ARE DOING 40 OR 50 EXAMINATIONS PER CASE DETECTED WHICH IS ABOUT SIMILAR TO THE U.S. RATE. SO THIS IS PRETTY AGGRESSIVE MICROSCOPY AND YET NO IMPACT ON INCIDENTS ON MORTALITY. SO WHAT'S GOING ON THERE. IF WE GO BACK AND QUESTION OUR ASSUMPTIONS AROUND THE PILLARS OF DOTS AND DIAGNOSTICS THERE. THIS IS DATA FROM SWEDEN, THE RAW DATA -- IF YOU LOOK AT THESE PATIENTS, THESE AT THESE PATIENTS THESE WERE SPENT IN THE HOSPITAL FOR MONTHS TO YEARS. THESE SAME CRITERIA DON'T APPLY TO PATIENTS THAT ARE MISSING IN CLINIC, THOSE ARE PATIENTS WHO ARE COMING IN WEEKS AFTER THEY STARTED COUGHING. THEY HAVE NOT DECLARED THEMSELVES TO BE SMEAR POSITIVE OR SMEAR NEGATIVE YET. THAT IS TO SAY EVERY SMEAR POSITIVE PATIENT NOW WAS A SMEAR NEGATIVE PATIENT. YOU JUST DIDN'T DETECT THEM. SO DETECTING PATIENTS EARLY MAY ALLOW YOU TO OBVIATE MORTALITY ALTOGETHER AND THEY MEAN THAT REALLY WE SHOULD NOT FOCUS SO MUCH ON POSITIVE VERSUS NEGATIVE IF YOU HAVE A WAY TO DETECT DISEASE IN GENERAL BESIDES THE MICROSCOPE. SO THE WHOLE IDEA THAT SMEAR POSITIVE AND SMEAR NEGATIVE WAS A DIFFERENT PATHOLOGY SEEMED TO MATTER LESS IN A MODERN PROGRAM WHERE WE PULL HAD ACCESS TO THOSE SERVICES. MAYBE THE MICROSCOPE IS THE PROBLEM AND NOT THE LACK OF DIAGNOSTIC SERVICES. THEN LET'S GO BACK AND LOOK AT THIS ASSUMPTION WE PULLED FROM THIS GRAPH. AND IT'S VERY INTERESTING, IT'S VERY CLEAR THE SMEAR POSITIVE PATIENTS ARE THE MOST CONTAGIOUS. BUT THE FACT THAT YOU CAN GO OUT INTO THE FIELD AND LOOK AT CHILDREN AND FAMILIES WITH SMEAR POSITIVE PATIENTS AND FIND THAT THEY ARE INFECTED AND THEIR OTHER COHORTS ARE NOT TELL YOU ALREADY THAT BY THE TIME YOU SEE A SMEAR POSITIVE PATIENT IN CLINIC, THEY'VE ALREADY INFECTED THEIR FAMILY MEMBERS. YOU'RE TOO LATE. SO THIS PATIENT NOW BECOMES IN MY MIND AND I'VE BEEN SAYING THIS FOR SOME YEARS AND SLOWLY GETTING TRACTION, OTHER PATIENTS WE NEED TO FOCUS ON BEFORE IT AFFECTS CO-WORKERS. THIS DIAGNOSTIC DELAY THAT HAPPENS IN PATIENTS -- PATIENTS JUST DON'T FEEL WELL OR COUGH, COMES TO THE CLINIC, NO DIAGNOSIS IS MADE. THE COUGH IS WORSE, THEY COME BACK TO CLINIC AND THEY GET A MICROSCOPY NEGATIVE BECAUSE THEY HAVEN'T BEEN -- MICROSCOPY. IF THEY INFECT THEIR DAUGHTER, THEY FINALLY COME BACK TO CLINIC AND GET DIAGNOSED. IT DOESN'T ALWAYS HAPPEN THIS CASE BUT THERE ARE MANY CASES JUST LIKE THIS. SO YOU HAVE TWO OPTIONS. THE TRADITIONAL OPTION IS SAYING DO YOU KNOW WHAT, THERE ARE MASSES OF TB PATIENTS OUT HERE WHO ARE ALREADY SMEAR POSITIVE AND NOT BEING DETECTED. IF YOU DON'T CLEAN THEM UP AND GET THEM ON THERAPY AND OFF THE STREET AND TROP TRANSMITTING YOU WON'T HAVE AN IMPACT ON THE TB PROGRAM. THAT'S TRUE. YOU CAN'T GO INTO, YOU SHOULDN'T BE THINKING OF GOING INTO A PROGRAM A COUNTRY WITH NO TB CONTROL WITH HIGHLY SENSITIVE DIAGNOSTIC SERVICES. BUT ONCE YOU GOT MICROSCOPY CLINICS ESTABLISHED AND YOU'VE TAKEN THE BULK OF THOSE PATIENTS OFF THE STREET YOU NEED TO START THINKING OF ALTERNATIVES, HOW TO DETECT PEOPLE HERE THE FIRST TIME THEY COME TO CLINIC. AND OBVIOUSLY ONE METHODOLOGY THERE WOULD BE TO IMPLEMENT A HIGHLY SENSITIVE MOLECULAR TEST SIMILAR TO CULTURE. SO THIS IS A PICTURE TAKEN WHILE I WAS AT THE NIH AND -- MAY HAVE BEEN WITH ME GOING FOR A WALK OR A CUP OF COFFEE. THIS IS OFF IN FRONT OF THE BUILDING AND THIS IS ACT-UP WHO ARE PROTESTING THE LACK OF ANTI-RETROVIRAL DRUG RESOFTEN AND AVAILABILITY FOR TREATMENT IN PATIENTS IN THE UNITED STATES. THIS WAS FASCINATING AND TO ME AT THE TIME IRRELEVANT THOUGH I DID LEARN A GREAT LESSON WHEN TONY CAME OUT ON THE BALCONY AND WAVED, HE SAID IT IS SO GREAT HAVING YOU HERE TO HELP US STOP THIS PROGRAM. IT WAS DISAPPOINTING -- THEN WALKED AWAY. HOPING FOR A FIGHT BUT THEY DIDN'T GET THAT. BUT THEY DID MISS AN IMPORTANT POINT THAT WAS HAPPENING. DURING THE TIME WHEN THEY WERE STANDING BUS DOWN FROM CONNECTICUT WAVING THEIR SIGNS IT'S TERRIBLE WHEN THINGS HAPPEN IN AFRICA, ALSO RELATED TO HIV. THESE ARE TB NOTIFICATION RATES IN ZAMBIA, NINE FOLD INCREASES, TENFOLD INCREASES ACROSS AFRICA IN TB RATES. TUBERCULOSIS IS THE CANARY IN A COAL MINE FOR HIV. AS HIV RATES RAMMED UP ALONG HERE, TB RATES FOLLOWED SOON THEREAFTER. A LOT ABOUT THE IMPORTANCE OF THE COMMUNITY AND CONTROL OF TUBERCULOSIS IN BOTH INFECTIONS AND DISEASE. IT HAD A DOUBLE IMPACT, THOUGH, NOT JUST ON INCREASING CASE LOADS AND SWAMPING MEDICAL SERVICES REALLY QUICKLY AND WERE UNABLE TO CARE FOR THESE PATIENTS. BUT IT ALSO, THERE'S A DISPROPORTIONATE INCREASE IN SMEAR NEGATIVE DISEASE SO IN ZAMBIA IN 2000 ONLY 20% OF PULMONARY TB CASES WERE MICROSCOPY POSITIVE. TAKE THAT FROM THE VIEW POINT OF THE HEALTH CLINIC DIRECTOR OR EVEN THE TB CONTROL PROGRAM DIRECTOR. THE 500 FEBRILE COUGHING PEOPLE STANDING IN LINE IN YOUR CLINIC, YOU CAN ONLY TAKE 20% OF THE PATIENTS WITH MICROSCOPY. WHY BOTHER WITH MICROSCOPY SERVICES AND BECAME QUICKLY TRUE THAT IN MANY COUNTRIES -- WE JUST GOT TO TREAT EVERYBODY WHO IS COUGHING, EVEN THOUGH SIX MONTHS WAS COMPLEX THERAPY AND PEOPLE WERE ALREADY SICK. THEY DON'T TOLERATE THERAPY VERY WELL, THERE'S NOTHING ELSE TO DO. THIS BECAME A HUGE PROBLEM FOR LOGISTICS IN MANAGEMENT AND FOR THE AMOUNT OF DRUGS AND THE HUGE PROBLEM IN THAT WE DIDN'T KNOW WHERE WE WERE IN THE EPIDEMIC BECAUSE YOU COULDN'T COUNT A TREATING CASES A NATURAL CASE. THE SECOND THING THAT HAPPENED WITH HIV THAT CHANGED, THE IMPACT OF HIV ON THE DIAGNOSTICS WAS MICROSCOPY FUNCTION, CAME FROM A SURPRISING EXAMPLE FROM THE UNITED STATES. THIS WAS DATA FROM NEW YORK AND NEW JERSEY IN THE 1990'S, AND HOSPITAL OUTBREAKS. A NUMBER OF HOSPITAL OUTBREAKS REPORTED AT THE CBC, NWR. THESE WERE AS YOU CAN IMAGINE, THESE WERE HIV WARDS. YOU CAN SEE VERY HIGH INFECTION RATES HERE. SOMEONE CAME IN TO THE H IT V WARD AND MORE PEOPLE WITH TUBERCULOSIS -- QUICKLY GOT INFECTED. MORTALITY WAS VERY HIGH FROM THESE PATIENTS AND VERY VERY FAST, WITHIN A FEW WEEKS. NOW WHEN THIS WAS REPORTED, THIS WAS REPORTED AS NDR OUTBREAK. SO IN THE HIGHLIGHT FROM THE CBC, MULTIDRUG RESISTENT TUBERCULOSIS IS A TERRIBLY DAMAGING AND RAPIDLY FATAL DISEASE. W.HO STARTED USING THE PHRASE E BOLI WITH WINGS. IT WAS CAST TO THE PUBLIC WITH HOW WE NEED TO BE AFRAID OF MRTB. IN FACT WHAT THIS SHOWS IS THESE ARE PEOPLE ALL RECEIVING DRUGS FOR -- TUBERCULOSIS. IE THEY WEREN'T RECEIVING APPROPRIATE THERAPY. THEY ARE TELLING US WITH HIV-INFECTED INDIVIDUALS, UNTREATED TUBERCULOSIS WAS RAPIDLY FATAL. THIS IS A LESSON YOU LEARN DRAMATICALLY IN AFRICA WOULD BE A PROJECT IN MALAWI RELATIVELY A FEW YEARS AGO. AND MALAWI HIV INFECTED PATIENTS THAT WERE NEGATIVE HAD A MORTALITY OF 50% DURING THE PERIOD THEY WERE TRYING TO FIND A DIAGNOSIS WHICH DEVELOPED AFTER FOUR WEEKS. THERE'S PROBABLY A HUGE ICEBERG UNDER WATER OF DEATHS IN AN HIV-INFECTED INDIVIDUALS. TOPS FROM INDIA, SOUTH AFRICA AND EGYPT AMONG THE HIV INFECTEDS WHO DIE IN HOSPITALS, THE TB RATES ARE 60-8 0%. THIS IS THE FIRST CHINK IN THE ARMOR IN THE APPROACH TO TB CASE. THE FIRST WAS IT DIDN'T SEEM TO BE WORKING THAT WELL FOR PLACES LIKE PERU WHO WERE INCLUDED IN THE MICROSCOPY. THE SECOND IS HIV MAKES PEOPLE VERY DISCIPLINED WITH MICROSCOPY AND THE THIRD IS DRUG RESISTANCE IS MERGING AS YOU KNOW FROM W.H.O. IN YOUR OWN WORK. THERE'S NOW BROAD PARTS OF THE WORLD WHERE NDR IS A COMMON PROBLEM AND THAT IS INCOME MICROSCOPY CAN'T TELL YOU IF YOU'RE DRUG RESIST EMPT OR NOT. FASCINATING RECENT DATA FROM INDIA AND CHINA. CHINA HAD A NATIONAL PROGRAM ACROSS THE WHOLE COUNTRY REPORTING 6.8% OF NEW CASES UNTREATED, NEVER BEEN TREATED FOR TB OR MULTIDRUG RESISTENT. THEY'RE NOT CREATING MULTIDRUG RESISTANCE. WELL THEY ARE BECAUSE 26% OF PRETREATED PATIENTS WERE NDR. THERE'S THAT MUCH NDR CIRCULATING IN THE COMMUNITY. THERE'S PROBABLY 100,000 YEARLY CASES OF NDR OF TUBERCULOSIS IN CHINA AND HARDLY ANY OF THEM TREATED. THIS BECOMES A REALLY IMPORTANT IDEA IN OUR THINKING OF WHAT KIND OF DIAGNOSTIC ASSAY DO WE WANT TO DEVELOP. SO IN SUMMARY, WHERE ARE WE WITH THE DIAGNOSTICS. AS YOU REMEMBER FROM THE HISTORY, THERE WAS A HUGE EPIDEMIC OF TUBERCULOSIS IN EUROPE AND NORTH AMERICA IN THE PERIOD, DURING THIS PERIOD HERE, IN FACT THERE WERE CASE REPORTS OF TUBERCULOSIS IN SOUTH AFRICA. EUROPEANS IN AFRICA ARE SAYING I STUMBLED ACROSS THE BIZARRE IN AFRICA, HOW COULD THAT BE. IN AFRICA AND IN ACAUSE IT WAS NOT WIDELY REPORTED ITS PREVALENCE. IT MOVED TO THE REST OF THOSE POPULATIONS AND ESPECIALLY WITH HIV OF COURSE AND NOW THERE'S THE SECOND EPIDEMIC. AND THE CONCERN IS WHETHER OR NOT THIS SECOND EPIDEMIC IS CONTROLLABLE WITHOUT THE CURRENT WE HAVE, SIX MONTHS OF THERAPY MICROSCOPY DIAGNOSIS IS GOING TO BE ABLE TO CONTROL THAT DISEASE IN THE HIV IS NDR ERA. SO THIS IS WHAT WE'RE TRYING TO DO AT FIND. WE CONSIDER OURSELVES FOR DIAGNOSTIC DEVELOPMENT -- SLEEPING SICKNESS, YES. WE TRY NOT TO WORK IN THE DISCOVERY AND RESEARCH SPACE, LEAVE THAT TO INSTITUTES LIKE THIS ONE. HOPING TO PICK UP THE ASIAN CONCEPTS, METHODOLOGIES AND PUT THEM INTO DEVELOPMENT PROCESS AND TURN THEM INTO A PRODUCT. THAT PRODUCT GOES INTO A REGULATORY CALLED A TRIAL, EVALUATION THEN. BECAUSE COUNTRIES DON'T IMPLEMENT TECHNOLOGY SIMPLY BECAUSE THEY PERFORMED DURING A TRIAL, THE IMPLEMENTATION STUDIES OR DEMONSTRATION PROJECTS LOOKING AT THE NATIONAL PROGRAM SETTINGS AND THESE ARE QUITE LARGE SETTINGS. OUR STUDIES ANYWHERE FROM 3,000 TO 100,000 PATIENTS DEPENDING ON WHAT GOVERNMENTS NEED TO KNOW. AND IMPORTANTLY, AT THE END, THIS SHOULD TURN INTO SOME SORT OF INTERNATIONAL AND FOLLOWED BY NATIONAL POLICY. WE SPENT A LOT OF TIME IN GENEVA AND THAT'S PART OF WHY WE'RE THERE, ARE ENSURING THAT THESE THINGS ARE LINKED THAT WE DON'T SPEND $10 MILLION ON THIS PROCESS. WE DID A FAIR AMOUNT OF WORK RELATIVELY EARLY ON WITH TECHNOLOGIES THAT WERE NOT GOING TO CHANGE THE WORLD BUT BECAUSE WE NEEDED TO ESTABLISH OUR PROCESSES IN THE PATHWAY AND MAKE SURE WE HAVE NEW POLICY PROCEDURES IN PLACE. ALL OF THIS WORK ON OUR SIDE IS GENERALLY SAID BY A DIRECT INVESTMENT TO CORPORATE PARTNERS, SELECTION OF THE BEST TECHNOLOGY AVAILABLE TO DO SO. AND THEN BALANCING OUR INVESTMENT AGAINST SOME PRICE REDUCTION FROM THE PRIVATE SECTOR. AND PRICE CONTROLS, ACTIVE MANAGEMENT AND ALL THOSE THINGS NECESSARY TO ENSURE THOSE TESTS ARE AVAILABLE. THAT'S BEEN QUITE EFFECTIVE. I WOULD SAY IN GENERAL, THE COST FOR FINES DEVELOPED PRODUCTS IS ABOUT 25 TO 20% OF THE COST OF THE PRODUCT IN THE PRIVATE SECTOR MARKETS. SO THIS IDEA OF PDP PRODUCT DEVELOPMENT PARTNERSHIPS SPRANG UP FROM ROCKEFELLER INVESTMENTS EARLY ON. AND WITH THE GATES FOUNDATION, THEY HAVE POPULATED AN IMMENSELY COMPLICATED MAP OF GLOBAL PLAYERS THAT ARE MEANT TO FIX THESE MARKET FAILURES FOR THE DEVELOPMENT OF VACCINES, DRUGS, DIAGNOSTICS, OTHER INTERVENTIONS. BUT YOU CAN SEE THE DIAGNOSTIC SPACE HAS BEEN PRETTY EMPTY. I ESTABLISHED TBDI IN THE 90'S AND RAN STI IN THE 2000'S, THE STEVE REID'S GROUP, YOU MAY KNOW HIM. AND FIND IS NOW IN THAT SPACE SO IT IS A RELATIVELY UNCROWDED SPACE COMPARED TO THE OTHERS. AT FIND WE ARE SPECIFIED TO BE IN DEVELOPMENT AND WE WORK BASICALLY JUST LIKE A COMPANY BUT WE DON'T DO, WE DON'T HAVE WET LABS. SO WE DON'T DO THE WORK OURSELVES, WE HIRE IT ALL OUT TO ACADEMIC INVESTIGATORS WHO WORK DIRECTLY -- PROCESS OF DEVELOPMENT. YOU DON'T NEED TO BE ABLE TO READ THIS SLIDE. IT'S JUST ... MOVING ALONG. SO IN THINKING WHICH DIAGNOSTICS WERE DEVELOPED, WE REALIZED THE DIAGNOSTICS WERE NECESSARY AT ALL PHASES, ALL LEVELS OF THE HEALTH SYSTEM. BETTER TESTED THE REFERENCE LEVEL TO MAKE CULTURE TESTING FASTER. AT THE PERIPHERAL LEVEL TO IMPROVE MICROSCOPY AND IDEALLY IT'S ONE OF THE CARES AND PRIMARY CARE WHICH IS A VERY DIFFICULT PLACE TO WORK IN THE WORLD. WE STARTED AT ALL THESE LEVELS AT THE SAME TIME. UNFORTUNATELY THESE ARE MUCH EASIER TO DEVELOP SO THEY GO FIRST. IT HAS APPEARED THAT FIND STARTED WORKING FIRST ON VERY COMPLEX ASSAYS AND CLOSELY IS WORKING TOWARDS THE PERIPHERY. THAT'S HOW IT WORKS IN THE DEVELOPMENT. SO THE PRINCIPLES THAT WE USE IN FORMING OUR NEW TEST DEVELOPMENT FOR THE ASSAY I DESCRIBE TODAY COMES FIRST FROM THE IDEA OR THE KNOWLEDGE THAT LABORATORIES IN DEVELOPING COUNTRIES IS VERY LIMITED. WE DID A SURVEY IN 2003, IT'S BEEN ABOUT A YEAR TRYING TO UNDERSTAND EXACTLY HOW MUCH LAB CAPACITY IS THERE. AND DOCUMENTED THAT IN THE 22 COUNTRIES WITH 85% OF THE TB BURDEN GLOBALLY, HALF OF THOSE HAVE TWO REFERENCE LABORATORIES THAT CAN EVEN DO BLOOD TESTING IN THE WHOLE NATIONAL PROGRAM. THE LIKELIHOOD THAT YOU AS A PATIENT WOULD EVER GET TESTED IS ESSENTIALLY ZERO. SO WE CANNOT DEVELOP ASSAYS THAT REQUIRE LABORATORY PAST AN IMPORTANT WAY AND HAVING AN IMPACT ON EARLY PATIENT MANAGEMENT. THE CLOSER THE PATIENT AND LESS DELAY IS STUDIES ON DIAGNOSTIC DELAYS FROM TWO WEEKS TO TWO YEARS. BUT IN GENERAL IT'S TWO TO FOUR MONTHS IN THOSE CASES COUNTRIES WHERE THERE'S A HEALTH SYSTEM. SOME OF THAT DELAY IS THE PATIENT. ANOTHER DELAY IS MICROSCOPY NEGATIVE COMING BACK IN TWO WEEKS NOT MY -- MICROSCOPY COME BACK IN TWO WEEKS. IT'S NOT MORE THAN -- AWAY. EARLY DETECTIONS WON'T INCREASE CURE RATES. WE USED TO NOT WORRY ABOUT THAT. IN FACT THE YEAR I MOVED TO THE ORGANIZATION WAS EDITING THE DRAFT THAT WAS JUST GOING TO COME OUT ON THE PROPER MANAGEMENT OF TB CONTROL. AND THIS STRUCK BY THE ADVICE BY THE WORLD HEALTH ORGANIZATION IN COUNTRIES MAY DECIDE REASONABLY TO IGNORE THE WHOLE CONSENT OF DRUG RESISTANCE IN TUBERCULOSIS AND NOT TREAT THOSE PEOPLE. IT'S A HIDDEN SUBTEXT IF THEY DIE ANYWAY AND IT'S TOO EXPENSIVE TO TAKE CARE OF THEM. IN AN ERA WHERE MANY COUNTRIES 20-40% OF NEW CASES IN SOME COUNTRIES, YOU CANNOT IGNORE THE RESISTANCE ESPECIALLY KNOWING THEY GOT THAT WAY BY TREATING ONLY THE DRUG ACCEPTABLE CASES SO ONLY THE DUG RESISTENT CASES WERE FLOURISHING IN THE DRUG RESISTANT GROUP. LASTLY THE CO-INFECTED PATIENTS WILL BE CRITICAL TO MORTALITY. WE WANT SOMETHING THAT WORKS WELL WITH HIV, SOMETHING THAT WOULD SCREEN FOR DRUG RESISTANCE EARLY ON SO WE CAME OFTEN WITH A SERIES OF DESIGN REQUIREMENTS. BELIEVE ME THE ACTUAL DESIGN REQUIREMENT DOCUMENTS LOOK LIKE THE TECHNO DOCUMENT. THIS IS A SERIES OF SLIDES TO HELP YOU UNDERSTAND. THE DROP OUT RATES IF YOU TEST A PATIENT IN CLINIC AND TELL THEM TO COME BACK TOMORROW FOR RESULT IS ABOUT 20%. IT'S GREAT ADVANTAGE TO HAVE SOMETHING SHORT ENOUGH THAT PEOPLE CAN WAIT. IN SUBTHREE HOURS CULTURE. RANDOM ACCESS. IF YOU HAVE A VERY FAST ASSAY BUT YOU HAVE TO TURN 20 SPECIMENS READY TO TEST -- IT HAS TO BE RANDOM ACCESS. IF YOU'RE GOING TO PURCHASE A PLATFORM IT BETTER BE A MULTIDISEASE PLATFORM. ALL OF US IN THE DEVELOPING WORLD HAVE SEEN LAG TREES PLAGUED WITH DOZENS OF INSTRUMENTS THAT HAVE BEEN RE REPLACED AND ONLY USED FOR ONE TYPE OF ASSAY. SAFETY IS CRITICAL. THERE'S NO DOUBT -- ACROSS MUCH OF THE DEVELOPING WORLD. THE ABSENCE OF THE NEED FOR MOLECULAR TRAINING. WE'VE BEEN SCALING UP MOLECULAR TRAINING USING A MORE COMPLEX TECHNOLOGY CENTRALIZED TESTING TECHNOLOGY ON A CLUB ASSAY OVER 27 COUNTRIES IN THE LAST FIVE YEARS. IT'S COST $16 MILLION AND THE NEED TO MAINTAIN DOZENS AND DOZENS OF LABS WITH MULTITRAINING PEOPLE IN THE DEVELOPING WORLD IS A MASSIVE BURDEN. THERE ARE STEPS, ALL THE LEADERS ON BOARD, NO WELCOME TO THE FRIDGE TO GET A BOTTLE OF SOMETHING. NO COLD STEWARDS FOR REAGENT AND IT'S IMMUNE TO CONTAMINATION -- NDR. SO THIS SEEMED A LOT TO ASK BUT WE BEGAN TO LOOK AROUND FOR THE TECHNOLOGIES WE'D WANT. NOW THE ONLY TECHNOLOGY THAT SEEMED CONCEIVABLY POSSIBLE TO DELIVER SENSITIVITY NEAR CULTURE SENSITIVITY WHILE PATIENTS WOULD BE MOLECULAR TESTING. WE SPEND A LOT OF TIME LOOKING AT -- METABOLISM IS SLOWLY YOU CAN'T GET AN ACCURATE READ OUT. WILL THOSE TESTS IF YOU LOOK AT SYSTEMATIC ANALYSIS OF PUBLISHED PAPERS ON SOME OF THOSE CE-MARKED APPROVED ASSAY. YOU SEE GENERALLY IN POSITIVE PATIENTS BEARING HIGH SENSITIVITY AND RELATIVELY LOW SPECIFICITY. FOR THE NEGATIVE PATIENTS, MODERATE SENSITIVITY OF SORT OF 55 TO 75%. SO WE WANTED TO DO BETTER THAN THAT. IF YOU LOOK AT THE TOP, YOU SEE THAT THESE ARE MICROSCOPY SCORES 1-4 PLUS AND THIS IS BASICALLY THE NUMBER OF LOGS -- AND MY PSYCHIATRY IS SLIGHTLY MORE SENSITIVE THAN -- BUT REALLY LIMIT PCR IS TRADITIONALLY AROUND 10-3.5 -- THE CULTURE AT 200-300 ORGANISMS AND MIDGET IS PERHAPS 10 TO 20 ORGANISMS. WE WANTED TO TAKE THE EXISTING ASSAY AND TURN THEM AROUND AS SENSITIVE AS A CULTURE ASSAY. YOU CAN IMPLEMENT THE FIELD. IT WOULD BE BASICALLY THE COMPETITIVE ASSAY THAT IS MUCH SLOWER. WE SPENT A LOT OF TIME LOOKING AT TECHNOLOGY PLATFORMS. NOT JUST AMPLIFICATION SYSTEMS BUT THE KIND OF SITUATION THEY HAD WHAT THE USERS NEEDS WERE AND WHETHER OR NOT THE PLATFORM ADAPTED TO THE USER NEEDS. WHEN WE WERE DOING THIS WORK IN 2002, THERE WAS REALLY ONLY ONE COMPANY THAT COULD MEET THE REQUIREMENTS AND THAT IS, WHY? YOU CAN JUMP OUT OF AN AIRPLANE AND LAND ON SOMEBODY WITH A PLATFORM AND YOU CAN RAPIDLY DETECT CLEAN DNA. CLEAN DNA DOESN'T COME IN THE CLINIC WHAT YOU GET IS SOME VICT CUSS MATERIAL THAT YOU NEED TO TURN INTO COLLEEN DNA. WE SPENT THE BETTER PART OF FIVE YEARS FIGURING OUT HOW TO DO THAT. WE DID IT IN THE AUTOMATED SYSTEM AND NON-AUTOMATED MANUAL PROCESS. IT'S VERY HARD TO TURN THAT INTO A PROCESS SIMPLE ENOUGH FOR A TECHNOLOGY TO DO OR USE IN THE LAB. SO CONVENTIONAL NUCLEI IDENTIFICATION AS YOU KNOW THE DNA -- AND WE WANTED TO PUT ALL THOSE IN ONE PLACE. THE ONLY TECHNOLOGY AVAILABLE TO DO THAT AT THE TIME WAS THE GENE EXPERT PLATFORM TO DEVELOP THE COMPANY OUT OF CALIFORNIA. I STARTED THIS TALK, WELL I'LL GET BACK TO IT IN JUST A SECOND. THIS IS WHAT THE PLATFORM LOOKS LIKE. THIS IS NOT THE INSTRUMENT, THIS IS THE DISPOSABLE. IT'S A CASSETTE THAT HAS A ROTARY PLUNGER IN THE CENTER WITH A VALVE AT THE BOTTOM. YOU CAN BASICALLY SPIN IT, WITHDRAW FROM ANY OF THESE CHAMBERS, FLUID UP IN THE CENTRAL CAVITY SPIN IT SOMEWHERE ELSE AND PUSH IT BACK IN THE OTHER CHAMBER SO IT ALLOWS YOU TO DO WHAT ABOUT MICRO SERIES YOU WANT TO AND THE ORDER TOGGLING, FLUSHING, WASHING ETCETERA. AND THIS LARGE WASTE CHAMBER IS ALSO CHAMBERS FOR FLUIDIC COMPONENTS. YOU CAN SEE OUR TUBE READ -OUT WINDOW. IT COST THE COMPANY $180 MILLION FOR THIS PLATFORM. IT COULD BE MANUFACTURED AT HIGH SPEED AND AT LOW COST. WELL WHY WAS THAT POSSIBLE? WELL, WE GET BACK TO THE STORY OF COSTING 1876, DISCOVERING THE CAUSE OF ANTHRAX, AND YOU LINK IT TO -- WHICH WAS GOT THE CONTRACT TO SCREEN THE U.S. POSTAL SERVICE FOR ANTHRAX SCORES. BECAUSE THEY HAPPENED TO HAVE DEVELOPED THIS ASSAY AND IT WAS LOOKING FOR AN APPLICATION BASICALLY. THE COMPANY WAS FANTASTIC MICRO FLUIDICS AND PCR EXPERTISE. THEY LICENSED THE REAL TIME PCR TECHNOLOGY FROM SILVERMORE. FEDERAL GOVERNMENT HAS BEEN INVOLVED IN THIS SUCCESS OF THIS TECHNOLOGY REALLY FROM THE START. MORE THE -- TO THE NIH AND BEYOND. THIS CONTRACT TURNED INTO A MULTIMILLION DOLLAR IMPORTANT CONTRACT FOR THE COMPANY IN TWO WAYS. ONE, THEY WERE ABOUT TO GO BROKE. THEY'VE BEEN SPENDING, THEY WERE WAY IN DEBT AND SPENDING A LOT OF MONEY FOR THIS PLATFORM AND HAD NO SALES. THE CEO WAS NOT A CLINICAL IBE PERSON AND THEY WERE LOOKING FOR APPLICATION AND TRYING TO FIGURE OUT WHAT IT WAS AND ONE LANDED IN THEIR LAPS SO THEY THEY WERE FORTUNATE. THEY HAVE THE CLINICAL PLATFORM WITH ONE MODULE FOR 16 OR SET FOR A HUNDRED IN THE INSTRUMENT, RANDOM ACCESS THINGS. YOU CAN SLIDE IN THE CARTRIDGE AND PUSH GO AND GET AN ANSWER. IT'S A CLOSED SYSTEM. ONE OF THE THINGS WE WANTED TO DO IS ENSURE THAT WE HAD A BACTERIAL CAPTURE STEP RATHER THAN NUCLEIC ACID CAPTURE STEP. NUCLEIC ACID CAPTURE SYSTEM WORKS VERY WELL. THE PROBLEM IS THEY'RE VERY -- SO WE WANTED A -- FOLLOWED BY A LARGE WASH STEP. AND WHAT WE DID IS COLLABORATED IN A THREE-WAY PARTNERSHIP, I DON'T WANT TO HEAR FROM -- UMBJ WITH THE ACADEMIC PARTNER AND FIND. SO FIND'S RESPONSIBLE WAS TO DEVELOP THE PROBABLE CONCEPT, PUT IN THE REQUIREMENTS, THE TECHNICAL CONSIDERATIONS IN THE PROJECT MANAGEMENT FUNDS THE ACTIVITIES, DO THE EVALUATIONS AND ADMINISTRATION AND GET THE APPROVALS. --'S JOB WAS TO MAKE MANUFACTURING INEXPENSIVE AS POSSIBLE. TROUBLESHOOT THINGS FROM THE IMPLEMENTATION -- JOB WAS DEFINE -- WHAT WE DECIDED TO DO BECAUSE WE WANTED TO TARGET -- VERY GOOD MARKER FOR MULTI-- IN TUBERCULOSIS. IT'S A LUCKY TARGET BECAUSE THERE'S ABOUT A 39 AMINO ACID REGION WHICH ENCODES ALL OF THE RESISTENT MARKERS. WITH FIVE MOLECULAR BEACONS. IF YOU HAVE A DROPOUT THAT MEANS THERE'S A MUTATION SO THEY ARE ENGINEERED. SOME OF THEM HAVE SPECIAL CHEMISTRIES SO THEY WILL DETECT THE MUTATION THAT'S RELEVANT. WE CONSIDER THE RPOB AS A REASONABLE SCREEN FOR -- BECAUSE OF THE FOLLOWING KINDS OF DATA. THIS IS THE PROBLEM OF NON-MULTIDRUG RESISTENT THAT IS NOT -- PLUS FOR SAMPLING. THIS IS THE PREVALENCE OF SAMPLING MONO RESISTANCE IN A LARGE MULTINATIONAL SCREAM AT W.H.O. 30 COUNTRIES HAVE 0% WITH MONO RESISTANCE. 1.1% IN 13 SETTINGS. THREE SETTINGS HAD MORE THAN 3% MEANING IF YOU HAVE RESISTANCE YOU ALMOST CERTAINLY ARE NDR RATED MARKER. SO LOOKED ABOUT 200 PAPERS AND MAPS. EVERY MUTATION IS REPORTED AND MADE SURE WE COULD DETECT MORE THAN 5% OF THEM. I'VE GOT A WHOLE SERIES OF VALIDATION SLIDES WHICH MAINS WE'LL GO QUICKLY THROUGH AT THIS POINT. WE MADE SURE THAT ALL OF THE -- WE MADE SURE WE COULD REACH OUR ANALYTIC DETECTED -- AND THAT'S WHERE WE ENDED UP AROUND 130. THIS IS WHERE YOU DO 20 AT EACH SPOT AND GET 95% DETECTION RATE. WE RAN OF COURSE LOADS OF DOING EXCLUSIVITY ASSAYS FROM INSIDE AND OUTSIDE THE MICRO BACTERIA. WE THEN TOOK AMPLICON, AND JUST SPIKE IT DIRECTLY INTO THE INSTRUMENT. AS YOU CAN SEE THAT YOU GET, START TO GET POSITIVE RESULTS THE 10 TO THE 8TH COPIES. THIS IS THE LEVEL OF CONTAMINATION THAT'S VERY UNLIKELY. SO WHAT'S THE ASSAY TO LOOK LIKE. WE WANTED THIS TO BE SIMPLEST AS POSSIBLE AND THE FIRST STEP HAS TO BE SOMETHING THAT MAKES THIS SAFE TO USE. SO WE DESIGNED A SAMPLE REAGENT YOU POUR IN, VISUALLY ABOUT TWICE AS MANY SAMPLING AGENT AS SAMPLE. IT DOESN'T MATTER IF YOU GET IT WRONG EVEN BY 100%. CLOSE THAT AND SHAKE IT UP SO IT'S ALL EXPOSED TO THIS REAGENT. WAIT A FEW MINUTES AND THEN TAKE A PLASTIC -- AGAIN IN A NON-VOLUME PRECISE DEPTH, TRANSFER ABOUT TWO MILLS OF THAT MATERIAL INTO THE CARTRIDGE. AT THAT POINT THE SPUTEM IS ELECTRIFIED. OUR SAMPLE REAGENT WOULD KILL TEN TO THE 8 ORGANISMS IN 15 MINUTES. YOU COULD LEAVE IT IN FOR UP TO 8 TO 24 HOURS MUCH CHANGE, WITHOUT MUCH LOSS OF YOUR TARGET DNA. SO WE AFTER THE DEVELOPMENT WE TOOK THIS TO CLINICAL TRIALS. OUR SOURCE OF EVALUATION WAS DONE IN A STUDY -- SOUTH AFRICA -- INDIA -- PERU. THE DESIGN WAS THE SAMPLES FOR PATIENTS, TWO OF THOSE WITH EXPERT THAT HAS BEEN PROGRESSIONED AS FOR CULTURE. AND ONE OF THOSE WAS THE EXTRA RESULT. THERE WAS IN THE END NO DIFFERENCE BETWEEN PROCESS OR SPUTEM THEY DID DIRECT TESTING AND FOUR CULTURES PER PATIENT. HERE'S THE DATA. WE COULD NOT HAVE BEEN HAPPIER, AS YOU CAN SEE, THESE ARE THE SITES. THE SUMMARY OF THE SITES, IF YOU LOOKED AT DOING THREE EXPERT VERSUS FOUR CULTURES WE DETECTED THE NEAR POSITIVE PATIENTS. 90% OF NEGATIVE PATIENTS. IN THE MIDST OF THE COUNTRY WE WERE STUDYING THAT WAS 97.6% OF ALL PATIENTS DETECTED IN 90 MINUTES IN PERIPHERAL LABORATORY. SO THIS WAS REALLY REWARDING. NOW IF YOU ONLY DO TWO TESTS OR ONE TEST, IT'S LOWER SENSITIVITY. YOU STILL DETECT OVER 90% OF PATIENTS EVEN WITH THE EXPERTS COMPARED TO TRIPLE CULTURE. SO IN FACT, ON ALL THE ANALYSIS DONE SINCE, THIS ASSAY IS SLIGHTLY MORE SENSITIVE THAN CONVENTIONAL CULTURE WHICH IS WHAT COUNTRY WE'RE TRYING TO IMPLEMENT TO INCREASE SENSITIVITY. ONE ADDITIONAL BENEFIT OF COURSE OF HAVING A RAPID AS SAY IS PATIENTS DO GET THE RESULTS. THESE ARE THE PERCENTAGE OF THE RESULTS THAT GOT TO THE PATIENT. IF YOU GOT A POSITIVE CULTURE RESULT, THAT'S GREAT YOU'RE 100% INFECTED BUT ONLY 70% OF THE TIME DID THAT INFORMATION GET TO THE PATIENT -- END OF THE DAY. THOSE RESISTENT DETECTION IS GOOD AT 95% -- SINCE WE REENGINEERED WE'VE SLIGHTLY IMPROVED THOSE NUMBERS. THEN WE CARRY OUT AN IMPLEMENTATION PROJECT. I WON'T BELABOR THIS EXCEPT TO SAY WE PUT IT IN MORE PERIPHERAL SITES. LABORATORY PERIPHERAL RURAL INDIA WHERE IT WAS 40 DEGREES CENTIGRADE IN THE LABORATORY. AGAIN WITH HIGHLY VARIABLE HIV PREFERENCES AND HAD HIGH PERFORMANCE. WE TOOK ALL THIS DATA TO W.H. O. AS WE HAD DONE WITH THE OTHER TECHNOLOGIES AND THEY CAME ALL WITH A STRONG RECOMMENDATION TO IMPLEMENT THIS AS WIDELY AS POSSIBLE. HIV IN INDIA ARE RISK PATIENTS AND THOSE COUNTRIES READY TO IMPLEMENT FOR ALL TB SUSPECTS. THIS MADE IT OUT ON THE NEWS WHICH HAS BEEN GOOD AND BAD BECAUSE WE'RE A NON-PROFIT ORGANIZATION AND WHEN THERE'S A LOT OF NEWS ABOUT US AND THIS COMPANY, IT'S THE GENERAL ASSUMPTION THAT SOMEHOW WE'RE THE DISTRIBUTOR OR FOR-PROFIT COMPANY ETCETERA OR SLEEPING WITH THE ENEMY. THERE'S BEEN A LOT OF JUST WE'LL THROW THESE HEADLINES UP, A LOT OF INTERESTING OPERATIONS OF RESEARCH DONE WITH EXPERTS SINCE THAT TIME. IN SETTINGS WHERE LOOKING AT SCREENING HIV-ASSOCIATED TB IN PATIENTS GETTING A.R.T. OR ASYMPTOMATIC, THEY FIND THEY SCREENED EVERYONE, 70% OF HIV POSITIVE PATIENTS STARTING THE A.R.T. CULTURE POSITIVE, 75% WERE BY EXPERT AND 25% BY MICROSCOPY. INTERESTING THOSE NOT DETECTED BY EXPERT DID FINE. THOSE WHO WERE DETICKED HAD A HIGH MORTALITY. SO THAT SEEMED TO BE ESPECIALLY RELEVANT. ESPECIALLY GIVEN THE FACT THAT THERE IS CULTURE CROSS CONTAMINATION IN MANY THESE LABORATORIES AND SOME OF THESE CULTURE POSITIVE IN TRUE PATIENTS. HIGH COST EFFECTIVE IS SCREENING ALL HIV-INFECTED BEFORE -- SOUTH AFRICA AND PREDOMINANTLY A TB SUSPECT A SINGLE ASSAY SUSPECTED -- VERSUS 22% FOR USING A LIFE CYCLER. THERE WERE A NUMBER OF STEPS WHERE WE HAD TO MAKE TOUGH DECISIONS OF COST VERSUS -- WE HAD A LONG BREAK WITH A COMPANY ABOUT REAGENTS ON BOARD. AS THIS CARTRIDGE HAS -- NITROGEN FIXED TCR REAGENTS INCLUDING ENZYMES -- AND INSIDE THE SAME CARTRIDGE YOU'VE GOT FLUIDS. THIS IS GOING TO BE SHIFTED UPSIDE DOWN AND SHAKING ON A TRUCK. DESIGNING THIS IN SUCH A WAY THAT YOUR ENZYMES WOULD STAY FRESH AND NONE OF YOUR AGENTS WOULD SOLIDIFY. IF WE HAD TO GO TO THE FRIDGE AND GET IT NEVER WOULD HAVE WORKED. WE STARTED WITH A PRICE THAT IS -- $16 -- PER YEAR THIS IS OUR NEGOTIATED PRICE WHICH IS BASICALLY THE COST OF GOODS PLUS MODEL. AND FURTHER FALL AS YOU GET TO HIGHER VOLUMES. WHAT WE'VE DONE RECENTLY AND WHAT THE U.S. GOVERNMENT HELPED US DO IS WE WROTE A CONTRACT ASKING IF WE PAID PAID THEIR -- WOULD THEY DROP THE PRICE INDEPENDENT OF VOLUME DOWN TO THE HIGH VOLUME PRICE AND THEY SAID YES. SO THE U.S. GOVERNMENT, THE GATES FOUNDATION STEPPED IN -- AND BETWEEN THE THREE OF THEM COVERED THE COST OF THE MANUFACTURING EQUIPMENT AND NOW THE ASSAY IS $9. THIS IS WHAT HAPPENED SINCE IT WAS CE MARKED IN 1912. A LEAD ARTICLE TO THE ENDORSEMENT OF W.H.O. AND ABOUT DOUBLING PER QUARTER OF THE ORGANIZATION. IF YOU'VE BEEN IN THE TB LABS IN DEVELOPING COUNTRIES YOU MAY HAVE SEEN THESE. IT'S SPENDING THE SPEED OF -- SO THERE'S SEVERAL STUDIES OF COST EFFECTIVENESS. IT ALWAYS IS COST EFFECTIVE. BUT FOR TB BECAUSE IT STRIKES EARLY AND IT'S FATAL, ALMOST ANYTHING YOU DO IS COST EFFECTIVE IF. IT'S REALLY NOT HOW COST EFFECTIVE, HOW AFFORDABLE IS IT. WE GENERATED SOME NUMBERS. WHAT WOULD IT COST THE WORLD IF YOU TREATED, IF YOU TESTED ALL NBR TB SUSPECT. IT TURNS OUT IT WOULD COST UP TO $14 MILLION OR AROUND 1% OF ALL TESTING CONTROLLED. TB IS ABOUT 2% OF CURRENT FUNDING. IF YOU ARE TESTING EVERYBODY ABOUT 5-10% OF TB CONTROL COSTS WHICH DEPENDING ON THE COUNTRY, FOR EXAMPLE IN KENYA WHEN YOU SCALE A MODEL FOR PUTTING EXPERT EVERYWHERE AND TESTING EVERYTHING DRAMATIC IT'S ABOUT 1% OF THE BUDGET. SO I THINK IN THE CURRENT CONTEXT, OR CERTAINLY IN THE HIV CONTEXT IS NOT ONLY COST EFFECTIVE BUT IT'S AFFORDABLE. SO I THINK THIS IS MY FINAL SLIDE. THE WORK WE'VE BEEN DOING AS I MENTIONED BEFORE EARLY ON WAS TO TRY TO GET TECHNOLOGIES. WE HAD THREE APPROVED BY W.H.O. -- THREE MORE PRESENTED IN 2009 AND 12 AND WE'RE LOOKING FOR -- TWO ASSAYS IN THE COMING FEW WEEKS. THANK YOU VERY MUCH. [APPLAUSE] >> IT WASN'T A DISCUSSION BUT IT COULD TURN INTO ONE IF YOU HAVE ANY QUESTIONS. >> [INDISCERNIBLE] HAD A LOW DETECTION RATE OR SENSITIVITY. IS THAT TRUE? DOES THIS ONLY PICK UP CERTAIN RESISTANCE MARKERS AND CAN YOU PICK UP TB IN GENERAL OR JUST THE RESISTANCE? >> SO THE SEQUENCES WE USED ON THE -- OUR TB SPECIFIC SEQUENCES. SO -- IF YOU PICK UP -- WITH TB SEQUENCE, IT IS TB. SO IT'S BOTH DETECTION. YOU GET NBR FOR FREE BASICALLY TO DETECT THE MARKER. THE VARIABILITY PERFORMANCE ACROSS SITE IS BASED ON DIFFERENT THINGS. HIV PREVALENCE IS ONE OF THEM. IN GENERAL YOU GET A SMALL BUT DETECTABLE DIFFERENCE SENSITIVITY WITH HIV INFECTIONS. THE OTHER ISSUE THAT'S REALLY IMPORTANT IS SPECIMEN COLLECTION IN UGANDA SETTING IT'S VERY POOR WE GET A LOT OF SALIVA. >> ANY GENERAL LESSONS LEARNED ABOUT PUBLIC PARTNERSHIPS FOR COMMERCIALIZATION, DEVELOPMENT PARTICULARLY IN DIAGNOSTICS? >> YES THAT'S A FASCINATING QUESTION. AND IT'S SOMETHING I'VE BEEN STUDYING FOR A LONG LONG TIME SO I'LL TRY TO BE PRECISE. IT'S AN INTERESTING QUESTION BECAUSE THE QUESTION IS HOW MUCH MANAGEMENT IS REQUIRED IN THIS PROCESS. CAN YOU DO IT CHEAPLY AND QUICKLY. CAN THE U.S. GOVERNMENT OR ANOTHER DONOR GO TO A COMPANY AND SAY HERE, DEVELOP THIS ASSAY, GIVE US THE FOLLOWING PRICE, WE'RE FUNDED. IT'S A RISK QUESTION. IT MIGHT WORK. FOR US, THE PROCESS IS VERY, A NUMBER OF TECHNICAL AND LOGISTIC OBSTACLES HAVING IT DONE THIS WAY. IN THIS PROSPECTIVE TRIAL TO MAKE SURE WE UNDERSTAND WHO DOESN'T HAVE TB AND THE DIRECT CATEGORIZATION. WE USE 8,000 SPUTUM SPECIMENS. IT'S VERY DIFFICULT FOR THOSE DONORS TO LAY DOWN A SPUTUM SPECIMEN. GOING BACK AND DOING LOOKING AGAIN AT THE DESIGN REQUIREMENTS TAKING THE EARLY VERSIONS TO THE FIELD, DOING STRESS TESTING, LOTS OF THAT KIND OF WORK WILL BE VERY DIFFICULT TO THE UNMANAGED PROCESS. GOING IN AND AUDITING THE MANUFACTURING COSTS OF GOODS REQUIRED A SPECIAL KIND OF TRUST RELATIONSHIP THAT IS DIFFICULT TO ESTABLISH IN A DIRECT DONOR MANUFACTURER RELATIONSHIP ESPECIALLY WITH GOVERNMENTS. -- HAS SAID THEY LIKE THE PROCESS, THEY LIKE HAVING THEIR ACADEMIC PARTNER HELPING WITH THE REAGENTS. THEY WOULD RATHER JUST WORK WITH THE PDP ON ACTUAL ASSAY DEVELOPMENT AND ENSURING IT IS DELIVERABLE. IS THAT THE ANSWER? >> I WAS THINKING ABOUT WHAT COULD THE NIH DO IN TERMS OF COMMERCIALIZATION, LICENSING, HELPING THE PROCESS. AGAIN, PUBLIC OR PRIVATE. >> YOU CAN DO ALL THE SPECIES. THE PIECES THAT ARE NECESSARY TO HAVE IN PLACE ARE OBVIOUSLY ACTIVE MANAGEMENT BUT IT'S FLEXIBLE MANAGEMENT. IT'S A CASE BY CASE BASIS. WHAT'S THE BACKGROUND, HOW IMPORTANT IS IT, WHEN WAS IT DEVELOPED, WHO PAID FOR IT, HOW IMPORTANT, YOU WAIVE THE FREEDOM -- ETCETERA, ETCETERA. IT HAS TO BE A FLEXIBLE AGENCY AND IT NEEDS TO BE PRETTY FAST. SO I TRIED TO DO THIS WHEN I WAS AT W.H.O. I TRIED TO GET A CONTRACT WITH -- TO DEVELOP THIS ASSAY WHICH I COULDN'T WHICH IS ONE REASON, THE W.H.O. BUREAUCRACY WAS CLEARLY WAS A TEN YEAR PROCESS JUST TO GET IT DONE. SO I THINK THE FLEXIBILITY OF ACTIVE MANAGEMENT, THE ACCESS TO REAGENTS AND REFERENCE MATERIALS, THE ABILITY TO ON A MOMENT'S NOTICE FLY EVERYONE TO STOCKHOLM TO LOOK AT THE MANUFACTURING FACILITIES. BEING ABLE TO CALL IN EXTERNAL AUDITORS, ETCETERA. >> SOME OF THAT WOULD BE DIFFICULT FOR THE NIH. >> GIVEN THE PROBLEMS YOU MENTIONED IN KAMPALA AND ALSO IN PEDIATRICIAN CASES WRITS REALLY TOUGH TO SPUTUM SAMPLES -- >> WE HAVEN'T DONE A FORMAL STUDY. WE HAVE DEVELOPED WITH DAVID WHO HAS DONE A LOT OF THE WORK ON THE ASSAY -- WE DEVELOPED A STOOL PROCESSING PROTOCOL WHICH WE HOPE WILL BE SUCCESSFUL IN CHILDREN. IT'S NOW BEING IMPLEMENTED BY SOUTH AFRICA AND WE'LL GET SOME DATA. >> ONE LAST QUESTION. EXTREMELY DRUG RESISTENT TB HAS NOW BECOME A PROBLEM AND CAN THE PRIMERS AND MARKERS YOU USE HERE CAN BE USED TO PICK UP XTR TB AS WELL. >> WE LOOKED INTO EXACTLY THIS QUESTION. NOT NECESSARILY ON THIS PLATFORM. A LONG STORY BUT WE'RE ALSO LOOKING AT THE NEXT GENERATION OTHER PLATFORMS. BUT THE QUESTION IS, CAN YOU, TEND MORE TESTING FOR OTHER DRUGS AND IF SO WHICH DRUGS AND WHAT DOES THAT DO TO COST STRUCTURE, ETCETERA. WE DIDN'T DO IT INITIALLY FOR SOME VERY FUNDAMENTAL REASONS. WHAT DO YOU DO IN REGROWTH. IN MANY COUNTRIES YOU SAY YOU HAVE XTR TB AND YOU'RE FINISHED. THERE'S NOTHING ELSE YOU CAN DO. THAT'S NOT VERY MUCH TIME FOR A DIAGNOSTIC DEVELOPER. THE SECOND REASON IF YOU HAVE ACCESS TO SECOND LINE DRUGS, CURE RATES IN COUNTRIES WITHOUT SUBSTANTIAL SOURCES TO ADMINISTER THOSE ARE QUITE LOW. AND SIMPLY GENERATING MORE TDR OUT OF YOUR MDR IS POST STRATEGY. THE OTHER REASON IS THAT WE HAVE ACTUALLY VERY LITTLE DATA ABOUT WHAT OUR IN VITRO TESTS MEAN. IF YOU ARE -- RESISTENT IN HONG KONG IT DOESN'T MATTER, EVEN IF YOU ARE -- RESISTENT AS WELL. DOES THAT MEAN PBA IS WORKING ANYWAY OR IS THAT BECAUSE IT DIDN'T MATTER IN THE FIRST PLACE. IT'S HARD TO SAY. IT'S VERY HARD THEN TO JUSTIFY DOING IT, DEVELOPING IT INTO AN ASSAY. FOR EVERY DRUG EXCEPT FOR SAMPLING WE KNOW WE'RE MISSING SOMETIMES 10, SOMETIMES MORE THAN 20% OF THE MUTATIONS BECAUSE WE SIMPLY HAVEN'T MAPPED THEM ALL. WHEN THEY INVOLVE OVER EXPRESSION OR OTHER THINGS THAT ARE MORE DIFFICULT TO DETECT, IT MAKES IT HARDER TO DESIGN THEM. WHEN YOU DEVELOP A MOLECULAR ALLEGE -- ASSAY -- WE HAVE ONE ASSAY DEVELOPED OVER TIME -- SO IT'S 98% SENSITIVE. AND 75 FOR -- SO WHAT HAVE YOU LEARNED WHEN YOU TEST. YOU KNOW THEY HAVE HIGH NDR RISK AND RESISTANCE. -- ISN'T GOING TO TELL YOU MUCH BECAUSE IT JUST ISN'T HELPING. SO WE WILL DEVELOP SOME OF THESE. OUR INTEREST IN A COMPANY'S NEW REGIMEN COMING OUT IN 2017 AND BEYOND, PBA, NEW DRUG-BASED REGIMEN. SO WE'RE TRYING TO WORK WITH THE DRUG COMPANIES WHAT THEY ALREADY KNOW ABOUT THE RESISTANCE MARKERS AND THE DRUG DEVELOPING AND HOW WE COULD AHEAD OF TIME START DEVELOP ASSAY. >> THERE'S A LOT OF THINGS THAT CAUSE ACUTE FEBRILE DISEASES CAN YOU MAKE THIS THING KIND OF MULTIPLEX. IF YOU ADDED A SECOND, THIRD, FOURTH OR FIFTH DISEASE TO THE TEST, HOW DOES THAT AFFECT THE COST. >> WE'VE SEEN A LOT OF TIMES THIS ISSUE. SO IT'S A COMPLICATED ANSWER BUT WE HAVE BEEN DOING SOME LARGE STUDIES IN CAMBODIA AND LAOS LOOKING AT IT AND WHAT CAUSES IT. SO WE DID SOME ASSAYS AND SAME CULTURE ASSAYS ON SEVERAL THOUSAND PEOPLE TO FIND OUT WHAT'S WRONG WITH THEM. YOU GET A SMATTERING OF INTERESTING THINGS IN DUPLICATE AND TRIPLICATE POSITIVE AND WE TESTED CONTROLS AS WELL. AND YOU GET FASCINATING DATA. ONE OF THE DATA POINTS IS, THE CONTROL IN OUR STUDY WAS WHOEVER BROUGHT THE PATIENT IN. TYPICALLY THE TEN YEAR OLD BOY WITH A FEVER AND HIS MOTHER. AND THE CASE WITH THE TEN YEAR OLD WAS SICK IN THE CLICK AND YOU WORK HIM UP. WE ASKED THE MOTHER AND THE PATIENT THE SAME QUESTION, DO YOU HAVE A FEVER NOW OKAY WE'LL MEASURE IT. HAVE YOU HAD A FEVER IN THE LAST WEEK. OF THE CONTROLS, ALMOST ALL OF THEM HAD FEVER IN THE LAST WEEK ARE VERY HIGH NUMBERS. IN FACT, AS MANY AS PATIENTS HAD FEVER AT THE TIME OF VISITING. SO YOU REALIZE YOU'RE LOOKING AT SORT OF, YOU'RE LOOKING AT JUST THE TIP OF THE ICEBERG IN TERMS OF THE CLINICAL PATIENTS YOU HAPPEN TO SEE HAVE THE SAME STUFF IN THEM AS ALL THE NON-CLINICAL PATIENTS. AND IT'S OFTEN MULTIPLE THINGS. THIS IS ONE OF THE ISSUES OF MULTIPLEX, YOU SET UP SOMETHING -- ETCETERA AND YOU RUN THAT AND EVERY POSITIVE GIVES A FALSE POSITIVE. THAT'S HARD FOR GROUPS TO ADJUST TO. WHEN YOU START INCLUDING, IF IT'S A PULMONARY ASSAY, MOST OF THOSE ARE NOT PATHOGENS. SO YOU GET SOME -- YOU DON'T KNOW WHAT TO DO WITH THOSE DATA. BUT THE REAL PROBLEM WITH MULTIPLEX TESTING IS THE BUSINESS CASE. YOU MENTIONED THIS. IT COSTS MORE. MOST OF THE CONTROL AND THE MOTION ASSAYS YOU RUN, YOU START LOSING SENSITIVITY AND YOU START HAVING DIFFICULTY CONTROLLING OVER PART OF EVERY REACTION. AND THE NUMBER OF PATIENT CONTROLS -- GO UP, AS THE COST ESCALATES, NOBODY WANTS TO PAY FOR THAT EXTRA ONE. WE'VE GOT A PROGRAM -- THE FIRST THING YOU DO IN SLEEPING SICKNESS EVALUATIONS IS TO SEE IF THEY HAVE MALARIA. WE'RE WORKING WITH STANDARD DIAGNOSTICS WITH JAPAN AND KOREA AND WE DEVELOPED FOR THEM ASSAYS FOR BOTH. IT DRIVES THE COST UP $.15. GOES FROM $.7 5 TO $.90 AND YOU GO TO THE GOVERNMENT OF VIETNAM AND THEY WOULD SAY WE WOULD NEVER BY THAT. EVEN IN THE CONGO, WE HAVE SO FEW PEOPLE WITH SLEEPING SIGNALS THAT WE JUST TAKE A TEST AND NOT HAVE ALL OF OUR TESTING TO BE MORE EXPENSIVE. AND THE MORE ASSAYS YOU ADD TO THAT AND WHAT VALUE I'M GETTING. OBVIOUSLY IF YOU CAN CLUSTER THOSE AND SAY THIS PERSON HAS A DOCK CYCLINE -- THOSE PARADIGMS ARE HARD TO WORK OUT. AND WE HAVE A HUGE DATA CAP. WHEN WE THANK YOU TO OUR FRIENDS IN THE FIELD ABOUT EVALUATING THESE PEOPLE AND ASKING THEM WHAT ASSAYS, YOU KNOW, WHAT DOES IT LOOK LIKE IN A MULTIPLEX ASSAY. HOW IS IT PACKAGED, HOW IS IT WRAPPED, HOW DO YOU USE IT, WHAT DOES IT DO, WHAT DOES IT TELL YOU. THEY SAY LOOK, 95% OF THE KIDS THAT COME TO THE CLINIC SICK GO HOME, ARE GET BETTER. 5% HAVE A TERRIBLE OUTCOME. IF YOU CAN TELL ME WHO THOSE FIVE ARE I'LL TREAT THEM FOR PARASITES AND BACTERIA AND WATCH THEM FOR VIRUSES AND IT WILL SAVE ME MONEY -- SO MARKERS OF ILLNESS ARE VERY INTERESTING. UNFORTUNATELY EVERY ILLNESS TURNS UP TO BE SEVERE ILLNESS AND NOT DIAGNOSTIC MARKERS AND WE DON'T HAVE VERY GOOD ONES. >> FOR A FRIDAY AFTERNOON PERFORMANCE, IT WAS ABSOLUTELY EXCELLENT. ANYBODY WHO HAS ADDITIONAL QUESTIONS COME ON DOWN IN FRONT. AND THANK YOU FOR ALL OF YOU. THANK YOU VERY MUCH.