PARTNERSHIPS FOR ENHANCED ENGAGEMENT IN RESEARCH (PEER) Cycle 8 (2019 Deadline) Evaluation of a novel SS-LAMP assay for rapid, low-cost diagnosis of tuberculosis in Morocco PI: Hassan Ait Benhassou (h.aitbenhassou@mascir.com), Moroccan Foundation for Advanced Science Innovation and Research (MAScIR), in partnership with Université Mohammed V U.S. Partner: Adithya Cattamanchi, University of California, San Francisco Project Dates: October 2020 - October 2021 Project Overview:   Project members working in the lab (photo courtesy of Dr. Benhassou). Tuberculosis (TB) is one of the deadliest infectious diseases worldwide. Each year, about 1% of the world’s population is newly infected, about 9 million develop the disease, and approximately 2 million of them die. In Morocco, as in most developing countries, where the timely and accurate diagnosis of TB remains a great challenge, the disease constitutes a major public health threat, with 30,000 new cases each year. Currently, the conventional methods used routinely to diagnose the disease, such as microscopy and culture, are complex, unreliable, labor-intensive, technically challenging, and time-consuming. Although semi-automated PCR (Xpert MTB/RIF) is now available, it has high device and consumable costs and requires stable electricity. The laboratory of the PI Dr. Ait Benhassou has developed a novel assay called SS-LAMP (Single Step Loop Mediated Isothermal Amplification) for the diagnosis of TB. SS-LAMP provides a number of advantages over microscopy, including superior sensitivity and significantly less operating time, and compared to GeneXpert it does not require expensive instrumentation or electricity. Furthermore, SS-LAMP has the advantage of being able to be directly used without the need of sputum processing steps and to be easily integrated into a portable, battery-powered Lab-on-Card device developed in the PI’s lab. Their SS-LAMP is proposed to provide a low-cost, more accurate, and more convenient alternative to sputum smear microscopy for the detection of pulmonary TB in limited resource settings. In this last mile pilot study supported by PEER, the researchers will evaluate on a large population the clinical accuracy and operational features of the SS-LAMP for the detection of pulmonary TB in clinical settings in Morocco. They will compare the performance of the SS-LAMP assay with sputum smear microscopy and XpertMTB/RIF. The project will involve the enrollment of 700 consenting individuals with TB typical symptoms in Casablanca and Tangier. Three sputum samples will be collected from each of these TB presumptive cases. The single SS-LAMP test will be compared with GeneXpert MTB/RIF, using mycobacterial culture as a reference standard. Thanks to its simplicity, robustness, ease of use, and ability to be performed in simple laboratories, small-scale hospitals, and primary care facilities, SS-LAMP appears promising as a diagnostic tool for containing the spread of TB in Morocco and other high burden countries. The roll-out of the SS-LAMP assay can play a key role in strengthening access to quality care for the most vulnerable and underserved populations in overpopulated urban zones, as well as in remote rural villages. The PI and his team believe that this test will revolutionize TB diagnosis and control in Morocco, as patients will receive accurate and rapid results and can be placed on an appropriate drug regimen, saving households and health systems time and money. At the educational level, the project should also contribute to ensuring and improving access to knowledge, improving the quality of research, and stimulating innovation, in order to contribute to the country development. Final Summary of Project Activities Given that the project focused on infectious disease diagnostics, it was significantly impacted by the COVID-19 outbreak and subsequent shutdowns, particularly as the PI and his team were drawn into Moroccan pandemic mitigation efforts. In the project ramp-up, two preparation meetings and a one-day training on the use of the MAScIR TB SS-LAMP solution were organized for the Laboratory of Tuberculosis technicians of the Pasteur Institute (PI) of Morocco. Patients were then enrolled in the Laboratory of Mycobacteria and Tuberculosis of Casablanca, but the Laboratory of Mycobacteria Genetics of Tangier was excluded from the study due to COVID-19 restrictions and lack of staff. Patients with suspected pulmonary TB were included and each patient recruited submitted samples for both Acid-Fast Bacillus (AFB) test and the MAScIR TB-LAMP and the Xpert MTB/RIF test to compare the effectiveness of the new kit. This study demonstrated that the MAScIR TB SS-LAMP had a high accuracy (95%) in the detection of pulmonary tuberculosis. The AFB results were used as a reference. Given this success and to promote the team’s solution among stakeholders, as well as ensure its implementation on the ground, the team met with different national and international private companies, universities, institutions, government representatives, diplomatic delegations, and the local USAID mission in Morocco. During October 2020, the team held four brainstorming technical meetings (via Microsoft teams) with Tronico Alcen (France) regarding the industrialization of the LAMP-TB/ Lab-on-Card for the diagnosis of the tuberculosis. During COVID-19, Tronico developed a device called EasyCov similar to the project team’s lab-on-card for the rapid diagnosis of COVID-19. In collaboration with this company, the team submitted a pre-proposal in response to a grant call launched by the Moroccan CNRST institute/OCP/UM6 Polytechnic University. The project team also launched a discussion with the French start-up C4Diagnostics. The focus was a potential collaboration for the development of an assay based on LAMP technology for the diagnosis of COVID-19. C4Diagnostics is a biotech start-up specialized in the development of diagnostic kits, and they wanted to take advantage of the PI’s lab expertise in the development of the LAMP-based tuberculosis assay for the development of their COVID-19 test. An agreement was signed to launch the collaboration. The team also signed a partnership agreement with Laprophan Laboratories for medical R&D projects in line with the country's health needs. MAScIR and Laprophan sought to meet the current needs of Moroccan industry and economic operators to promote "Made in Morocco". The team also met with Pharma5 to discuss the capabilities and logistics for the production of 1 million MAScIR TB SS-LAMP test kits. Pharma5 has been the leading supplier of 100% Moroccan Tuberculosis treatments for over 35 years. Alongside the public authorities, the laboratory is participating in national efforts to raise awareness and treat this disease, which is still very prevalent in Morocco. In the frame of this scope and by integrating the PEER team’s solution, Pharma5 is planning to provide a diagnosis/treatment package against TB. At the academic and research levels, the team closely interacted with national universities, including Mohammed V University. Despite the pandemic, the project developed a new course entitled "A promising LAMP technology: Perspectives and Challenges in diagnostics" at the Faculty of Science of Rabat. The team also received delegations from the Sheikh Khalifa Ibn Zaid Al Nahyan Foundation, the Mohammed VI International University Hospital, the National Reference Laboratory, and the Mohammed VI University of Sciences of Health - UM6SS. The visitors learned about the various projects of the MAScIR Foundation, including their SS-LAMP/Lab-on-Card solution. They also met with Imperial College London and Istanbul Koc University who have a project for the diagnosis of TB among Syrian refugees in Turkey and are interested in signing a technology transfer contract with MAScIR in order to use their SS-LAMP/Lab-on-Card solution. As the team contributed greatly in the efforts of the Moroccan government to resolve the COVID-19 pandemic by providing cost-effective RT-PCR kits, they had the privilege of demonstrating their work to high-ranking government representatives. Specifically, they received Mrs. Noureddine Boutayeb, Minister Delegate to the Minister of the Interior; Said Amzazi, Minister of National Education, Vocational Training, Higher Education, and Scientific Research; and Khalid Ait Taleb, Minister of Health. Mrs. Bouchra Meddah, Director of Medicines and Pharmacy, Ministry of Health, and Mr. Mohamed Rhajaoui, Director of the National Institute of Hygiene, Ministry of Health, also accompanied the delegation. The ministerial delegation learned about the various projects carried out by the center and the solutions developed. Stakeholders expressed particular interest in the SS-LAMP/Lab-on-Card tuberculosis diagnostic solution. Furthermore, the team received Dr. Hakima Yahia, head of the Moroccan Laboratory of Forensic Sciences at the General Directorate of National Security, and his team. They are interested in adapting and testing the SS-LAMP solution for forensic identification of bodily fluids. The team also met with Mr. Chakib Benmoussa, Moroccan Ambassador to France and President of the Special Commission on the Development Model. Alongside with government agencies, the project organized a visit to their research laboratories for a delegation of diplomats comprised of Ms. Sylvia Lopez-Ekra, new resident coordinator of operational activities of the United Nations in Morocco, as well as Ms. Leila Farah Mokaddem, Hanan Hanzaz, Maryam Bigdeli, and Anna Barone, the country representatives in Morocco of the African Development Bank, United Nations Industrial Development Organization, World Health Organization, and European Bank of Investment, respectively. After discussing the research work carried out by the Foundation, the members of the delegation expressed their desire to initiate a broader dialogue with MAScIR and to build an institutional and multifaceted partnership to promote expertise of the Foundation in supporting the private and productive sectors of the African continent. Discussions also focused on the potential support that these organizations, both in terms of funding and support aimed at strengthening the visibility of the MAScIR Foundation at the regional level, particularly in the field of health. The delegation was particularly interested in the Moldiag startup resulting from the team’s lab research work, and specialized in the development and production of molecular diagnostic kits, including tuberculosis kits. Dr. Bigdeli also strongly recommended MAScIR TB SS-LAMP to be pre-qualified with the WHO. The team was also honored to receive the ambassadors of Switzerland, Canada, Egypt, Japan, Mexico, Cuba, and the United Kingdom, along with Kevin Lothridge and David L. Sylvester, respectively executive director and deputy executive director of the National Forensic Science Technology Center (USA), to whom they presented their TB diagnostic assay. The research work was, and continues to be, disseminated as well through workshops, meetings, social and other online media, and newspapers. Back to PEER Cycle 8 Grant Recipients