Cepheid GXMPX-10 Xpert Mpox GeneXpert Real Time PCR Test Instruction Manual
- June 9, 2024
- Cepheid
Table of Contents
- GXMPX-10 Xpert Mpox GeneXpert Real Time PCR Test
- Proprietary Name
- Common or Usual Name
- Intended Use
- Summary and Explanation
- Principle of the Procedure
- Materials Provided
- Storage and Handling
- Materials Required but Not Provided
- Materials Available but Not Provided
- Warnings and Precautions
- Chemical Hazards⁸,⁹
- Specimen Collection, Transport and Storage
- Procedure
- Running the Test
- Quality Control
- Interpretation of Results
- Retests
- Limitations
- Conditions of Authorization
- Performance Characteristics
- References
- Cepheid Headquarters Locations
- Technical Assistance
- Table of Symbols
- Revision History
- Documents / Resources
GXMPX-10
Xpert Mpox GeneXpert Real Time PCR Test
Instruction Manual
GXMPX-10 Xpert Mpox GeneXpert Real Time PCR Test
Instructions for Use
For Use Under an Emergency Use Authorization (EUA) Only
For Use with GeneXpert® Dx or GeneXpert® Infinity Systems
Trademark, Patents and Copyright Statements
Cepheid®, the Cepheid logo, GeneXpert®, and Xpert®
are trademarks of Cepheid, registered in the U.S. and other countries.
All other trademarks are the property of their respective owners.
THE PURCHASE OF THIS PRODUCT CONVEYS TO THE BUYER THE NON-TRANSFERABLE RIGHT
TO USE IT IN ACCORDANCE WITH THESE INSTRUCTIONS FOR USE. NO OTHER RIGHTS ARE
CONVEYED EXPRESSLY, BY IMPLICATION OR BY ESTOPPEL.
FURTHERMORE, NO RIGHTS FOR RESALE ARE CONFERRED WITH THE PURCHASE OF THIS
PRODUCT.
© 2023 Cepheid.
See Section 25, Revision History for a description of changes.
For use under the Emergency Use Authorization (EUA) only.
For In Vitro Diagnostic Use
Proprietary Name
Xpert® Mpox
Common or Usual Name
Xpert Mpox
Intended Use
The Xpert® Mpox is a real-time PCR test intended for the qualitative detection
of DNA from monkeypox virus clade II and non-variola Orthopoxvirus DNA in
human lesion swab specimens (i.e., swabs of acute pustular or vesicular rash)
from individuals suspected of mpox by their healthcare provider.
Testing on the GeneXpert Dx and GeneXpert Infinity instruments is limited to
laboratories certified under the Clinical Laboratory Improvement Amendments of
1988 (CLIA), 42 U.S.C. §263a, that meet requirements to perform high or
moderate complexity tests.
Testing on the GeneXpert Xpress (Hub Configuration) instrument is limited to
laboratories certified under CLIA that meet requirements to perform high,
moderate, or waived complexity tests. Testing on the GeneXpert Xpress (Hub
Configuration) instrument is authorized for use at the Point of Care (POC),
i.e., in patient care settings operating under a CLIA Certificate of Waiver,
Certificate of Compliance, or Certificate of Accreditation.
Results are for the identification of monkeypox virus (clade II) and non-
variola Orthopoxvirus DNA which are generally detectable in human pustular or
vesicular lesion specimens during the acute phase of infection. Positive
results are indicative of the presence of monkeypox virus (clade II) and/or
non-variola Orthopoxvirus DNA; clinical correlation with patient history and
other diagnostic information is necessary to determine patient infection
status. Positive results do not rule out bacterial infection or co-infection
with other viruses. The agent detected may not be the definite cause of
disease. Negative results obtained with this device do not preclude monkeypox
virus (clade II) and/or non-variola Orthopoxvirus infection and should not be
used as the sole basis for treatment or other patient management decisions.
Negative results must be combined with clinical observations, patient history,
and epidemiological information.
Laboratories within the United States and its territories are required to
report test results to the appropriate public health authorities.
The Xpert Mpox is intended for use by trained operators who are proficient in
performing a test using either GeneXpert Dx, GeneXpert Infinity and/or Gene
Xpert Xpress systems.
The Xpert® Mpox test is only for use under the Food and Drug Administration’s
Emergency Use Authorization.
Summary and Explanation
Monkeypox virus (MPXV) is an enveloped double-stranded DNA virus that belongs
to the Orthopoxvirus genus of the Poxviridae family. Mpox is a viral zoonotic
disease capable of human-to-human transmission. The first human case of mpox
was identified in 1970 in the Democratic Republic of the Congo (DRC). The
disease is considered endemic to Central and West Africa¹. Two clades of
monkeypox virus have been described; monkeypox virus clade I (formerly Congo-
basin) is associated with a higher rate of mortality compared to clade II
(formerly West-African).¹,²
Monkeypox virus has an incubation period ranging from 5-21 days, initial
symptom onset typically last 1-5 days and consists of fever, headache,
myalgia, lymphadenopathy, and fatigue before the appearance of
vesiculopustular rash lasting approximately 2-3 weeks³. Human-to-human
transmission occurs via direct contact with lesions or bodily fluids, through
contaminated fomites, or through respiratory secretions¹,³. In the spring of
2022 several cases of mpox, specifically monkey virus clade IIb, were
identified in nonendemic areas¹. This was followed by U.S. Department of
Health and Human Services declaring mpox as a Public Health Emergency (PHE) in
the United States on August 4, 2022⁴.
Principle of the Procedure
The Xpert Mpox test is an automated in vitro diagnostic test for the
qualitative detection and identification of monkeypox virus (MPXV) clade II
DNA and non-variola Orthopoxvirus DNA. The Xpert Mpox test is performed on
GeneXpert® Instrument Systems.
The GeneXpert Systems automate and integrate sample preparation, nucleic acid
extraction and amplification, and detection of the target sequences in simple
or complex samples using real-time PCR tests. The systems consist of an
instrument, computer, and preloaded software for running tests and viewing the
results. The systems require the use of single-use disposable cartridges that
hold the real-time PCR reagents and host the real-time PCR process. Because
the cartridges are self-contained, cross-contamination between samples is
minimized. For a full description of the system, see the GeneXpertDx System
Operator Manual or the GeneXpert Infinity System Operator Manual.
The Xpert Mpox test includes reagents for the detection of MPXV clade II (MPXV
target 1 and target 2) and non-variola Orthopoxvirus (OPXV, OPXV-E9L NVAR)
targets in lesion swab specimens. 5 A Sample Processing Control (SPC), a
Sample Adequacy Control (SAC), and a Probe Check Control (PCC) are also
included in the cartridge utilized by the GeneXpert instrument. The SPC is
present to control for adequate processing of the sample and to monitor for
the presence of potential inhibitor(s) in the realtime PCR reaction. The SPC
also ensures that the real-time PCR reaction conditions (temperature and time)
are appropriate for the amplification reaction and that the real-time PCR
reagents are functional. The SAC reagents detect the presence of a single copy
human gene and monitor whether the sample contains human DNA. The PCC verifies
reagent rehydration, PCR tube filling, and confirms that all reaction
components are present in the cartridge including monitoring for probe
integrity and dye stability.
The Xpert Mpox test is designed for use with lesion swabs collected by a
health care provider from patients suspected of having mpox.
The specimen is collected and placed into a transport tube containing 3 mL of
viral transport medium or Universal Transport Medium(VTM/UTM®). The specimen
is briefly mixed by rapidly inverting the collection tube 5 times. Using the
supplied transfer pipette, the specimen is transferred to the sample chamber
of the Xpert Mpox test cartridge. The GeneXpert cartridge is loaded onto the
GeneXpert Instrument System platform, which performs hands-off, automated
sample processing, and real-time PCR for detection of viral DNA.
Materials Provided
The Xpert Mpox test kit contains sufficient reagents to process 10 specimens or quality control samples. The kit contains the following:
Tubes | 10 |
---|---|
Bead 1, Bead 2, Bead 3 and Bead 4 (freeze-dried) | 1 of each per cartridge |
Lysis Reagent (Guanidinium Thiocyanate) | 1 mL per cartridge |
Binding Reagent | 1 mL per cartridge |
Elution Reagent | 3.0 mL per cartridge |
Wash Reagent | 0.4 mL per cartridge |
Disposable 300 µL Transfer Pipettes | 2 bags of 12 per kit |
Flyer | 1 per kit |
Instructions to locate (and import) the Assay Definition
File (ADF) and documentation such as the IFU on
www.cepheid.com
Quick Reference Instructions
For use with the GeneXpert Xpress System (Hub Configuration) only| 1 per
kit
Note
Safety Data Sheets (SDS) are available at
www.cepheid.com or
www.cepheidinternational.com under
the SUPPORT tab.
Note
The bovine serum albumin (BSA) in the beads within this product was
produced and manufactured exclusively from bovine plasma sourced in the United
States. No ruminant protein or other animal protein was fed to the animals;
the animals passed ante- and post- mortem testing. During processing, there
was no mixing of the material with other animal materials.
Storage and Handling
- Store the Xpert Mpox test cartridges at 2–28 °C until the expiration date provided on the label.
- Do not open a cartridge until you are ready to perform testing.
- Do not use cartridges that have passed the expiration date.
- Do not use a cartridge that is wet or has leaked.
Materials Required but Not Provided
- Nylon flocked swab (Copan P/N 502CS01, or equivalent)
- Viral transport medium/Universal transport medium (VTM/UTM), 3 mL (Copan P/N 3C047N or equivalent)
- GeneXpert Dx System or GeneXpert Infinity System (catalog number varies by configuration): GeneXpert Instrument, computer, barcode scanner, and operator manual.
- For GeneXpert Dx System: GeneXpert Dx software version 4.7b or higher
- For GeneXpert Infinity-80 and Infinity-48 systems: Xpertise software version 6.4b or higher
- Printer: If a printer is required, contact Cepheid Technical Support to arrange for the purchase of a recommended printer
Materials Available but Not Provided
External controls are available from ZeptoMetrix® (Buffalo, NY).
- External Positive Control: Catalog # NATMPXVPOS-6C
- External Negative Control: Catalog # NATMPXVNEG-6C
Warnings and Precautions
10.1 General
-
For in vitro diagnostic use.
-
For use under emergency authorization only.
-
For prescription use only.
-
This product has not been FDA cleared or approved but has been authorized by FDA under an EUA for use by authorized laboratories.
-
This product has been authorized only for the detection of nucleic acid from monkeypox virus or other non-variola orthopoxviruses, not from any other virus or pathogens.
-
The emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of infection with the monkeypox virus, including in vitro diagnostics that detect and/or diagnose infection with non-variola Orthopoxvirus, under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the declaration is terminated or authorization is revoked sooner.
-
Laboratories within the United States and its territories are required to report all results to the appropriate public health authorities.
-
Treat all biological specimens, including used cartridges, as if capable of transmitting infectious agents. Because it is often impossible to know which might be infectious, all biological specimens should be treated with standard precautions.
-
Guidelines for specimen handling are available from the U.S. Centers for Disease Control and Prevention6 and the Clinical and Laboratory Standards Institute⁷.
-
Performance characteristics of this test have been established with the specimen types listed in the Intended Use Section only.
The performance of this test with other specimen types or samples has not been evaluated. -
Follow your institution’s safety procedures for working with chemicals and handling biological samples.
-
Do not allow Lysis Reagent, which contains guanidinium thiocyanate, to contact sodium hypochlorite (bleach). This mixture can produce a highly toxic gas.
-
Testing of lesion swab specimens using the Xpert Mpox test run on the GeneXpert Dx or Infinity Systems, is authorized for use or laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, that meet the regulatory requirements to perform high or moderate complexity testing.
-
Biological specimens, transfer devices, and used cartridges should be considered capable of transmitting infectious agents requiring standard precautions. Follow your institution’s environmental waste procedures for proper disposal of used cartridges and unused reagents. These materials may exhibit characteristics of chemical hazardous waste requiring specific disposal. If country or regional regulations do not provide clear direction on proper disposal, biological specimens and used cartridges should be disposed per WHO [World Health Organization] medical waste handling and disposal guidelines.
10.2 Specimens
-
Specimen collection and handling procedures require specific training and guidance.
-
For collection and transport of lesion swab specimens, use viral transport medium/universal transport medium (Copan P/N 3C047N, or equivalent) and nylon flocked swab (Copan P/N 502CS01, or equivalent).
-
Specimens must be collected and tested before the expiration date of the viral transport medium (VTM/UTM) tube.
-
Maintain proper storage conditions during specimen transport to ensure the integrity of the specimen (see Section 12).
Specimen stability under shipping conditions other than those recommended has not been evaluated. -
Proper sample collection, storage, and transport are essential for correct results.
10.3 Test/Reagent
- The test has been validated using Cepheid GeneXpert Dx software version 4.7b or higher, and Cepheid Xpertise software version 6.4b or higher. Cepheid will validate future software versions for use with the Xpert Mpox test.
- Do not substitute Xpert Mpox test reagents with other reagents.
- Do not open the Xpert Mpox test cartridge lid except when adding sample.
- Do not use a cartridge that has been dropped after removing from the kit or shaken after the cartridge lid has been opened. Shaking or dropping the cartridge after opening the lid may yield false or non-determinate results.
- Do not place the sample ID label on the cartridge lid or on the barcode label.
- Do not use a cartridge with a damaged barcode label.
- Do not use a cartridge that has a damaged reaction tube.
- Do not use reagents beyond their expiry date.
- Each single-use Xpert Mpox test cartridge is used to process one test. Do not reuse spent cartridges.
- Each single-use disposable pipette is used to transfer one specimen. Do not reuse disposable pipettes.
- Do not use a cartridge if it appears wet or if the lid seal appears to have been broken.
- Wear clean lab coats and gloves. Change gloves between the handling of each specimen.
- In the event of a spill of specimens or controls, wear gloves and absorb the spill with paper towels. Then, thoroughly clean the contaminated area with a 1:10 dilution of freshly prepared household chlorine bleach. Final active chlorine concentration should be 0.5%. Allow a minimum of two minutes of contact time. Ensure the work area is dry before using 70% denatured ethanol to remove bleach residue. Allow surface to dry completely before proceeding. Or, follow your institution’s standard procedures for a contamination or spill event. For equipment, follow the manufacturer’s recommendations for decontamination of equipment.
Chemical Hazards⁸,⁹
- Signal Word: WARNING
- UN GHS Hazard Statements
- Harmful if swallowed
- May be harmful in contact with skin
- Causes eye irritation
- UN GHS Precautionary Statements
- Prevention
- Wash hands thoroughly after handling.
- Response
- If skin irritation occurs: Get medical advice/attention.
- IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing.
- If eye irritation persists: Get medical advice/attention.
- Call a POISON CENTER or doctor/physician if you feel unwell.
Specimen Collection, Transport and Storage
Proper specimen collection, storage, and transport are critical to the
performance of this test. Inadequate specimen collection, improper specimen
handling and/or transport may yield a false result. See Section 12.1 for
lesion swab collection procedure. Lesion swab specimens can be stored at room
temperature (15–30 °C) for up to 48 hours in viral transport medium (VTM/UTM)
until testing is performed on the GeneXpert Instrument Systems. Alternatively,
lesion swab specimens can be stored refrigerated (2–8 °C) up to seven days in
viral transport medium (VTM/UTM) until testing is performed on the GeneXpert
Instrument Systems.
Refer to the CDC Guidelines for Collecting and Handling Specimens for Mpox
Testing https://www.cdc.gov/poxvirus/Mpox/clinicians/prep-collection-
specimens.html
12.1 Lesion Swab Collection Procedure
- Using a sterile swab apply firm pressure to the lesion and swipe the swab back and forth at least 2-3 times before rotating the swab and repeating using the other side of the swab. If the lesion ruptures while swabbing, ensure to collect the lesion fluid (See Figure 1).
- Remove and place the swab into the tube containing 3 mL of viral transport medium (VTM/UTM). Break swab at the indicated break line and cap the specimen collection tube tightly.
Procedure
13.1 Preparing the Specimen and Cartridge
Important
Start the test within 30 minutes of adding the sample to the cartridge.
-
Obtain the following items: Xpert Mpox test cartridge, 300 µL transfer pipette (provided), and an appropriately collected and labeled test sample.
-
Remove a cartridge from the package.
-
Inspect the cartridge for damage. If damaged, do not use it.
-
Ensure the specimen tube is tightly capped. Mix specimen by inverting the specimen tube five times. Open the cap on the specimen transport tube.
-
Open the cartridge lid by lifting the lid.
-
Remove the transfer pipette from the wrapper.
Note
Do not place unwrapped pipette on the workbench. -
Squeeze the top bulb of the transfer pipette completely and then place the pipette tip in the specimen transport tube (Figure 2).
Number| Description
---|---
1| Squeeze here
2| Pipette
3| Overflow Reservoir Bulb
4| Sample -
Slowly release the top bulb of the pipette slowly to fill the length of the pipette before removing from the tube. After filling pipette, excess sample will be seen in the overflow reservoir bulb of the pipette (Figure 2). Check that the pipette does not contain bubbles.
-
To transfer the sample to the cartridge, squeeze the top bulb of the transfer pipette completely again to empty the contents of the pipette into the large opening (Sample Chamber) in the cartridge shown in Figure 3. Dispose of the used pipette in a biohazard container. Note
Take care to dispense the entire volume of liquid into the sample chamber. False negative results may occur if insufficient sample is added to the cartridge. -
Close the cartridge lid.
13.2 Running External Controls
External controls (described in Section 9) are available but not provided.
Note
The positive external control should provide a “MPXV Clade II Detected”
result. If a different result is obtained, repeat the positive external
control run.
Note
The negative external control should provide a “MPXV Clade II NOT DETECTED,
Non-variola OPXV NOT DETECTED” result. If a different result is obtained,
repeat the external control run.
Note
If the expected results for the external control materials are not obtained
upon repeat, contact Cepheid Technical Support.
When to Run External Controls – Positive and Negative Controls
Use external controls in accordance with local, state, and federal
accrediting organizations as applicable as well as according to the
frequencies indicated below.
– Each time a new shipment of Xpert Mpox kits is received, even if it is the
same lot previously received.
– Each time a new operator is performing the test (i.e., operator who has not
performed the test recently).
– When problems (storage, operator, instrument, or other) are suspected or
identified.
If using Positive Control #NATMPXVPOS-6C from ZeptoMetrix® (Buffalo, NY), the positive control #NATMPXVPOS- 6C must be diluted prior to use as follows:
- Label a 3 ml VTM/UTM tube “Diluted Positive Control”. Uncap the tube.
- Using an exact volume transfer pipette provided in the kit, add one draw (300 µL) of the (undiluted) Positive Control material to the VTM/UTM tube.
- Recap the tube tightly and mix by inverting the tube 5 times.
- Open the cartridge lid.
- Using a new exact volume transfer pipette provided in the kit, transfer one draw (300 µl) of the diluted Positive Control material into the large opening (Sample Chamber) in the cartridge shown in Figure 3.
- Close cartridge lid.
- Change gloves and clean workstation between and after running the controls.
- Proceed to Section 14 (Running the Test).
If using negative control #NATMPXVNEG-6C from ZeptoMetrix® (Buffalo, NY), the negative control (NATMPXVNEG- 6C) is ready to use directly. No additional preparation steps are necessary.
- Using new exact volume transfer pipette provided in the kit, add one draw (300 µl) of the Negative Control material into the large opening (Sample Chamber) in the cartridge shown in Figure 3.
- Close cartridge lid.
- Proceed to Section 14 (Running the Test).
Running the Test
- For the GeneXpert Dx System, see Section 14.1.
- For the GeneXpert Infinity System, see Section 14.2.
14.1 GeneXpert Dx System
14.1.1 Starting the Test
Before you start the test, make sure that:
Important
- The system is running the correct GeneXpert Dx software version shown in Section 8- Materials Required but Not Provided.
- The correct assay definition file is imported into the software.
This section lists the basic steps for running the test. For detailed
instructions, see the GeneXpert Dx System Operator Manual.
Note
The steps you follow can be different if the system administrator changed the
default workflow of the system.
-
Turn on the GeneXpert Dx System, then turn on the computer and log on. The GeneXpert software will launch automatically. If it does not, double-click the GeneXpert Dx software shortcut icon on the Windows® desktop.
-
Log on using your username and password.
-
In the GeneXpert System window, click Create Test.
The Create Test window displays. The Scan Patient ID barcode dialog box displays. -
Scan or type in the Patient ID. If typing the Patient ID, make sure the Patient ID is typed correctly. The Patient ID is associated with the test results and displays in the View Results window and all the reports. The Scan Sample ID barcode dialog box displays.
-
Scan or type in the Sample ID. If typing the Sample ID, make sure the Sample ID is typed correctly.
The Sample ID is associated with the test results and displays in the View Results window and all the reports. The Scan Cartridge Barcode dialog box displays. -
Scan the barcode on the cartridge. Using the barcode information, the software automatically fills the boxes for the following fields: Select Assay, Reagent Lot ID, Cartridge SN, and Expiration Date.
Note
If the barcode on the cartridge does not scan, then repeat the test with a new cartridge. If you have scanned the cartridge barcode in the software and the assay definition file is not available, a screen displays indicating the assay definition file is not loaded on the system. If this screen displays, contact Cepheid Technical Support. -
Click Start Test. In the dialog box that displays, type your password, if required.
-
Open the instrument module door with the blinking green light and load the cartridge.
-
Close the door. The test starts and the green light stops blinking.
-
When the test is finished, the light turns off.
-
Wait until the system releases the door lock before opening the module door, then remove the cartridge.
-
Dispose of the used cartridges in the appropriate specimen waste containers according to your institution’s standard practices.
14.1.2 Viewing and Printing Results
This section lists the basic steps for viewing and printing results. For more
detailed instructions on how to view and print the results, see the GeneXpert
Dx System Operator Manual.
- Click the View Results icon to view results.
- Upon completion of the test, click the Report button of the View Results window to view and/or generate a PDF report file.
14.2 GeneXpert Infinity System
14.2.1 Starting the Test
Before you start the test, make sure that:
Important
- The system is running the correct Xpertise software version shown in Section 8 – Materials Required but Not Provided.
- The correct assay definition file is imported into the software.
This section lists the basic steps for running the test. For detailed
instructions, see the GeneXpert Infinity System Operator Manual.
Note
The steps you follow can be different if the system administrator changed the
default workflow of the system.
-
Power up the instrument. The Xpertise software will launch automatically. If it does not, double-click the Xpertise software shortcut icon on the Windows® desktop.
-
Log on to the computer, then log on to the GeneXpert Xpertise software using your username and password.
-
In the Xpertise Software Home workspace, click Orders and in the Orders workspace, click Order Test. The Order Test – Patient ID workspace displays.
-
Scan or type in the Patient ID. If typing the Patient ID, make sure the Patient ID is typed correctly.
The Patient ID is associated with the test results and displays in the View Results window and all the reports. -
Enter any additional information required by your institution and click the CONTINUE button.
The Order Test – Sample ID workspace displays. -
Scan or type in the Sample ID. If typing the Sample ID, make sure the Sample ID is typed correctly.
The Sample ID is associated with the test results and displays in the View Results window and all the reports. -
Click the CONTINUE button. The Order Test – Assay workspace displays.
-
Scan the barcode on the cartridge. Using the barcode information, the software automatically fills the boxes for the following fields: Select Assay, Reagent Lot ID, Cartridge SN, and Expiration Date. After the cartridge is scanned, the Order Test – Test Information workspace displays.
Note
If the barcode on the cartridge does not scan, then repeat the test with a new cartridge. If you have scanned the cartridge barcode in the software and the assay definition file is not available, a screen displays indicating the assay definition file is not loaded on the system. If this screen displays, contact Cepheid Technical Support. -
Verify that the information is correct and click Submit. In the dialog box that displays, type your password, if required.
-
Place the cartridge on the conveyor belt. The cartridge automatically loads, the test runs, and the used cartridge are placed into the waste container.
14.2.2 Viewing and Printing Results
This section lists the basic steps for viewing and printing results. For more
detailed instructions on how to view and print the results, see the GeneXpert
Infinity System Operator Manual.
- In the Xpertise Software Home workspace, click the RESULTS icon. The Results menu displays.
- In the Results menu, select the VIEW RESULTS button. The View Results workspace displays showing the test results.
- Click the REPORT button to view and/or generate a PDF report file.
Quality Control
15.1 Internal Controls
Each test includes a Sample Processing Control (SPC), a Sample Adequacy
Control (SAC), and a Probe Check Control (PCC).
Sample Processing Control (SPC) —Ensures the sample was processed
correctly. The SPC verifies that sample processing is adequate. Additionally,
this control detects sample-associated inhibition of the real-time PCR test,
ensures the PCR reaction conditions are appropriate for the amplification
reaction. The SPC should be positive in a negative sample and can be negative
or positive in a positive sample. The SPC passes if it meets the assigned
acceptance criteria.
Sample Adequacy Control (SAC) —Detects human cells or human DNA present
in the sample. This test includes primers and probe for the detection of a
single copy human gene. The SAC signal is only to be considered when the
sample is negative for both MPXV and OPXV analytes and SPC is positive. A
negative SAC indicates that no human cells are present in the sample due to
insufficient mixing of the sample or because of an inadequately collected
sample.
Probe Check Control (PCC) —Before the start of the PCR reaction, the
GeneXpert System measures the fluorescence signal from the probes to monitor
bead rehydration, reaction tube filling, and probe integrity. The PCC passes
if it meets the assigned acceptance criteria.
15.2 External Controls
Use external controls in accordance with local, state and federal accrediting
organizations as applicable. If the expected results for the external control
materials are not obtained, repeat the external controls, prior to releasing
patient results. If the expected results for the external control material are
not obtained upon repeat, contact Cepheid Technical Support.
Note
Cepheid recommends that all laboratories perform external QC with each new
lot and shipment of reagents, at a minimum, while running the Xpert Mpox test
under Emergency Use Authorization (EUA).
Interpretation of Results
The results are interpreted automatically by the GeneXpert System and are clearly shown in the View Results window. The Xpert Mpox test provides test results for the monkeypox virus and non-variola Orthopoxvirus targets, SAC, and SPC according to the algorithms shown in Table 1.
Table 1. Xpert Mpox Results Algorithm
Result | MPXV | OPXV | SAC | SPC |
---|---|---|---|---|
MPXV Clade II DETECTED | + | +/- | +/- | +/- |
Non-Variola OPXV DETECTED | – | + | +/- | +/- |
MPXV Clade II NOT DETECTED, Non-Variola OPXV NOT DETECTED | – | – | ||
+ | + | |||
INVALID | – | – | – | – |
– | – | – | + | |
– | – | + | – |
See Table 2 to interpret test results statements for the Xpert Mpox test.
Table 2. Xpert Mpox Result Interpretation
Result | Interpretation |
---|---|
MPXV Clade II DETECTED | Monkeypox virus Clade II DNA DETECTED |
This specimen is POSITIVE for monkeypox virus clade II.
Laboratories should notify appropriate Federal, State, or local public health
agencies of the test results in accordance with applicable laws.
Non-Variola OPXV DETECTED| Non-Variola Orthopoxvirus Viral DNA
DETECTED.
This specimen is POSITIVE for non-variola Orthopoxvirus DNA.
Low levels of monkeypox viral DNA in a specimen may on rare occasions, result
in monkeypox virus clade II DNA Not Detected and non- variola Orthopoxvirus
DNA Detected. This result may occur in the case of low monkeypox viral DNA
concentrations at levels near or below the limit of detection, or may indicate
another Orthopoxvirus infection although no other known orthopoxviruses are
currently circulating in the United States.
If clinically indicated, consider collecting another specimen.
Laboratories should notify appropriate Federal, State, or local public health
agencies of the test results in accordance with applicable laws.
MPXV Clade II NOT DETECTED, Non- Variola OPXV NOT
DETECTED| Monkeypox Clade II Viral DNA and Non-Variola Orthopoxvirus
Viral DNA not detected.
This specimen is NEGATIVE for monkeypox virus clade II DNA. If clinically
indicated, consider collecting another specimen.
Laboratories should notify appropriate Federal, State, or local public health
agencies of the test results in accordance with applicable laws.
NO RESULT| If the result is NO RESULT, repeat the test with a new
cartridge.
INVALID| If the result is INVALID repeat the test, if the second test is
INVALID collect a new specimen.
ERROR| The result is an instrument error or cartridge defect. Repeat the
test using a new cartridge.
If the results of the viral targets (monkeypox virus clade II or non-variola
Orthopoxvirus) are positive, the test can be considered valid regardless of
the results for the SPC and SAC.
The Xpert Mpox test includes an Early Assay Termination (EAT) function which will provide earlier time to results in high titer specimens if the signal from the target nucleic acid reaches a predetermined threshold before the full 45 PCR cycles have been completed. When viral titers are high enough to initiate the EAT function, the SPC, SAC and/or other target amplification curves may not be seen, and their results may not be reported.
Retests
17.1 Reasons to Repeat the Test
If any of the test results mentioned below occur, repeat the test once
according to instructions in Section 17.2.
An ERROR result could be due to, but not limited to, Probe Check Control
failure, system component failure, or the maximum pressure limits were
exceeded.
An INVALID result indicated that either all targets are negative or when both
the MPXV and OPXV targets are negative there is an SPC and/or SAC failure. The
sample was not properly processed, PCR is inhibited, or the sample was not
properly collected.
A NO RESULT indicates that insufficient data was collected. For example,
cartridge failed integrity test, the operator stopped a test that was in
progress, or a power failure occurred.
If an External Control fails to perform as expected, repeat the external
control test and/or contact Cepheid for assistance.
17.2 Retest Procedure
To retest a non-determinate result (INVALID, NO RESULT, or ERROR), use a new
cartridge.
Use the leftover sample from the original specimen transport medium tube or if
running a control, use a new external control.
- Put on a clean pair of gloves. Obtain a new Xpert Mpox test cartridge and a new transfer pipette
- Check that the specimen transport tube or external control tube is closed.
- Mix the sample by rapidly inverting the specimen transport medium tube or external control tube 5 times. Open the cap on the specimen transport tube or external control tube.
- Open the cartridge lid.
- Using a clean transfer pipette (supplied), transfer sample (one draw) to the sample chamber with the large opening in the cartridge.
- Close the cartridge lid.
Limitations
-
Xpert Mpox has been evaluated only for use in combination with the recommended external controls – External Positive NATMPXVPOS-6C and External Negative Control NATMPXVNEG-6C (ZeptoMetrix (Buffalo, NY), for use on the GeneXpert Dx, GeneXpert Xpress (hub configuration) and GeneXpert Infinity Systems using the procedures provided in these instructions for use only. Modifications to these procedures may alter the performance of the test.
-
Xpert Mpox has only been validated for use with specimens collected from lesions using a synthetic swab (Copan P/N 502CS01, or equivalent) which is placed into UTM or VTM. Test performance has not been validated for use with other collection media and/or specimen types. Use of other collection media and/or specimen types may lead to false positive, false negative or invalid results.
-
A specimen with a result of “MPXV Clade II NOT DETECTED, Non-Variola OPXV NOT DETECTED” does not preclude monkeypox virus infection and should not be used as the sole basis for treatment or other patient management decisions.
Collection of multiple specimens (and specimens collected at different time points) from the same patient may be necessary to detect the virus. -
Reliable results depend on proper sample collection, storage, and handling procedures.
-
Detection of monkeypox clade II viral DNA or non-variola Orthopoxvirus viral DNA is dependent on the number of copies present in the specimen. Detection of monkeypox clade II viral DNA or non-variola Orthopoxvirus viral DNA may be affected by sample collection methods (e.g., if a specimen is improperly collected, transported, or handled), patient factors (e.g., presence, type, and duration of symptoms), stage of infection (e.g., if collected too early or too late in the course of illness) and/or presence of interfering substances.
-
The performance of this test was established based on the evaluation of a limited number of clinical specimens. The clinical performance has not been established with all circulating variants but is anticipated to be reflective of the prevalent variants in circulation at the time and location of the clinical evaluation. Performance at the time of testing may vary depending on the variants circulating, including newly emerging strains of monkeypox virus and their prevalence, which may change over time. Results from the Xpert Mpox test should be interpreted in the context of other available laboratory and clinical data.
-
As with any molecular test, mutations within the target regions of Xpert Mpox could affect primer and/or probe binding resulting in failure to detect the presence of viral DNA.
-
Negative results do not preclude monkeypox virus clade II and/or non-variola Orthopoxvirus infection and should not be used as the sole basis for treatment or other patient management decisions.
-
False negative results may arise from improper sample collection, degradation of the viral DNA during shipping/storage, the presence of PCR inhibitors, and/or mutation(s) in the monkeypox virus and/or non-variola Orthopoxvirus.
-
False positive results may arise from contamination during specimen handling or preparation, or between patient specimens.
-
Results from the Xpert Mpox test should be interpreted by a trained professional in conjunction with the patient’s history and clinical signs/symptoms and epidemiological risk factors.
-
Viral nucleic acid may persist in vivo, independent of virus viability. Detection of analyte target(s) does not imply that the corresponding virus(es) are infectious or are the causative agents for clinical symptoms.
-
This test has been evaluated for use with human specimen material only.
-
The test performance was established during the 2022 mpox outbreak in the US. The performance may vary depending on the prevalence and population tested.
-
This test is a qualitative test and does not provide the quantitative value of detected organism present.
-
This test has not been evaluated for patients without signs and symptoms of monkeypox virus clade II infection.
-
This test has not been evaluated for monitoring treatment of monkeypox virus clade II and/or non-variola Orthopoxvirus infection.
-
This test has not been evaluated for screening of blood or blood products for the presence of monkeypox virus clade II and/or non-variola Orthopoxvirus.
-
This test cannot rule out diseases caused by other bacterial or viral pathogens.
-
The effect of interfering substances has only been evaluated for those listed within the labeling. Interference by substances other than those described could lead to erroneous results.
-
This test has not been evaluated for immunocompromised individuals.
-
The current US outbreak of mpox is caused by monkeypox virus clade II. A positive result for non-variola Orthopoxvirus most likely represents the presence of monkeypox virus clade II, although there is a small possibility that this result could represent the presence of a different non-variola Orthopoxvirus detected by the non-variola Orthopoxvirus primer and probe set. If clinical concern for infection with an Orthopoxvirus other than monkeypox, healthcare providers should contact the jurisdictional public health authorities for guidance.
-
Based on an in silico analysis, some vaccinia, cowpox and camelpox virus strains have genomic sequences containing two or more mismatches with the OPXV target primers and probe (Table 9 of Inclusivity Section below), and therefore may not be detected by the Xpert Mpox test. Wet-testing of contrived low-positive samples spiked with genomic DNA from one strain of vaccinia virus demonstrated detection of the non-variola OPXV target.
-
Results from an in silico analysis show potential for Xpert Mpox test cross-reactivity with variola, cowpox and ectromelia viruses that could result in a false “MPXV Clade II DETECTED” result. If variola (smallpox), cowpox or ectromelia infection is suspected, the provider is advised to contact the local health department immediately for patient evaluation.
-
The impacts of specific vaccines, antiviral therapeutics, antibiotics, chemotherapeutic or immunosuppressant drugs on the performance of this test have not been evaluated.
-
Detection of the Sample Adequacy Control (SAC) indicates that human nucleic acid is present and implies that human biological material was collected and successfully extracted and amplified. It does not necessarily indicate that the specimen is of appropriate quality to enable detection of monkeypox virus (clade II) and/or non-variola Orthopoxvirus. All MPXV and nonvariola OPXV-negative specimens must have a positive Sample Adequacy Control result to be identified as valid negatives.
Conditions of Authorization
The Cepheid Xpert Mpox Letter of Authorization, along with the authorized Fact
Sheet for Healthcare Providers, the authorized Fact Sheet for Patients and
authorized labeling are available on the FDA website: https://www.fda.gov
/medical-devices/emergency-use-authorizations-medical-devices/monkeypox-
emergencyuse-authorizations-medical-devices
To assist clinical laboratories and/or Patient Care Settings using the Xpert
Mpox (referred to in the Letter of Authorization as “Your Product”), the
relevant Conditions of Authorization are listed below.
-
Authorized laboratories a that receive Xpert Mpox must notify the relevant public health authorities of their intent to run your product prior to initiating testing.
-
Authorized laboratories using Xpert Mpox must have a process in place for reporting test results to healthcare providers and relevant public health authorities, as appropriate.
-
Authorized laboratories using Xpert Mpox must include with test result reports all authorized Fact Sheets. Under exigent circumstances, other appropriate methods for disseminating these Fact Sheets may be used, which may include mass media.
-
Authorized laboratories using Xpert Mpox must use Xpert Mpox as outlined in the authorized labeling.
Deviations from the authorized procedures, including the authorized instruments, authorized extraction methods, authorized clinical specimen types, authorized control materials, authorized other ancillary reagents and authorized materials required to use Xpert Mpox are not permitted. -
Authorized laboratories must have a process in place to track adverse events and report to Cepheid Customer Technical Support 1-888-838 3222 and to FDA pursuant to 21 CFR Part 803.
-
All operators using Xpert Mpox must be appropriately trained in performing and interpreting the results of Xpert Mpox, use appropriate personal protective equipment when handling Xpert Mpox, and use Xpert Mpox in accordance with the authorized labeling.
-
Cepheid, authorized distributors, and authorized laboratories must collect information on the performance of Xpert Mpox and report any significant deviations from the established performance characteristics of Xpert Mpox of which they become aware to DMD/OHT7-OIR/OPEQ/CDRH (via email: CDRH-EUA Reporting@fda.hhs.gov ). In addition, authorized distributor(s) and authorized laboratories report to Cepheid (+1 888 838 3222 or techsupport@cepheid.com ).
-
Cepheid, authorized distributors, and authorized laboratories using Xpert Mpox must ensure that any records associated with this EUA are maintained until otherwise notified by FDA. Such records will be made available to FDA for inspection upon request.
a The letter of authorization refers to “authorized laboratories” as follows: (1) Testing on the GeneXpert Dx and GeneXpert Infinity instruments is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, that meet the regulatory requirements to perform high or moderate complexity tests, and (2) Testing on the GeneXpert Xpress (Hub Configuration) instruments is limited to laboratories certified under CLIA that meet requirements to perform high, moderate, or waived complexity tests. Testing is authorized for use at the Point of Care (POC), i.e., in patient care settings operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation.
Performance Characteristics
20.1 Clinical Performance
The performance of the Xpert Mpox test was evaluated using frozen,
retrospective clinical lesion swab specimens in either universal transport
medium (UTM) or viral transport medium (VTM) collected from patients suspected
of mpox . All of the clinical specimens were previously characterized as
positive or negative for non-variola Orthopoxvirus using an FDA cleared real-
time-PCR assay. A total of 31 positive specimens, including four low positive
specimens (4/31, 12.9%), and 30 negative specimens were tested on the Xpert
Mpox test in a double-blinded fashion in a point of care setting by untrained
users.
Positive Percent Agreement (PPA), Negative Percent Agreement (NPA) were
determined by comparing the results of the Xpert Mpox test relative to the
known results from the FDA cleared real-time-PCR test.
The Xpert Mpox test demonstrated a PPA and NPA of 100.0% and 96.6% for MPXV,
respectively (Table 3). The initial non-determinate rate for the Xpert Mpox
test was 6.5% (4/61). On repeat testing, all four specimens yielded valid
results. The final non-determinate rate for the Xpert Mpox test was 0.0%
(0/61).
Table 3. Xpert Mpox Test Performance Results Using Lesion Swab Specimens
| FDA cleared real-time-PCR assay
---|---
Positive| Negative| Total
Xpert Mpox| Positive| 31| 1| 32
Negative| 0| 29| 29
Total| 31| 30| 61
PPA| 100% (95% CI: 100%-100%)
NPA| 96.6% (95% CI: 96.6-96.7%)
20.1.1 Xpert Mpox Test Performance Around LoD
A total of 20 contrived samples were tested in a blinded fashion by untrained
users to evaluate the performance of the Xpert Mpox test near the LoD. At the
same point of care site where testing of clinical specimens was conducted,
contrived samples were integrated into the workflow along with clinical
specimens. The 20 contrived swab samples included 10 monkeypox positive
contrived swab samples at ≤2x LoD and 10 negative samples in a negative
clinical buccal swab matrix. Overall agreement with expected results was 100%
for monkeypox virus positive and negative samples.
20.2 Analytical Performance
20.2.1 Analytical Sensitivity (Limit of Detection)
The Limit of Detection (LoD) is the lowest concentration (genomic copies,
GC/mL) per sample that can be reproducibly distinguished from negative samples
with 95% confidence or the lowest concentration at which at least 19 of 20
replicates are positive. LoD studies for the Xpert Mpox test were conducted
using heat-inactivated monkeypox virus (USA/MA001/2022, Lineage B.1, clade
IIb) and vaccinia virus gDNA (Modified Vaccinia Virus Ankara). The
concentration of the monkeypox virus stock was 4.23 × 10⁴ GC/mL as determined
by digital droplet (dd) PCR. The concentration of vaccinia virus gDNA stock
was 1.82 × 10⁷ GC/mL as provided by the manufacturer. The monkeypox virus and
vaccinia virus gDNA were serially diluted in pooled negative matrix (PNM),
which is made of negative human buccal swab material in universal transport
media (UTM-RT Virus Specimen Collection Kit, Copan). Fifty microliters of the
spiked PNM were pipetted onto a dry sterile swab, and the wetted swab was then
inserted into 3 ml of UTM and tested on the Xpert Mpox test for preliminary
LoD and LoD confirmation studies. The confirmed LoD values for both MPXV and
OPXV are listed in Table 4.
The LoD for the MPXV target was confirmed to be 2.12 × 10¹ GC/mL in UTM.
The LoD for the OPXV target was confirmed to be 4.23 × 10¹ GC/mL for monkeypox
virus and 6.00 × 10¹ GC/mL for vaccinia virus gDNA in UTM.
Table 4. Xpert Mpox Test Limit of Detection (LoD)
Organism | Xpert Mpox Test Targets (GC/mL) |
---|---|
MPXV | OPXV |
*Inactivated Monkeypox Virus (GC/mL)** | 2.12 × 101 |
Vaccinia Virus gDNA (GC/mL)** | – |
*For an MPXV Clade II detected result based on the Xpert Mpox test interpretation, the LoD of the Xpert Mpox test is 2.12 x 10¹ GC/mL
**For a non-variola OPXV detected result based on the Xpert Mpox test
interpretation, the LoD of the Xpert Mpox test is 6.00 x 10¹ GC/mL
20.2.2 Analytical Specificity (Exclusivity)
An in silico analysis was performed to evaluate the Xpert Mpox test for
analytical specificity (cross-reactivity). Potential crossreactivity was
assessed according to percent homology of the organisms’ genomic sequences
listed in Table 7 to the primers and probes in the Xpert Mpox test. The Xpert
Mpox test contains two monkeypox virus clade II specific targets (MPXV target
1 and target 2), one non-variola Orthopoxvirus (OPXV) target, and SPC and SAC
internal control targets.
With the exception of variola virus, vaccinia virus, cowpox virus, and
ectromelia virus, in silico analysis showed that the Xpert Mpox test primers
and probe sets do not show ≥80% homology to the genomic DNA sequences
evaluated of the microorganisms and viruses listed in Table 7. There is
potential cross-reactivity of the MPXV target 1 primers and probes with
variola, vaccinia and cowpox virus and of MPXV target 2 primers and probes
with ectromelia virus sequences as evidenced by the more than 80% sequence
identity (Table 5).
Table 5. Organisms with Significant Matches to the Xpert Mpox Test MPXV Target Primers and Probe Sequences
Xpert Mpox test targets| Species| Refseq Accession ID|
Forward Primer| Probe| Reverse Primer
---|---|---|---|---|---
MPXV target 1| Variola Virus (smallpox)| NC_001611.1| 88%
(22/25nt)| 92%
(23/25nt)| 92%
(23/25nt)
MPXV target 1| Cowpox virusa| NC_003663| 100%
(25/25nt)| 88%
(22/25nt)| 92%
(23/25nt)
MPXV target 1| Camelpox virusa| NC_003391| NSM*| 92%
(23/25nt)| 92%
(23/25nt)
MPXV target 1| Vaccinia virusb| NC_006998| 92%
(23/25nt)| 92%
(23/25nt)| 92%
(23/25nt)
MPXV target 2| Ectromelia virusc (mousepox)| NC_004105| 92%
(23/25nt)| 80%
(20/25nt)| 92%
(23/25nt)
*NSM: No significant match
a Based on the epidemiology of currently circulating orthopoxviruses, and
lack of evidence for human-to-human transmission of cowpox and camelpox virus,
a false positive result due to cowpox or camelpox infection is unlikely
b In vitro testing of vaccinia genomic DNA (gDNA) at a concentration of
1.00 x 10⁶ copies/mL showed no signal with MPXV targets
c The in silico analysis showed sufficient mismatches to the probe
sequence of the MPXV target to prevent detection of ectromelia virus
In addition, the OPXV target primer and probe sets have ≥80% homology for
variola virus genome The forward and reverse primers for the Xpert Mpox test
OPXV target are exact matches to the locus in the variola genome, however, the
probe has three mismatches (Table 6). Though the Xpert Mpox test demonstrated
91% identity to the variola locus, the results of in vitro testing with
variola DNA conducted by Li, et al. demonstrated that testing with a PCR assay
using the same non-variola OPXV primers/probe sequences as Xpert Mpox did not
provide a positive result when tested against a wide range of variola virus
samples⁵.
A ≥80% homology to human genomic DNA was observed for the SAC primers and
probe as they are designed to detect human genomic DNA.
Table 6. Percent Homology of Xpert Mpox OPXV Target Primers and Probe with Variola Virus
Species| Refseq Accession ID| Forward Primer| Probe|
Reverse Primer
---|---|---|---|---
Variola Virus (smallpox)| NC_001611.1| 100%
(23/23nt)| 91%
(29/32nt)| 100%
(28 / 28nt)
Based on the epidemiology of currently circulating orthopoxviruses, a false
positive result for the MPXV target (monkeypox virus clade II) due to cowpox
or variola virus infection is unlikely. As with any clinical diagnostic test,
results should be interpreted in the context of clinical evaluation and
current epidemiology. The World Health Organization (WHO) declared smallpox
eradicated, therefore the possible variola virus cross-reactivity with the
MPXV target 1 primers and probe do not pose any practical risk to the Xpert
Mpox test.¹⁰ If variola infection (smallpox) is suspected, the provider is
advised to contact the local health department immediately for patient
evaluation. The in silico analysis showed a two nucleotide deletion in the
ectromelia genome sequences compared to the probe sequence of the MPXV target
2. This is predicted to be sufficient to prevent probe binding with the genome
of ectromelia virus, avoiding detection of this virus.
In silico exclusivity analysis results can be found in Table 7. In vitro
testing of vaccinia genomic DNA (gDNA) at a concentration of 1.00 x 10⁶
copies/mL showed no signal with MPXV targets while the OPXV target was
positive, as expected.
Table 7. Analytical Specificity of the Xpert Mpox Test**
Species| Refseq Accession ID| MPXV clade II Assay I| MPXV
clade II Assay II
---|---|---|---
Forward Primer| Probe| Reverse Primer| Forward Primer|
Probe| Reverse Primer
Variola Virus (smallpox)| NC_001611.1| 88%
(22/25nt)| 92%
(23/25nt)| 92%
(23/25nt)| 84%
(21/25nt)| 44%
(11/25nt)| NSM
Herpes simplex virus (HSV-1)| NC_001806| NSM| NSM| NSM| NSM| NSM| NSM
Herpes simplex virus (HSV-2)| LS480640.1| NSM| NSM| NSM| NSM| NSM| NSM
Varicella-zoster virus (Chickenpox)| NC_001348.1| NSM| NSM| NSM| NSM| NSM| NSM
Staphylococcus aureus| AP017922.1| NSM| NSM| NSM| NSM| NSM| NSM
Streptococcus pyogenes| NZ_LS483338.1| NSM| NSM| NSM| NSM| NSM| NSM
Pseudomonas aeruginosa| NC_002516.2| NSM| NSM| NSM| NSM| NSM| NSM
Corynebacterium jeikeium| NC_007164.1| NSM| NSM| NSM| NSM| NSM| NSM
Escherichia coli| NZ_CP077969.1| NSM| NSM| NSM| NSM| NSM| NSM
Bacteroides fragilis| NZ_CP069563.1| NSM| NSM| NSM| NSM| NSM| NSM
Neisseria gonorrhoeae| NZ_CP097846.1| NSM| NSM| NSM| NSM| NSM| NSM
Mycoplasma pneumoniae| NZ_CP014267.1| NSM| NSM| NSM| NSM| NSM| NSM
Human papilloma virus (HPV)| NC_027779.1| NSM| NSM| NSM| NSM| NSM| NSM
Treponema pallidum| NC_016842.1| NSM| NSM| NSM| NSM| NSM| NSM
Molluscum contagiosum virus| MN931752.1| NSM| NSM| NSM| NSM| NSM| NSM
Streptococcus mitis| JVJJ01000007.1| NSM| NSM| NSM| NSM| NSM| NSM
Staphylococcus epidermidis| JUKL01000001.1| NSM| NSM| NSM| NSM| NSM| NSM
Streptococcus agalactiae| NZ_CP012480.1| NSM| NSM| NSM| NSM| NSM| NSM
---|---|---|---|---|---|---|---
Lactobacillus species (acidophilus)| NZ_CP054559.1| NSM| NSM| NSM| NSM| NSM|
NSM
Acinetobacter calcoaceticus| NZ_CP020000.1| NSM| NSM| NSM| NSM| NSM| NSM
Enterococcus faecalis| NC_021023.1| NSM| NSM| NSM| NSM| NSM| NSM
Streptococcus Group C and Group G| AP012976.1| NSM| NSM| NSM| NSM| NSM| NSM
Corynebacterium diphtheriae| NZ_CP025209.1| NSM| NSM| NSM| NSM| NSM| NSM
Chlamydia trachomatis| NC_000117.1| NSM| NSM| NSM| NSM| NSM| NSM
Mycoplasma genitalium| NC_000908.2| NSM| NSM| NSM| NSM| NSM| NSM
Human genome*| Multiple accession numbers| 88%
(22/25nt) chr 12| NSM| 76%
(19/25nt)| ****
84%
(21/25nt)
Chr 18
84%
(21/25nt)
Chr 6
80%
(20/25nt)
Chr 13
| 76%
(19/25nt)
Chr18 72%
(18/25nt)
Chr6| 84%
(21/25nt)
Chr 5
80%
(20/25nt)
Chr 10
Candida albicans| Multiple accession numbers| NSM| NSM| NSM| NSM| NSM| 64%
(16/25nt)
Trichophyton rubrum| Multiple accession numbers| NSM| NSM| NSM| NSM| NSM| NSM
Trichomonas vaginalis*| Multiple accession numbers| 68%
(17/25nt)| NSM| NSM| NSM| NSM| 88%
(22/25nt)
Cowpox virus| NC_003663| 100%
(25/25nt)| 88%
(22/25nt)| 92%
(23/25nt)| 92%
(23/25nt)| 76%
(19/25)| 92%
(23/25nt)
Camelpox virus| NC_003391| NSM| 92%
(23/25nt)| 92%
(23/25nt)| NSM| 76%
(19/25)| 88%
(22/25nt)
Vaccinia virus| NC_006998| 92%
(23/25nt)| 92%
(23/25nt)| 92%
(23/25nt)| NSM| 76%
(19/25)| 96%
(24/25nt)
Ectromelia virus (mousepox)| NC_004105| NSM| 88%
(22/25nt)| NSM| 92%
(23/25nt)| 80
(20/25nt)| 92%
(23/25nt)
*Multiple chromosome organisms
**NSM: no significant match was reported by BLAST
20.3 Analytical Reactivity (Inclusivity)
The analytical reactivities of the Xpert Mpox test MPXV and OPXV targets were
evaluated in silico against sequences from multiple strains of monkeypox virus
clade IIa and clade IIb, using comprehensive data sets from NCBI and GISAID
(Table 8). According to this analysis, the two MPXV targets and the OPXV
target that are present in the Xpert Mpox test are predicted to have 0 to 1
mismatch in the primer and probe sequences with all monkeypox clade II
sequences analyzed. As the presence of no more than one mismatch in the primer
and probe sequences is not expected to impact test performance, the Xpert Mpox
test exhibited 100% inclusivity to monkeypox clade II sequences evaluated.
The analytical reactivity of the Xpert Mpox test OPXV target was evaluated
against sequences from monkeypox, vaccinia, cowpox, camelpox and ectromelia
viruses (Table 8). Based on the in silico analysis, some vaccinia, cowpox and
camelpox virus strains have genomic sequences containing two or more
mismatches with the OPXV target primers and probe (Table 9), and therefore may
not be detected by the test.
Table 8. Sequences Included in Inclusivity Analyses for MPXV and OPXV Targets
Virus| Source| Download Date| Number of unique, non-
synthetic sequences analyzed
---|---|---|---
Monkeypox – clade I| GISAID| 10/15/2022| 43
Monkeypox – clade IIa| GISAID| 10/15/2022| 2
Monkeypox – clade IIb| GISAID| 10/15/2022| 3,057
Monkeypox – unassigned| NCBI| 10/15/2022| 2,552
Vaccinia| NCBI| 10/15/2022| 87
Cowpox| NCBI| 10/15/2022| 9,287
Camelpox| NCBI| 10/15/2022| 992
Ectromelia| NCBI| 10/15/2022| 129
Table 9. Percent of Organism-Specific Sequences with Two or More Mismatches with OPXV Target Primers and Probes*****
Organism| Oligonucleotide| % of sequences with 2 or more
mismatches
---|---|---
Vaccinia virus| OPXV probe| 1.2% (1/86)
OPXV reverse primer| 1.2% (1/86)
Cowpox virus| OPXV probe| 56.5% (52/92)
OPXV reverse primer| 7.6% (7/92)
Camelpox virus| OPXV probe| 100.0% (9/9)
- Only the primers and probes with two or more mismatches listed
** Cowpox and Camelpox viruses are not currently circulating in humans; further these viruses are not known to transmit from human-to-human
20.4 Interfering Substances Study
The assay uses a well-established nucleic acid extraction method; therefore,
interference from common endogenous substances is not expected. This is
further supported by the results of an Interfering Substances study in which
potentially interfering substances that may be present in a skin swab was
evaluated for potential to impact the performance of the Xpert Mpox test.
Positive and negative samples were prepared in pooled negative matrix (PNM),
which is made of negative human buccal swab material in UTM, and tested in the
presence of potentially interfering substances. Negative matrix samples (n=3)
were tested to determine the impact of such substances in the performance of
the sample processing control (SPC) and sample adequacy control (SAC). In
addition, positive samples, containing monkeypox virus at 3X LoD (n = 3), were
tested to determine the impact of such substances in the detection of
monkeypox virus. The evaluated substances are listed in Table 10, with active
ingredients and concentrations tested shown. None of the substances tested
were found to impact performance of the test at the concentrations tested in
study.
Table 10. Potentially Interfering Substances Tested in the Xpert Mpox Test
Substance/Class| Description/Active Ingredient| Concentration
Tested
---|---|---
Control| Pooled negative matrix| 100% (v/v)
Abrevea| Behenyl alcohol| 7% (w/v)
Acyclovir| Antiviral medication| 7 mg/mL
Albumin| Protein| ≥ 2.2 mg/mL
Blood/EDTA| Blood (human)| 5% (v/v)
Mucin| Purified Mucin protein (Bovine or porcine submaxillary gland)| 60 µg/mL
Hydrocortisone cream| Cortisol hormone| 5% (w/v)
Benadryl cream/ointment| Diphenhydramine (antihistamine)| 5% (w/v)
Carmex| Camphor, white petrolatum| 7% (w/v)
Casein| Milk protein| 7 mg/mL
Lanacane| Benzocaine| 3.5% (w/v)
KY Jelly| Glycerol (glycerine) and Hydroxyethyl cellulose| 7% (w/v)
Douche| Benzalkonium chloride| 7% (w/v)
Neosporin| Bacitracin, neomycin, and polymixin b| 5% (w/v)
Female urine| Female urine, human| 10% (v/v)
Male urine| Male urine, human| 10% (v/v)
Feces| Feces, human| 0.22% (w/v)
Seminal fluid| Seminal fluid, human| 7% (v/v)
Zinc Oxide ointment| Zinc oxide| 7% (w/v)
Vagisil cream| Benzocaine and resorcinol| 1% (w/v)
Cornstarch| Cornstarch| 2.5 mg/mL
References
-
World Health Organization. WHO Monkeypox Fact Sheet. https://www.who.int/news-room/fact-sheets/detail/monkeypox.
Published online May 19, 2022 Accessed January 17, 2023 -
World Health Organization. Monkeypox: experts give virus variants new names.
https://www.who.int/news/item/12-08-2022-monkeypox–experts-give-virus- variants-new-names. Published online August 12, 2022. Accessed January 17, 2023 -
World Health Organization. Clinical management and infection prevention and control for monkeypox: Interim rapid response guidance. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 Published online June 10, 2022.
Accessed October 16, 2022. -
U.S. Department of Health & Human Services. Determination that a Public Health Emergency Exists. Published August 4, 2022.
Accessed January 15, 2023. https://aspr.hhs.gov/legal/PHE/Pages/monkeypox- 4Aug22.aspx -
Li, Y, Olson VA, Laue, T, Laker, MT, et al. Detection of monkeypox virus with real-time PCR assays. J Clin Virol. 2006; 36(3):194-203.
-
Centers for Disease Control and Prevention. Biosafety in Microbiological and Biomedical laboratories (refer to latest edition). http://www.cdc.gov/biosafety/publications/
-
Clinical and Laboratory Standards Institute. Protection of Laboratory Workers from Occupationally Acquired Infections;
Approved Guideline. Document M29 (refer to latest edition). -
REGULATION (EC) No 1272/2008 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 16 December 2008 on the classification labeling and packaging of substances and mixtures amending and repealing, List of Precautionary Statements, Directives 67/548/EEC and 1999/45/EC (amending Regulation (EC) No 1907/2007).
-
Occupational Safety and Health Standards, Hazard Communication, Toxic and Hazard Substances (March 26, 2012) (29 C.F.R., pt. 1910, subpt. Z).
-
World Health Organization. Smallpox Overview. https://www.who.int/health-topics/smallpox#tab=tab_1. Accessed January 15, 2023
Cepheid Headquarters Locations
Corporate Headquarters
Cepheid
904 Caribbean Drive
Sunnyvale, CA
94089 USA
Telephone: + 1 408 541 4191
Fax: + 1 408 541 4192
www.cepheid.com
Technical Assistance
Before contacting Cepheid Technical Support, collect the following information:
- Product name
- Lot number
- Serial number of the instrument
- Error messages (if any)
- Software version and, if applicable, Computer Service Tag Number
US
Telephone: + 1 888 838 3222
Email: techsupport@cepheid.com
Table of Symbols
Symbol | Meaning |
---|---|
Catalog number | |
In vitro diagnostic medical device | |
Do not reuse | |
**** | Batch code |
**** | Consult instructions for use |
**** | Manufacturer |
Country of Manufacture | |
Contains sufficient for |
|
Control | |
Expiration date | |
Temperature limitation | |
Biological risks | |
**** | Caution |
Warning | |
For prescription use only |
Cepheid
904 Caribbean Drive
Sunnyvale, CA 94089
USA
Phone: +1 408.541.4191
Fax: +1 408.541.4192
For use under Emergency Use Authorization (EUA) Only
Revision History
Description of Changes: Initial Release of 302-9629
Purpose: Initial Release of Instructions for Use
Revision | Description of Change |
---|---|
Initial Release |
Xpert® Mpox (EUA) Documentation and ADF
For use under Emergency Use Authorization (EUA) only
This is not the full Instructions for Use. Access to the Xpert® Mpox full
Instructions for Use (IFU), EUA documentation and Assay Definition File (ADF)
is available online at https://www.cepheid.com/en_US/tests/Critical-
Infectious-Diseases/Xpert-Mpox. Under the Xpert Mpox Product Resources
section on the webpage, select the Xpert Mpox EUA item you wish to view. A new
tab on your internet browser will open to allow access to the Xpert Mpox EUA
item selected.
Note: This product has not been FDA cleared or approved but has been
authorized for emergency use by FDA under an EUA for use by authorized
laboratories.
This product has been authorized only for the detection of nucleic acid from
monkeypox virus or other non-variola orthopoxviruses, not for any other virus
or pathogens.
The emergency use of this product is only authorized for the duration of the
declaration that circumstances exist justifying the authorization of emergency
use of in vitro diagnostics for detection and/or diagnosis of infection with
the monkeypox virus, including in vitro diagnostics that detect and/or
diagnose infection with non-variola Orthopoxvirus, under Section 564(b)(1) of
the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless
the declaration is terminated or authorization is revoked sooner.
Please contact +1 888-838-3222 if you
require a printed copy free of charge or need technical support to access the
package insert.
Rx only. In Vitro Diagnostic Use Only.
In Vitro Diagnostic Medical Device
904 Caribbean Drive
Sunnyvale, CA 94089
USA
Phone: +1 408.541.4191
Fax: +1 408.541.4192
© 2023 Cepheid
302-9631, Rev. E Feb. 2023
Documents / Resources
|
Cepheid GXMPX-10 Xpert Mpox GeneXpert Real Time PCR
Test
[pdf] Instruction Manual
GXMPX-10, Xpert Mpox GeneXpert Real Time PCR Test, GXMPX-10 Xpert Mpox
GeneXpert Real Time PCR Test, GeneXpert Real Time PCR Test, Real Time PCR Test
---|---
References
- HHS Accessibility & Section 508 | HHS.gov
- cdc.gov/biosafety/publications/
- Cepheid | Enabling Access to Molecular Diagnostic Testing Everywhere
- Cepheid | Enabling Access to Molecular Diagnostic Testing Everywhere
- DETERMINATION THAT A PUBLIC HEALTH EMERGENCY EXISTS
- Cepheid | Mpox Molecular Test – Xpert Mpox
- Smallpox
- Mpox (monkeypox)
- Clinical management and infection prevention and control for monkeypox: Interim rapid response guidance, 10 June 2022