Senate Inquiry – Emerging tick-borne disease
Hearing held in Brisbane Friday, 15 April 2016
BURKE, Ms Jennie Maree, Director, Australian Biologics Testing Services Pty Ltd
Senate Inquiry – Emerging tick-borne disease
Hearing held in Brisbane Friday, 15 April 2016
BURKE, Ms Jennie Maree, Director, Australian Biologics Testing Services Pty Ltd
Welcome. I understand that you have been given information on parliamentary privilege and the protection of witnesses and evidence. I invite you to make an opening statement, and then we will ask you some questions.
I would like to talk initially about the accreditation with NATA, because we have found over the last few years that the fact that we do not have NATA at this stage has been used as an attack. What I want to say to start with is that accreditation with NATA is required for laboratories claiming Medicare. Laboratories not receiving Medicare payments have never had any legal or other requirement to gain NATA accreditation. There are quite a few small laboratories around Australia who do not have NATA accreditation and have no intent of doing so. Having NATA does not mean the laboratories’ results are always correct, and not having NATA does not mean the laboratories’ results are wrong. For example, in 2002, a Melbourne lab failed to test correctly for precancerous cervical cells.
Approximately 34,000 Victorian women were urged to be retested. This was a Medicare/NATA-accredited lab. More recently, 100 patients in South Australia were given false positive tests for prostate cancer. This was only discovered when a urologist ordered some retesting. Again, this was a NATA-accredited Medicare lab.
We applied for NATA accreditation in early 2014. We submitted what we thought was ample validation for the test. This now includes five years of successful quality assurance programs. In June last year, our NATA representative suggested that we do a probit regression study. We did this, and this was submitted. We know of no other laboratory that has submitted a probit regression study. This type of study has been used, usually in research papers, to validate PCR testing in samples with low levels of bacteria. We employed the services of a mathematician from the University of Newcastle. We tested 850 samples and showed excellent results. The probit regression is in our submission.
We have also participated in a pilot study for Borrelia serology using our immunoblot test. We then did the quality assurance program. We scored 100 per cent in both tests. This quality assurance program came from the Royal College of Pathologists Australasia. While we were waiting for NATA to come back to us after we had lodged the probit regression, we received a letter from Mr Andy Griffin, who is the deputy sector manager of legal and clinical services at NATA. This was on 30 November. He stated that we had not provided details of how we undertake our assay—this is PCR—or the primers used, therefore, they could not confirm that we were detecting Borrelia. He advised that we should, ‘Reconsider any decision to reapply for accreditation.’ Our primers and probe for PCR are our intellectual property. They enable us to offer better and more sensitive PCR. We do not divulge our primers at all. NATA has received our laboratory manual, which carries our full testing methods.
In our paper, which was entitled ‘Evidence of Borrelia in the Ixodes holocyclus tick’, we found Borrelia DNA in the tissue of a patient at the site of the bite. The tick was still attached when the patient went to the doctor. The tick was removed. It was first sent to the University of Newcastle for identification. They were not sure. It then went to the University of the Sunshine Coast, and ended up going to Japan to be identified. This has been published. So it has been discovered in Australia.
We have spoken with many scientists in the molecular field, and I had a conversation with the head of one of the very large routine pathology laboratories. No-one has known of labs being asked to divulge their intellectual property, such as primers, nor has anyone known of a laboratory being asked to submit a probit regression study. Validation of PCR testing is through quality assurance programs and sequencing. Both areas have been submitted to NATA. PCR is considered the gold standard of testing for microbial infections.
We feel that there have been serious breaches of NATA’s charter in their dealings with us. In their charter NATA has a guideline of the time they should take to respond to submissions. Over the two-year period of our application, we found that NATA had not responded within the times allowed by their guidelines. We calculated a loss of seven months. NATA is supposed to maintain confidentiality. We found that NATA had sent some of our documentation to the Society for Microbiology committee on critical microbiology, of which Dr Graves is the chair. This was without our permission. Dr Graves is our competitor, as he now offers PCR testing for Borrelia, and has been a vocal critic of our laboratory. This breached NATA rule R39(a). It should also be noted that the Borrelia PCR Dr Graves is offering is not NATA accredited.
RCPA maintains the stance that there is no Borrelia in Australia. This stance affects the NATA recognition of scientific fact. NATA has the monopoly on accreditation testing in Australia. We could go through accreditation with an American group called A2LA; however, TGA will not recognise any accreditation apart from NATA, even though the standards set by NATA and all other accreditation groups is an international standard. There is no organisation that acts as an overseer of NATA. If one has a problem with NATA, you complain to them and they investigate themselves. I contacted the Commonwealth ombudsman to see whether they could do anything about it. They had no control over NATA. I contacted the Department of Health and I spoke to someone there. He seemed quite concerned, then realised we were not a Medicare-checked lab and that was outside his jurisdiction. He told me he would get someone to contact me, and I have now waited four months—with no contact.
We have co-authored five papers on Borrelia, with the sixth almost finalised. We are part of a research group. Everyone else in the group is in America and Canada.
When samples are sent to us for testing—and this is PCR testing—they are tested by us and by Professor Sapi of the University of New Haven in Connecticut. Our two labs form the basis of five papers. I would also like to be clear that we do not change our test results dependent on travel history.
We have also had conversations with scientists in European specialist laboratories and they have confirmed that PCR testing of borreliosis patients generally comes up positive at over 39 cycles in PCR. This is one of the problems that NATA appears to have with us—that we run our PCR to 45 cycles. In an acute infection, in most infections, there is a huge amount of DNA. You get a strong result when you do PCR on an acute infection. Borrelia is quite different. It just does not seem to be getting across that this does not act like most other infections.
Borrelia patients, particularly when chronic, have incredibly low levels of DNA present in their body—or it certainly may be in the tissue but not in the bloodstream. RCPA has a guideline that you should never test urine for Borrelia. We find urine is actually quite a good source of positives. We know, and there are research papers showing this, that people shed Borrelia. In patients with Borrelia, as those organisms die, they will eventually be excreted through the urinary tract. There is work done, and we are doing some with an infectious disease specialist, where you can load a patient for three days or so with an antibiotic and then you collect the urine and we get quite strong positives.
In my submission, I have shown sequencing. I have brought another 10 sequences; I submitted four and we do have more at the laboratory. I would just like to say that all of the research that we have done, and I think, at the moment, we are up to 450 samples that we have done as part of our research, we fund. We have never had any help or any funding which does make it a little bit difficult for a very small laboratory. I am done.
Yes. After we found out about the breach of confidentiality and we had been told to not bother reapplying, we asked for an appointment with the CEO. We had an appointment with Jennifer Evans, who is the CEO of NATA, Andy Griffin, who was the person who wrote the comment about ‘rethink, reapplying,’ and John Styzinski, who is the general manager for NATA—myself, Moya and our quality manager attended. It was a very interesting meeting. I said, ‘We have presented the quality assurance programs.’ Of course we had to go outside of Australia for that; there are no quality assurance programs for PCR Borrelia in Australia. We go through Quality Control Molecular Diagnostics—QCMD. They are a very reputable group. They do quality assurance to 13 countries. They are based at the University of Glasgow. We pass; we always pass. We have got five years of that.
this is validation generally for PCR. We have also done a probit regression. Jennifer Evans looked at me and said, ‘We do not believe that you are detecting Borrelia.’ I really did not know how to respond because, to me, this is not science. They have been told, ‘It is not here,’ therefore, it does not seem to matter what we show.
We use three different technologies. We do PCR, which is considered gold standard for microbiology. We use a German immunoblot test and we use a German EliSpot test. These three are quite different: you have got a molecular biology, a serology and an immunology test. We get positives in all three tests. PCR is obviously the most sensitive. When we do our sequencing—we do not sequence in the laboratory; I cannot afford a sequencer. We send the product from our PCR to an external lab and they do the sequencing. That will tell us exactly what we have got from our PCR product. We use two different companies; we use AGRF—Australian Genome Research Facility—they got NATA about three years ago. No-one cared before and I do not think anyone really cares now.
We also send to the Ramaciotti Centre. They are based at the University of New South Wales. Lots of people use them. They do not have NATA. No-one cares. I do not think anyone has ever worried about the fact that we do not have NATA for our mycoplasma testing, which we have also done for 13 years or so. If it was not for the changes that are coming to the TGA, I really would not care if we had NATA.
Earlier, you mentioned the primers that you had developed. In my layman’s interpretation, I would interpret that as being like if I did a quote for a job; I provide the quote to you as commercial in confidence. I would interpret that your primers are your intellectual property—is that correct?
Yes, I pay a clinical scientist. He designed these particular primers. Mind you, I have a box of primers. Primers are what make your PCR work. You have these bits of DNA. We can get them out of research papers, and I have done that. I have read a good paper and had the primers made. I have tried them and they did not work on patients, so I have put them back in the freezer. We have had some designed. I know various scientists who are very good at designing primers. The set we have now are very good. We get excellent results. So, no, I do not want to tell. When the NATA assessor comes, they come from a different laboratory. It is like someone from your competitor coming to look at your work. No-one expects that one lab is going to show a different lab their intellectual property on how they might get really good results.
So the people that do the inspection of a laboratory for NATA do not actually work for NATA?
Ms Burke : And they do not get paid. My clinical scientist is a NATA examiner himself. It is a voluntary thing. He will go to a lab and do an assessment there.
Doesn’t this pose a potential conflict of interest?
Yes, it gets better. We have now been told, because we are supposed to have another assessment—normally, what happens is that one technical assessor per section of whatever you are doing attends, whether it is PCR, or maybe immunology, and you would get one assessor coming to look at your PCR and one NATA rep. When we had the meeting at Christmas, Jennifer Evans told us that they would give us a choice of three assessors and we could choose one. Two weeks ago, my quality manager received a letter from NATA, in which she gave two assessors. One was a microbiologist/pathologist from Queensland. I do not want anyone connected to the RCPA doing our assessment. For me, that is conflict of interest. How are they going to assess a lab, when they have already been told, absolutely, by the college, ‘It’s not here’?
The second assessor was a senior scientist from Westmead Hospital. I do not particularly want anyone from Westmead, either. This is another conflict of interest. This is where they did the original papers that said, ‘No, it’s not here’. So I asked the quality manager to write back and say, ‘Who is the third option?’ We were given the name of another senior scientist from another lab in Sydney. Now, I probably would not have a problem with him. Except in that letter, we were told that we were going to have all three assessors come to the laboratory. Instead of one NATA representative, we would have two NATA representatives, including Andy Griffin, who is the person who told us to rethink reapplying.
I have nine staff and they are not all full time. In my PCR section, I have one PhD who is full time, and I have one scientist who is part time. That is it. Apparently, I am going to have three people coming to assess 1½ staff. The quality manager wrote back and said, ‘It’s a really small lab; you won’t fit’. I am at the point where I think—is there any point in me wasting more money, because I do not think they have any intention of giving us accreditation no matter what we present.
When Australian Biologics applied to NATA for accreditation and submitted information was there a declaration, for want of a better word, that all of your particulars are confidential—a bit like a doctor patient relationship I suppose in laymen’s terms?
It is in their charter—
How does NATA explain the fact that the information in your application has been dispersed, for want of a better word, to other people. I am having difficulty because I have been into research facilities of manufacturers and I know these people very well—I have known then for 20-odd years. Even though I know them, when I visit and I go into their research facility, I have to sign a declaration that I will not divulge anything that I see in that research facility because they are receiving funding from the Australian government, foreign governments and Australian and multinational corporations. I cannot take a photo; I cannot take a camera in there. I have known these people most of my life. They trust me but they have to do that to me. I am having real difficulty understanding how your information of your company—your intellectual property—gets bandied around. I am having difficulty grasping this.
What happened was that they asked us to do clinical utility and clinical performance studies. We thought we were finished once we had done the probit regression. Apparently, the regulations had changed, making a lab need to do these particular studies. Except they had changed a year earlier and they had not told us—so we lodged this. We produced these papers. One study we presented was a paper Peter Mayne had written where he compared our results to IGeneX so that was submitted as the clinical performance. We also did a study which was a survey done of doctors, who used the test, as to the usefulness of the test. This was the Clinical Utility Study. We sent those to NATA.
Something else happened, and I wrote to them and I said, ‘By the way, I don’t want any of our information going to the Rickettsial lab because this is competition.’ Their quality manager wrote back and said it was a bit of a whoops moment, ‘we actually have sent your documents to the Australian Society for Microbiology, of which Dr Graves is the chair.’ They said this approach sought the committee’s opinion on the clinical utility of the assay in question. They said some submitted documentation was also supplied. I do not know what else was supplied; they would not tell me. It says, ‘Whilst this was supplied in such a way that it did not identify Australian Biologics in any way, NATA did not appear to either seek or receive your express permission to do so. This is contrary to NATA rule R39. NATA partially sustains your concern in this regard.’ They apparently tried to redact the documents. It is the most bodgie job you have ever seen. There is a capital A at the beginning and you can see the ICS. It is obvious it is us. My name was mentioned.
This is a redacted document?
Really badly redacted.
Last question: you mentioned the TGA before. That is the Therapeutic Goods Administration. If, for instance—correct me if I am wrong—a patient wants to claim a test, they have to have NATA approval for it to be able to claim it back on Medicare. The only way it can be acceptable to Medicare and the TGA is if it has NATA approval. NATA approval is like the gold tick. NATA is not accountable to any investigation or oversight from the Commonwealth.
It would appear so.
I have also noted that down for checking with the Chief Scientist.
Thank you, Chair.
I have made note of the long list of things that we have got for the Chief Scientist.
Ms Burke, thank you for your submission. I did not understand anything from page 11 onwards, which was the laboratory manuals and all of those pieces of paper. I had no idea, but thank you for providing it.
I think that was the probit regression; it is not simple.
It is a scientific process. You have got those things, so I do not need to understand them. But I think we do need to have an idea, for the record, as to why you did attach that document. I have read the rest of the submission, which actually raises more questions about the process of your accreditation and which we have been through. In terms of the history of your laboratory, you have been in the business for a number of years.
It has been 30 years.
You have been operating successfully that whole time within this field—no problems from the universities or any of the people?
No, we provide universities with sample testing for mycoplasma.
You have the business model in place, but it seems to have been particularly around this series of testing that the problem—
We started the molecular section in 2002. When I first set it up I wanted to test for bacteria that I was interested in. I am interested in bacteria that are involved in chronic disease. This is not tested in routine labs; they test acute infections. I used to be a colleague of Professor Lida Mattman, a professor in America, who did a lot of work on what are called ‘stealth pathogens’. I worked with her at her university.
She did mycoplasma testing and Borrelia testing. I thought, ‘Interesting bacteria, we will do these.’ We set up a whole group of bacteria to test. At that stage, I actually did not know that Borrelia was not allowed in Australia. Of course, we got positives. It took me a while to realise that we were not supposed to be getting positives. The other tests came in much later, when we started bringing in the immunoblot kit and the EliSpot kit.
‘You are getting positives because your laboratory is contaminated.’ We do the proper contamination checks. I mean, this is ridiculous. You cannot contaminate a PCR lab and also have that contamination affect immunoblots and EliSpots. This is impossible. They ignore the quality assurance programs. I do not know how we could fake a quality assurance program. What happens is: Glasgow university sends us 10 samples. We do not know what is in them. We have to extract the DNA. We run the test and then we send a report back that might say, ‘Sample A is negative, Sample B is positive,’ et cetera. We wait about a month and then we get the results that tells us whether we are correct. We pass.
With the other element—and I think you have that on record, and we will follow up with NATA—certainly the changes in terms of process mean that, within the system, NATA accreditation is even more important than it has been, I think.
What we were interested in were the potential changes to the TGA that would affect laboratories doing in-house tests. Our PCR is in-house; it is not a kit, it is our test.. This was really the point of applying for NATA.
I want to question, on the record, the statements you have in your submission about one of the other submissions, which has claimed to give information that was provided about your laboratory. I think it is important for that to be put on the record. Can you give a little bit of information on that. You have actually read another couple of submissions which are unnamed—which is not uncommon—in this process, but you believe that inaccurate information about what happened in your laboratory was put on the record?
This was about our overnight incubation of the immunoblot?
Originally, when we first started doing an immunoblot, we used a different kit. I was not very impressed with the results, because I assumed that if the patient has got Borrelia and I get a positive PCR we should be able to get a positive in another test as well—it certainly makes us feel better and probably the patient too. We used this other kit for six months to a year. Then I was reading various research papers where different immunoblot kits were being compared, and one of the ones that seemed to be quite good was the MIKROGEN kit. We made contact with the company. I have a permit to import the kits. We started using their kits. It was a little bit better than the original one, but it was not great. We were getting a lot more PCR positives and very few—some, but not a lot—of blot positives.
I then read a research paper from a European clinical microbiology presentation, and it was this poster. It was talking about the same MIKROGEN kit, and they were saying that when they were doing the tests, they did not find that the correlation between the other Borrelia tests and the MIKROGEN kit were all that great. What they did was increase the incubation of the test. Normally you do a one-hour incubation; they talked about doing an overnight incubation. I thought, ‘That might be interesting.’ I did not do anything for a while. The people who wrote the paper were doctors from the university hospital of Maastricht in Holland. What I did next was contact one of the doctors at MIKROGEN and say, ‘I have read this poster. What do you think?’ He said, ‘No, no, no. You don’t have to do that.’ So I did not. I waited another few months. During that time I tried to find one of these doctors. I phoned Holland multiple times at different places and universities and I finally found Dr Van Loo and spoke to her. I said, ‘I want to hear about how this worked.’ We had a talk. She said that they had validated the tests. They found it much more effective and had a much better correlation with their other tests.
At that stage we ran two tests on a patient. If a patient was asked to do an immunoblot, we did one that was a one-hour incubation and one that was an overnight incubation. We did this for a couple of months. During that period, the result we gave the patient was from the one-hour incubation, because that was the kit method. After a few months of testing, when we had adequate data, and during this time we could also correlate with the results of PCR, it was obvious that we were getting much better results with an overnight incubation. I know this particular doctor talked about us incubating until we got a positive. We get more negatives than positives. We do not even get 50 per cent positives. This is a farce. What we found was that when you do this, you do not create new bands. When you are doing an immunoblot you are looking for specific bands. What happens with the overnight incubation is that the fainter bands become strong enough to match the cut-off and you can give it a positive.
I think one of the issues is, again, that Borrelia does not act like other infections. When you do, for example, an immunoblot or some other kind of serology test for Epstein-Barr, you get really strong positives; the patient will be IgM positive for three to six months and then they become IgG and they remain that for years. Borrelia does not work like this; it affects the immune system so much that it just does not give you that standard effect. Until you come to realise this, it makes life really difficult.
I am going to have to get you to speed up a bit because we are going to run out of time. I apologise.
While I was doing this process I also spoke to another colleague, who is a professor in Canada, Professor Vett Lloyd, and I told her about this. She started to do the same thing with her blot. She also had the same reaction—that it was much better, much more reliable—and we are looking at writing a research paper on this at some stage.
The point, Ms Burke, is that another practitioner has actually claimed that you are falsifying your tests. As someone from outside the industry, the way that I read that paragraph is that you are falsifying your tests.
Yes. We have got used to this since we started testing Borrelia. I think as I wrote, one patient called and said, ‘A doctor down here said that they sent you water and you gave us a positive.’ and I said that if they had done that, they should have reported us. The stories are unbelievable. We have had had one scientist from another lab tell a patient that we did all our PCR in one room and so everything was contaminated. Now, we have PCR in three separate rooms. This was how it was originally set up. The people who set up my PCR had been senior scientists at CSIRO. One of the scientists was a man who actually did the first crystal structure of DNA; he is famous in the PCR world. So our tests were set up properly; the work is done properly; we really try to do our best for the patients. I find it really distressing to think that people in senior positions, who are supposed to be in the caring profession, have no problem directly lying to a patient. They obviously believe the end justifies the means. It is very depressing.
This may not be an accurate analogy, but NATA seems to be a group or association of Woolies and Coles, and even IGAs, and you are probably trying to open up a corner store and you have to apply to Woolies and Coles to have the permission to open up a corner store. This seems to be the case to me, which brings me to my question: it is probably more reasonable to have a government agency which is solely in charge of the testing procedures, rather than an association formed by the industry?
That is all I need to know.
That would be great.
Thank you very much. If you have further information, we are open to supplementary submissions as well.
I was going to leave you with more sequencing.
That is fine.
Would you like that?
Yes. That is fine. Thank you, but beyond that, if you have any further comments, the same offer is open to you as well. It is due as soon as possible. There are certain election things happening and so the sooner the better.