Diagnosis of TB: what is new from the laboratory Daniela Maria Cirillo San Raffaele Scientific Institute Milano, Italy

Topics Introduction: role of the laboratory in TB diagnosis Integrated laboratory network Biosafety guidelines Quality Assurance in the diagnosis of tuberculosis Laboratory diagnosis of tuberculosis Diagnostic algorithms Conclusion

Introduction Care of TB patients starts with a QA diagnosis A robust network of Tb laboratories is required: Adaquate biosafety Modern diagnostics SOPs QAs Integrated laboratory network

Integrated laboratory network An integrated laboratory network is: able to provide all primary diagnostic services without requiring patients to go to different laboratory facilities for specific tests ONE STOP SHOP

The past Weakest component of health systems for: slow policy change and constant underfunding Inappropriate technology transfer Inadequate infrastructure and biosafety Staff skills and number Inadequate lab strengthening plans Insufficient technical assistance

The present Joint effort to improve and expand TB lab capacity integrated into a global health system strengthening http://www.stoptb.org/wg/gli Research on new diagnostics tools accelerated and diagnostic pipeline rapidly growing ( expected point of care by 2015)

Quality Assurance Programme System designed to continuously improve the reliability and efficiency of laboratory services Three main components: Quality control (QC - IQA) External Quality Assurance (EQA) On site evaluation and review Proficiency Testing / Panel testing (PT) Blind rechecking Quality improvement (QI) QC: Also called Internal Quality Assurance, includes all means by which the laboratory controls operation, including instrument checks and checking new lots of laboratory reagents. EQA: A system of objectively checking the laboratory’s results by means of an external agency, such as reference laboratory. A process which allows participant laboratories to assess their capabilities by comparing their results with those in other laboratories in the network (intermediate and central laboratory) through panel testing and blinded rechecking. EQA also includes on-site evaluation of the OSE: Periodic visits to the laboratory to assess laboratory practices. Use of standardized CHECKLIST and forms for reporting of results Why? Obtain a realistic picture of laboratory practices Provide assistance with problem areas. Very poor performance may warrant an expanded visit to perform a comprehensive evaluation of laboratory procedures, assess quality practices, and assist with implementing corrective actions including providing training. PT: “A program in which multiple samples are periodically sent to members of a group of laboratories for analysis and/or identification; laboratory’s results are compared with an assigned value (and/or with those of other laboratories in the group), and reported to the participating laboratories and others.” (NCCLS) Rechecking: Random statistical sampling of specimens or slides for rechecking by a reference laboratory (intermediate or central laboratory) - Rechecking is always blinded , ensuring that the controller does not know the results from the peripheral laboratory. In other documents, this may also be referred to as rereading. QI: A process by which the components of smear microscopy diagnostic services are analyzed with the aim of looking for ways to permanently remove obstacles to success. Data collection, data analysis, and creative problem solving are the key components of this process. It involves continued monitoring, identifying defects, followed by remedial action including retraining when needed, to prevent recurrence of problems. QI often relies on effective on-site evaluation visits.

EQA Benefits Allows comparison of performance and results Serves as an early warning-system for problems Identifies systematic problems Provides objective evidence of laboratory quality Serves as an indicator of where to direct improvement efforts Identifies training needs Results may be compared between laboratories offering not only an opportunity for performances to be compared but also for systematic kit problems to be identified. Training needs may be identified and evaluated. The problems encountered in a panel may then be addressed in the next panel, creating a circular process.

Laboratory biosafety Mtb is a class 3 risk pathogen All biosafety strategies ( minimum requirements) should be based on procedures risk assessment Based on: Bacillary load of samples and workload Viability of bacilli Aeroosol generation Typology of the patients Fitness of the staff

Fluorescence Ziehl-Neelsen staining MICROSCOPY Rapid test Inexpensive Does not allow species identification Not applicable to all samples Specificity: >95% Sensitivity: 25-65% (90 % of infectious cases) Positive Predictive Value for TB depends on epidemiological situation Fluorescence Ziehl-Neelsen staining 1st AFB smear 80-82 % 2nd AFB smear 10-14 % 3rd AFB smear 5-8 % Excellent diagnostic test for TB control in high-incidence settings 10

LED Fluorescence Microscopy Advantages: increase in performance increase in lamp lifetime reduces initial, operating and maintenance costs (adaptable to existing microscopes) No need for dark room Batteries operated Domanda 1

New Policy and Smear microscopy definition of a TB case New definition in 2007*: “person with al least one smear-positive sample (1 AFB is sufficient) out of a total of two examined” 2 samples regardless the collection time *The definition/policy can be applied to countries performing microscopy under satisfactory quality assurance programmes 12

Same day approach same-day-diagnosis approach (microscopy of two consecutive spot-spot sputum specimens) is equivalent, in terms of diagnostic accuracy, to conventional case-finding strategies by microscopy

WHO recommends that: Countries that have successfully implemented the two- specimen case-finding strategy consider a switch to the same-day-diagnosis approach, especially in settings where patients are likely to default from the diagnostic process Countries that are still using the three-specimen case-finding strategy consider a gradual change to the same-day-diagnosis approach. Changes to a same-day-diagnosis strategy be preceded by a detailed situation assessment

WHO recommendations on sputum smear microscopy (2010) ZN light microscopy performed on UNCONCENTRATED sputum is suitable for all laboratory service levels Concentration of sputum is NOT recommended in programmatic settings Fluorescence microscopy is recommended for increased sensitivity (add 10%) LED microscopy is recommended over conventional fluorescence

TB Culture* Advantages Definitive diagnosis of TB Increases case finding of 30-50% Early detection of cases Provide strains for DST and epidemiological studies Disadvantages Complex and expensive compared to microscopy Requires complex handling of specimens Skilled technicians Appropriate infrastructure and biosafety levels LIMITATIONS: need for decontamination and identification *coverage 500.000/1000000

Culture: solid/liquid Low cost for reagents, not automated Culture level infrastructure Low contamination rate Long time to positivity Colony morphology ID required liquid Complex and expensive can be automated (MGIT) Highest infrastructure and biosafety levels Case finding increased 10% over solid Diagnostic delay reduced to days ID required Strip speciation tests needed for fast ID of Tbcomplex Molecular test for speciation of most common mycobacteria

TB Culture: solid/liquid

Standardization of procedures still difficult to set up Drug Susceptibility Testing (DST): the technical challenge still persists Standardization of procedures still difficult to set up The correct performance of DST requires the understanding of several steps such as: Origin of resistance and interpretative criteria Dosage and stability of the incorporated compounds Anti-mycobacterial activity of the incorporate drug Interpretation of results and data reporting 19

DST Definitive diagnosis of DRTB 3 main methods Absolute concentration method Proportion methods Resistant Ratio method

DST (2) Indirect methods suitable for regional/ national laboratories Adequate lab infrastructure and biosafety Accuracy varies with the drugs tested: R, H most accurate Second line : automated liquid DST are the gold standard Not recommended in the absence of QA capacity (200 high risk specimen per year) Formal link with Supranational Reference laboratories requested

Second line DST Recommended in appropriate structures for: Aminoglycosides, Fluoroquinolones, Polypeptides NOT recommended on routine for ethionamide, prothionamide, cycloserine,clofazimine, amox-clav, clarithromycin, linezolid)

WHO laboratory policies for culture and DST Automated liquid culture (2007) Use of liquid culture in the contest of comprehensive plan for strengthening lab capacity starting with national/central level Rapid speciation in combination with culture Second line DST (2008) to be conducted for selected drugs a central level Available at http://www.who.int/tb.dots/laboratory/policy/en/print.html

The effective treatment of MDR-TB is a life-saving intervention Early diagnosis of both TB and DR-TB are the key for an effective Tb control Novel technologies for rapid screening of anti-TB drug resistance have become a priority in Tuberculosis research

WHO policy on new diagnostics is evidence-driven Following new investments in research new diagnostics are finally moving Policy formulation needs to be an ongoing process at global and country level WHO asses policies by a systematic, structured process

Drug-Resistant TB: Definitions ISTC Training Modules 2008 Drug-Resistant TB: Definitions Mono-resistant: resistance to a single drug Poly-resistant: resistance to more than one drug, but not to the combination of isoniazid and rifampicin Multidrug-resistant (MDR): resistance to at least isoniazid and rifampicin Extensively drug-resistant (XDR): MDR plus resistance to fluoroquinolones and at least 1 of the 3 injectable drugs (amikacin, kanamycin, capreomycin) Begin with the definitions for drug resistance: Mono-resistant: The most common single drug-resistance pattern is mono-resistance to isoniazid. In general, this pattern of resistance is not usually associated with a worse outcome and does not require modification of the treatment regimen (as long as there are 4 drugs in the initial phase and rifampicin is included throughout the full duration of treatment). Rifampicin mono-resistance occurs, but is uncommon and is seen mainly in patients with HIV infection. The reasons for this association are not known. Poly-resistant: A general term used when the organism is resistant to more than one drug, but not the combination of isoniazid and rifampicin. MDR-TB: Resistance to at least isoniazid and rifampicin (the two most effective anti-tuberculosis drugs). MDR has a major adverse effect on the outcome of treatment. Patients with TB caused by MDR organisms generally require treatment with second line drug regimens. XDR-TB: MDR-TB plus resistance to the 2 most important classes of 2nd-line agents used in MDR-TB treatment: the fluoroquinolones and at least 1 of 3 injectable agents (amikacin, kanamycin, capreomycin). In addition to meeting the defining criteria, XDR-TB cases are often resistant to all four 1st-line agents. Consequently, patients with XDR-TB are significantly more difficult to treat and require specialized care. [Note: Material also covered (duplicate slide) in Management of Drug-Resistant TB module.]

Drug-Resistant TB: Definitions ISTC Training Modules 2008 Drug-Resistant TB: Definitions MONORESISTANT Begin with the definitions for drug resistance: Mono-resistant: The most common single drug-resistance pattern is mono-resistance to isoniazid. In general, this pattern of resistance is not usually associated with a worse outcome and does not require modification of the treatment regimen (as long as there are 4 drugs in the initial phase and rifampicin is included throughout the full duration of treatment). Rifampicin mono-resistance occurs, but is uncommon and is seen mainly in patients with HIV infection. The reasons for this association are not known. Poly-resistant: A general term used when the organism is resistant to more than one drug, but not the combination of isoniazid and rifampicin. MDR-TB: Resistance to at least isoniazid and rifampicin (the two most effective anti-tuberculosis drugs). MDR has a major adverse effect on the outcome of treatment. Patients with TB caused by MDR organisms generally require treatment with second line drug regimens. XDR-TB: MDR-TB plus resistance to the 2 most important classes of 2nd-line agents used in MDR-TB treatment: the fluoroquinolones and at least 1 of 3 injectable agents (amikacin, kanamycin, capreomycin). In addition to meeting the defining criteria, XDR-TB cases are often resistant to all four 1st-line agents. Consequently, patients with XDR-TB are significantly more difficult to treat and require specialized care. [Note: Material also covered (duplicate slide) in Management of Drug-Resistant TB module.]

Drug-Resistant TB: Definitions ISTC Training Modules 2008 Drug-Resistant TB: Definitions POLIRESISTANT Begin with the definitions for drug resistance: Mono-resistant: The most common single drug-resistance pattern is mono-resistance to isoniazid. In general, this pattern of resistance is not usually associated with a worse outcome and does not require modification of the treatment regimen (as long as there are 4 drugs in the initial phase and rifampicin is included throughout the full duration of treatment). Rifampicin mono-resistance occurs, but is uncommon and is seen mainly in patients with HIV infection. The reasons for this association are not known. Poly-resistant: A general term used when the organism is resistant to more than one drug, but not the combination of isoniazid and rifampicin. MDR-TB: Resistance to at least isoniazid and rifampicin (the two most effective anti-tuberculosis drugs). MDR has a major adverse effect on the outcome of treatment. Patients with TB caused by MDR organisms generally require treatment with second line drug regimens. XDR-TB: MDR-TB plus resistance to the 2 most important classes of 2nd-line agents used in MDR-TB treatment: the fluoroquinolones and at least 1 of 3 injectable agents (amikacin, kanamycin, capreomycin). In addition to meeting the defining criteria, XDR-TB cases are often resistant to all four 1st-line agents. Consequently, patients with XDR-TB are significantly more difficult to treat and require specialized care. [Note: Material also covered (duplicate slide) in Management of Drug-Resistant TB module.]

Drug-Resistant TB: Definitions ISTC Training Modules 2008 Drug-Resistant TB: Definitions MULTI DRUG RESISTANT Begin with the definitions for drug resistance: Mono-resistant: The most common single drug-resistance pattern is mono-resistance to isoniazid. In general, this pattern of resistance is not usually associated with a worse outcome and does not require modification of the treatment regimen (as long as there are 4 drugs in the initial phase and rifampicin is included throughout the full duration of treatment). Rifampicin mono-resistance occurs, but is uncommon and is seen mainly in patients with HIV infection. The reasons for this association are not known. Poly-resistant: A general term used when the organism is resistant to more than one drug, but not the combination of isoniazid and rifampicin. MDR-TB: Resistance to at least isoniazid and rifampicin (the two most effective anti-tuberculosis drugs). MDR has a major adverse effect on the outcome of treatment. Patients with TB caused by MDR organisms generally require treatment with second line drug regimens. XDR-TB: MDR-TB plus resistance to the 2 most important classes of 2nd-line agents used in MDR-TB treatment: the fluoroquinolones and at least 1 of 3 injectable agents (amikacin, kanamycin, capreomycin). In addition to meeting the defining criteria, XDR-TB cases are often resistant to all four 1st-line agents. Consequently, patients with XDR-TB are significantly more difficult to treat and require specialized care. [Note: Material also covered (duplicate slide) in Management of Drug-Resistant TB module.]

Drug-Resistant TB: Definitions ISTC Training Modules 2008 Drug-Resistant TB: Definitions MULTI DRUG RESISTANT ??? Begin with the definitions for drug resistance: Mono-resistant: The most common single drug-resistance pattern is mono-resistance to isoniazid. In general, this pattern of resistance is not usually associated with a worse outcome and does not require modification of the treatment regimen (as long as there are 4 drugs in the initial phase and rifampicin is included throughout the full duration of treatment). Rifampicin mono-resistance occurs, but is uncommon and is seen mainly in patients with HIV infection. The reasons for this association are not known. Poly-resistant: A general term used when the organism is resistant to more than one drug, but not the combination of isoniazid and rifampicin. MDR-TB: Resistance to at least isoniazid and rifampicin (the two most effective anti-tuberculosis drugs). MDR has a major adverse effect on the outcome of treatment. Patients with TB caused by MDR organisms generally require treatment with second line drug regimens. XDR-TB: MDR-TB plus resistance to the 2 most important classes of 2nd-line agents used in MDR-TB treatment: the fluoroquinolones and at least 1 of 3 injectable agents (amikacin, kanamycin, capreomycin). In addition to meeting the defining criteria, XDR-TB cases are often resistant to all four 1st-line agents. Consequently, patients with XDR-TB are significantly more difficult to treat and require specialized care. [Note: Material also covered (duplicate slide) in Management of Drug-Resistant TB module.]

Drug-Resistant TB: Definitions ISTC Training Modules 2008 Drug-Resistant TB: Definitions EXTENSIVELY DRUG RESISTANT Begin with the definitions for drug resistance: Mono-resistant: The most common single drug-resistance pattern is mono-resistance to isoniazid. In general, this pattern of resistance is not usually associated with a worse outcome and does not require modification of the treatment regimen (as long as there are 4 drugs in the initial phase and rifampicin is included throughout the full duration of treatment). Rifampicin mono-resistance occurs, but is uncommon and is seen mainly in patients with HIV infection. The reasons for this association are not known. Poly-resistant: A general term used when the organism is resistant to more than one drug, but not the combination of isoniazid and rifampicin. MDR-TB: Resistance to at least isoniazid and rifampicin (the two most effective anti-tuberculosis drugs). MDR has a major adverse effect on the outcome of treatment. Patients with TB caused by MDR organisms generally require treatment with second line drug regimens. XDR-TB: MDR-TB plus resistance to the 2 most important classes of 2nd-line agents used in MDR-TB treatment: the fluoroquinolones and at least 1 of 3 injectable agents (amikacin, kanamycin, capreomycin). In addition to meeting the defining criteria, XDR-TB cases are often resistant to all four 1st-line agents. Consequently, patients with XDR-TB are significantly more difficult to treat and require specialized care. [Note: Material also covered (duplicate slide) in Management of Drug-Resistant TB module.]

Impact of Resistance on Outcome ISTC Training Modules 2008 % of cases with failure or death, standard 4-drug regimen Resistance pattern New Cases (%) Retreatment (%) Pan-susceptible 4 10 Any Resistance 5 21 MDR 30 45 INH (not MDR) 6 23 RIF (not MDR) 13 29 Other 15 This table describes the outcome of treatment using a standard first line regimen in patients with various patterns of drug resistance. Investigators conducted a retrospective cohort study of patients with TB in the Dominican Republic, Hong Kong, Italy, Ivanovo Oblast (Russian Federation), the Republic of Korea, and Peru. The outcome was determined for new (previously untreated) and retreatment TB cases who received short-course chemotherapy with isoniazid, rifampicin, pyrazinamide, and either ethambutol or streptomycin between 1994 and 1996. Treatment outcome was defined according to WHO criteria. In this table, death during treatment and treatment failure were combined to provide a measure of unfavorable outcome. As the table shows, both MDR and rifampicin resistance were associated with a greater percentage of unfavorable outcomes than any of the other categories. Retreatment cases in all categories did less well than new cases. Again MDR cases had the highest percentage of unfavorable outcomes. The success rate of retreated cases drops substantially in all categories. Successful treatment outcomes for both new and retreated cases are significantly lower for RIF-resistant and MDR cases. [Reference: Espinal MA, et al. Standard Short-course Chemotherapy for Drug-Resistant Tuberculosis: Treatment Outcomes in 6 Countries. JAMA. 2000;283(19):2537-45] Espinal MA, et al. JAMA. 2000;283(19):2537-45

Mechanisms of resistance Production of enzymes that modify or destroy the antibiotic molecule Alteration of the target binding site Active escretion of the molecule (efflux pump) Membrane permeability reduction

Frequency of Resistance Mutations ISTC Training Modules 2008 INH = 1 in 106 RIF = 1 in 108 EMB = 1 in 106 Str = 1 in 106 I + R = 1 in 1014 In any given population of TB bacilli, naturally occurring resistant organisms occur at the rates as shown. [Review above] The greater the burden of disease, the larger the bacillary population and the greater the risk for harboring drug-resistant mutants and acquiring drug resistance. [Note: Year drug was discovered is listed under each drug.] [Image Credit: CDC/Dr. Ray Butler; Janice Carr. Illustration Credit: National Institute of Allergy and Infectious Diseases (NIAID). Illustrator: Krista Townsend]

Genes involved in drug-resistance for major anti-tubercular drugs

RIF resistance as surrogate marker for MDR TB RIF resistance as a mono resistance not very frequent (5-15% of them) 80-95% of RIF resistant strains are also resistant to INH Key-drug in the anti-TB regimen Low rate of spontaneous mutations Mutations affect an hot-spot region in the rpoB gene Khue et al. A 10-year prospective surveillance of Mycobacterium tuberculosis drug resistance in France 1995–2004. Eur Respiratory J. 2007 Ideal candidate for the molecular detection of resistance to the drug PAGE | 36 36

Commercial Line Probe Assays Hain Lifescience Innogenetics INNO-LiPA-Rif.TB 37

Yes (modified version) Comparison GenoType® MTBDRplus and INNO-LiPA Rif.TB GenoType® MTBDR INNO-LiPA Rif.TB Company Hain Lifescience Innogenetics M. tuberculosis detection Yes Detection of RMP Resistance in M. tb Complex Detection INH Resistance in M. tb Complex No Strip Assay PCR based From liquid or solid culture Direct assay Yes (modified version) TBCDetection: 23S-rRNA/16S-rRNA RMP-Resistance: rpoB gene INH-Resistance: katG gene/inhA gene Universalcontrol rpoB unicontrol kat G/inHA unicontrol

New generation of LiPA performs better in both Sm+ and Sm- samples Miotto al. JCM 2008

Policy statement by WHO and Partners June 27, 2008 Molecular line probe assays for rapid screening of patients at risk of MDR-TB Policy statement by WHO and Partners June 27, 2008 Endorsement of the two commercial line probe assays for rifampicin resistance detection: Tests are CE marked and meet predefined performance targets in controlled evaluation studies Both tests are highly sensitive and specific for rifampicin resistance detection from TB strains

Sputum samples Smear positive Smear negative Report as negative OR if TB is highly suspected (HIV+,child..) perform (liquid) culture Rif/ Rif INH LiPA Culture AFB positive, TB morphology MTB detected, INH(*) and RMP susceptible MTB detected, INH and/or RMP resistant (MDR-TB) Unsuccessful amplification Standard MDR treatment Culture (liquid/ solid) DST ( first and second line) Perform (liquid) culture MTBC, INH(*) and RMP mutation non detected NON MDR No culture Individualized treatment Culture AFB positive monitoring Start standard 1st line treatment Treatment with 2nd-3rd Drugs available/isolation ID Monitoring sputum conversion

Possible automation on LiPA LiPAs require: Level II biosafety areas Skilled laboratory staff Amplicon Contamination control

XPERT TB-MDR •time-to-result < 2 h •simple 1-step external sample prep. •time-to-result < 2 h •throughput: >16 tests / day / module •no need for biosafety cabinet •integrated controls •true random access •specific for MTB •sensitivity similar to culture •detection of rif-resistance via rpoB gene •test cartridges for GeneXpert System •several GeneXpert modules can be combined in 1 workstation •~1 day technician training required

Simple Sample Processing – Direct Sputum 4. Transfer 2ml to cartridge 2. Shake then stand 10 minutes Begin Test… 3. Shake then stand further 5 minutes Add 2:1 Sample Buffer to sample

Moving to “district” : Dharamsala, Delek Hospital

Sensitivity (cfu/ml) of pulmonary TB diagnostics Solid culture

Advantages Simple to perform Minimal training Virtually cross contamination free Minimal biosafety requirement Higher sensitivity in paucibacillary samples (HIV+)

Proportion of TB cases detected

Time to detection

Time to RFP resistance detection

Potential limits of Xpert MTB/RIF technology Unknown the performance at a district level If RFP resistance is diagnosed at a low level MDR prevalence environment, the assay needs to be confirmed Need to perform a culture for DST to evaluate other drug resistance Need to perform a culture for monitoring issue (culture conversion) It requires uninterrupted and stable electronic power supplies and yearly calibration Size for storage issues

New WHO recommendations WHO RECOMMENDATION, December 8th, 2010

New WHO recommendations WHO RECOMMENDATION, December 8th, 2010

New WHO recommendations WHO RECOMMENDATION, December 8th, 2010

Comparison GenoType® MTBDRplus and XpertTB/MDR XpertTB-MDRplus Company Hain Lifescience Cepheid M. tuberculosis detection Yes Detection of RMP Resistance in M. tb Complex Detection INH Resistance in M. tb Complex No Fully automated /training No/Yes Yes/No DNA tech PCR Mol Beacon From liquid or solid culture NA Direct assay Level of biosafety II microscopy Time to results Same day 2h Cost per test Low/Mod Mod/High Universal control Extraction control Cost of Maintenance Contamination control Low High Intermediate Reference labs Patients testing from Sm/ C+ (Rif) Fast tool Surveillance purposes Potential to District level as fast patients diagnostic tool, needs evaluation at district level

Sputum samples Xpert-TB/MDR-TB Contact tracing? Smear positive Smear negative Contact tracing? Report as negative OR if TB is highly suspected (HIV+,child..) perform (liquid) culture Rif/ Rif INH LiPA Culture AFB positive, TB morphology MTB detected, INH(*) and RMP susceptible MTB detected, INH and/or RMP resistant (MDR-TB) Unsuccessful amplification Standard MDR treatment Culture (liquid/ solid) DST ( first and second line) Perform (liquid) culture MTBC, INH(*) and RMP mutation non detected NON MDR No culture Individualized treatment Culture AFB positive monitoring Start standard 1st line treatment Treatment with 2nd-3rd Drugs available/isolation ID Monitoring sputum conversion

Genes involved in drug-resistance for major anti-tubercular drugs 40-80%

XDR molecular diagnosis: GenoType MTBDRsl (Hain Lifescience)

Technologies and laboratory appropriateness Introducing new technology requires addressing of core elements: Infrustructure, biosafety measures and maintenance Equipment validation and maintenance Specimen transport and referral mechanisms Management of laboratory commodities and supplies Laboratory information data and management system Laboratory quality management Strategies for HR development and retention GLI road map at :http://www.who.int/tb/dots/laboratory/policy/en

“Point of care assay” Closer if Large scale innovation and delivery will be fully supported by: Scientists and industry Large operational research trials Large view policy makers and regulators Retooling of existing resources