Predicate Devices

Reference Devices

AI/ML (Artificial Intelligence / Machine Learning)

No
The summary describes a physical device for collecting and transporting nasal specimens. There is no mention of any software, algorithms, or data processing that would indicate the use of AI or ML. The performance studies focus on the device's ability to collect and maintain the integrity of the sample for subsequent laboratory testing, not on any analytical capabilities within the device itself.

Therapeutic

No
The device is described as an in-vitro diagnostic device intended for the collection and transport of specimens for laboratory testing, not for therapeutic intervention.

Diagnostic

No

This device is intended to collect and transport specimens for in-vitro diagnostic use, not to perform the diagnostic testing itself.

SaMD (Software as a Medical Device)

No

The device description clearly states that the device is comprised of physical components: a revised Wash Head and a Transport Container, which are made of inert, biocompatible plastics. It also requires the use of the previously cleared CLEARinse Pro Handle, which is described as having a pump-containing Handle and a disposable collection Wash Head. These are all hardware components.

IVD (In Vitro Diagnostic)

Yes, this device is an IVD (In Vitro Diagnostic).

Here's why:

Intended Use/Indications for Use: The document explicitly states "CLEARinse CTS is for professional in-vitro diagnostic use." It also describes the device's purpose as collecting and transporting specimens for the detection of influenza A or B virus using legally marketed lateral flow immunoassays and molecular assays, which are in-vitro diagnostic tests.
Device Description: The description reinforces the intended use by detailing how the device is used to collect a nasal wash aspirate specimen for subsequent testing in a laboratory or testing site.
Intended User/Care Setting: The intended users are healthcare professionals, and the specimens are transported to a laboratory or testing site, which are typical settings for in-vitro diagnostic testing.
Performance Studies: The performance studies described (Limit of Detection and Sample Stability) are relevant to evaluating the performance of a device used in the collection and transport of specimens for in-vitro diagnostic testing.

The device is designed to collect and transport a biological specimen that will be analyzed in vitro (outside the body) to diagnose a condition (influenza). This aligns directly with the definition of an In Vitro Diagnostic device.

PCCP (Predetermined Change Control Plan) Authorized

N/A

Overview

Intended Use / Indications for Use

CLEARinse CTS is intended to collect and transport clinical nasal wash aspirate specimens that may contain influenza A or influenza B virus, by health care professionals, from the collection site to a laboratory or testing site. CLEARinse CTS specimens are suitable for use with legally marketed lateral flow immunoassays and molecular assays. CLEARinse CTS is for professional in-vitro diagnostic use.

Product codes

OBD

Device Description

CLEARinse CTS is intended to collect and transport clinical nasal wash aspirate specimens that may contain influenza A or influenza B virus, by health care professionals, from the collection site to a laboratory or testing site. CLEARinse CTS specimens are suitable for use with legally marketed lateral flow immunoassays and molecular assays. CLEARinse CTS is for professional in-vitro diagnostic use.

The product is an extension of the CLEARinse Pro device, a 510(k)-cleared (K082762) professional use medical device with indications for nasal lavage as well as mucus sample collection for subsequent testing. The CLEARinse Pro device has two main components: a pump-containing Handle and a disposable collection Wash Head. The CLEARinse Pro Handle and Instructions for Use are required for use of the CLEARinse CTS.

The CLEARinse CTS is comprised of two component assemblies: a revision to the 510(k)cleared Wash Head and a Transport Container to protect the Wash Head and specimen during transit. The CLEARinse CTS. used with the CLEARinse Pro Handle, will allow a nasal wash aspirate specimen to be collected by a medical professional, protected for transit, and ground shipped to a testing site. The user mounts the CLEARinse CTS Wash Head onto the CLEARinse Pro Handle and adds sterile saline as directed. The tip of the Wash Head is inserted into the patient's nostril and sterile saline is introduced. The irrigated saline and nasal secretions are then aspirated back into the Wash Head, collecting the specimen to be tested. The CLEARinse CTS Wash Head is removed from the Handle and placed into the Transport Container assembly (Container Cup, Filter Seal, Silicone Seal, and Container Lid) and then back into the CLEARinse CTS box for ground transportation of the specimen to a laboratory for testing.

The Wash Head is manufactured from inert, biocompatible plastics and is supplied as a sterile, single use device. The Transport Container is also manufactured from inert, biocompatible plastics and is a single use device but is not supplied sterile.

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

Nasal

Indicated Patient Age Range

Not Found

Intended User / Care Setting

Health care professionals, from the collection site to a laboratory or testing site.

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

Not Found

Summary of Performance Studies (study type, sample size, AUC, MRMC, standalone performance, key results)

Study Type: Limit of Detection (LoD) testing and Sample Stability testing.

Limit of Detection (LoD) Testing:

PCR LoD Test Results:
- Preliminary LoD testing: Spiked multiple concentrations (3X, 1X, 0.5X of established LoDs) of three different influenza strains (A/Netherlands/602/2009 (H1N1), A/Indiana/10/2011 (H3N2), B/Florida/07/2004) into pooled negative clinical nasal wash matrix (NWA and 0.9% saline solution). Tested using Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV.
  - FluA H1N1: All 3 replicates positive at 1X and 3X. 2 of 3 positive at 0.5X.
  - FluA H3N2: All 3 replicates positive at 1X and 3X. 0 of 3 positive at 0.5X.
  - FluB: All 3 replicates positive at 0.1X and 0.3X. 2 of 3 positive at 0.05X.
- Confirmatory LoD testing: 20 replicates of contrived samples for each of the three influenza strains, using the same procedure as preliminary study.
  - Influenza A H1N1: 19 out of 20 results within acceptance range of +/- 3 Ct of the mean for FluA1 analyte.
  - Influenza A H3N2 and B: 20 out of 20 Ct values within acceptance range for FluA1 or FluB, respectively.
- Key Results: Established LoD for PCR assays: 4.0 x 10-3 TCID50/mL for influenza A(H1N1) and B, and 2.6 x 10-1 TCID50/mL for influenza A(H3N2).
LFA LoD Test Results:
- Preliminary LoD testing: Spiked multiple concentrations (3X, 1X, 0.5X of established LoDs, plus additional levels) of three different influenza strains into NWA. Tested using PBM BioSign Flu A+B lateral flow assay (LFA).
  - FluA H1N1: All replicates positive at 0.5X and 0.25X. 0 of 3 positive at 0.125X.
  - FluA H3N2 and FluB: Higher levels were tested, with 3 of 3 positive results at 27X (FluA H3N2) and 20X (FluB).
- Confirmatory LoD testing: 20 replicates of contrived samples for each of the three influenza strains, using the same procedure as preliminary study.
  - FluA H1N1 (0.25X): 20 of 20 positive (100%).
  - FluA H3N2 (40X): 20 of 20 positive (100%).
  - FluB (20X): 20 of 20 positive (100%).
- Key Results: Established LoD for LFA assays: 2.6 x 101 TCID50/mL for influenza A(H3N2), 4.0 x 103 TCID50/mL for influenza A(H1N1) and 4.0 x 102 TCID50/mL for influenza B.

Sample Stability Testing:

A. Viral Nucleic Acid Stability:
- Sample Size: Not explicitly stated, but each device contained 2 mL of virus inoculum, and PCR assay was performed in triplicate for each time point and storage condition.
- Methodology: Contrived samples containing influenza strains at 2.5X LoD prepared in pooled NWA matrix. Samples in CLEARinse CTS Wash Head, sealed in Transport Container, incubated at 4°C and 27°C. Tested at 0, 4, 6, 24, and 48 hours using Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV Cartridge.
- Key Results: Samples used for viral nucleic acid testing are stable when stored for 48 hours at room and refrigerated temperature.
B. Viral Antigen Stability:
- Sample Size: Not explicitly stated, but each device contained 2 mL of virus inoculum, and LFA assay was performed in triplicate for each time point and storage condition.
- Methodology: Contrived samples containing influenza strains at 2.5X LoD prepared in pooled NWA matrix. Samples in CLEARinse CTS Wash Head, sealed in Transport Container, incubated at 4°C and 27°C. Tested at 0, 4, 6, and 48 hours using PBM BioSign Flu A + B test kit.
- Key Results: Samples used for antigen testing are stable when stored for 24 hours at room temperature or 48 hours refrigerated.

Key Metrics (Sensitivity, Specificity, PPV, NPV, etc.)

Not Found (Only LoD and stability data provided, not traditional diagnostic performance metrics for clinical samples)

Predicate Device(s)

DEN170029

Reference Device(s)

K082762

Predetermined Change Control Plan (PCCP) - All Relevant Information

Not Found

Regulation Number and Section

§ 866.2950 Microbial nucleic acid storage and stabilization device.

(a)
Identification. A microbial nucleic acid storage and stabilization device is a device that consists of a container and reagents intended to stabilize microbial nucleic acids in human specimens for subsequent isolation and purification of nucleic acids for further molecular testing. The device is not intended for preserving morphology or viability of microorganisms.(b)
Classification. Class II (special controls). The special controls for this device are:(1) The intended use for the labeling required under § 809.10 of this chapter must include a detailed description of microorganisms and types of human specimens intended to be preserved.
(2) The labeling required under § 809.10(b) of this chapter must include the following:
(i) A detailed device description, including all device components;
(ii) Performance characteristics from applicable analytical studies, including nucleic acid stability and microorganism inactivation;
(iii) A limiting statement that erroneous results may occur when the transport device is not compatible with molecular testing; and
(iv) A limiting statement that the device has only been validated to preserve the representative microorganisms used in the analytical studies.
(3) Design verification and validation must include the following:
(i) Overall device design, including all device components and all control elements incorporated into the analytical validation procedures;
(ii) Thorough description of the microorganisms and methodology used in the validation of the device including, extraction platforms and assays used for the detection of preserved nucleic acids; and
(iii) The limit of detection (LoD) of the molecular test used to establish microorganism nucleic acid stability.

Summary

0

Image /page/0/Picture/0 description: The image shows the logo of the U.S. Food and Drug Administration (FDA). On the left is the Department of Health & Human Services logo. To the right of that is the FDA logo, which is a blue square with the letters "FDA" in white. To the right of the blue square is the text "U.S. FOOD & DRUG ADMINISTRATION" in blue.

July 3, 2023

Aardvark Medical, Inc. Steven Bacich CEO 204 Cardinal Drive, Suite 300 Denton, TX 94960 United States

Re: K221664

Trade/Device Name: CLEARinse CTS Specimen Collection and Transport System Regulation Number: 21 CFR 866.2950 Regulation Name: Microbial Nucleic Acid Storage And Stabilization Device Regulatory Class: Class II Product Code: OBD Dated: June 7, 2022 Received: June 8, 2022

Dear Steven Bacich:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal

1

statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801 and Part 809); medical device reporting of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4, Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.

For comprehensive regulatory information about medical devices and radiation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email (DICE@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100).

Sincerely,

Noel J. Gerald -S

Noel J. Gerald, Ph.D. Branch Chief Bacterial Respiratory and Medical Countermeasures Branch Division of Microbiology Devices OHT7: Office of In Vitro Diagnostics Office of Product Evaluation and Ouality Center for Devices and Radiological Health

Enclosure

2

Indications for Use

510(k) Number (if known) K221664

Device Name CLEARinse CTS

Indications for Use (Describe)

CLEARinse CTS is intended to collect and transport clinical nasal wash aspirate specimens that may contain influenza A or influenza B virus, by health care professionals, from the collection site to a laboratory or testing site. CLEARinse CTS specimens are suitable for use with legally marketed lateral flow immunoassays and molecular assays. CLEARinse CTS is for professional in-vitro diagnostic use.

Type of Use (Select one or both, as applicable)

☑ Prescription Use (Part 21 CFR 801 Subpart D)
☐ Over-The-Counter Use (21 CFR 801 Subpart C)

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510(K) SUMMARY

Submitter's Name and Address:

Aardvark Medical Company. 204 Cardinal Drive, Suite 300 Denton. TX 94960 United States

Contact Name and Information:

Steven Bacich 650-218-5934 stevenbacich(@gmail.com

Date prepared:

June 7, 2023

Device Information:

Trade/Proprietary Name:

System Common or Usual Name: Classification Name: Classification Number: OBD Product Code:

CLEARinse™ CTS Specimen Collection and Transport Microbial Nucleic Acid Storage and Stabilization Device Microbial Nucleic Acid Storage and Stabilization Device Class II, 21 CFR 866.2950

Predicate Device:

| 510(k)

Number	Device	Product Code
DEN170029	PrimeStore® MTM	QBD

Device Description:

CLEARinse CTS Specimen Collection and Transport System

CLEARinse CTS is intended to collect and transport clinical nasal wash aspirate specimens that may contain influenza A or influenza B virus, by health care professionals, from the collection site to a laboratory or testing site. CLEARinse CTS specimens are suitable for use with legally marketed lateral flow immunoassays and molecular assays. CLEARinse CTS is for professional in-vitro diagnostic use.

The product is an extension of the CLEARinse Pro device, a 510(k)-cleared (K082762) professional use medical device with indications for nasal lavage as well as mucus sample collection for subsequent testing. The CLEARinse Pro device has two main components: a pump-containing Handle and a disposable collection Wash Head. The CLEARinse Pro Handle and Instructions for Use are required for use of the CLEARinse CTS.

The CLEARinse CTS is comprised of two component assemblies: a revision to the 510(k)cleared Wash Head and a Transport Container to protect the Wash Head and specimen during

4

transit. The CLEARinse CTS. used with the CLEARinse Pro Handle, will allow a nasal wash aspirate specimen to be collected by a medical professional, protected for transit, and ground shipped to a testing site. The user mounts the CLEARinse CTS Wash Head onto the CLEARinse Pro Handle and adds sterile saline as directed. The tip of the Wash Head is inserted into the patient's nostril and sterile saline is introduced. The irrigated saline and nasal secretions are then aspirated back into the Wash Head, collecting the specimen to be tested. The CLEARinse CTS Wash Head is removed from the Handle and placed into the Transport Container assembly (Container Cup, Filter Seal, Silicone Seal, and Container Lid) and then back into the CLEARinse CTS box for ground transportation of the specimen to a laboratory for testing.

The Wash Head is manufactured from inert, biocompatible plastics and is supplied as a sterile, single use device. The Transport Container is also manufactured from inert, biocompatible plastics and is a single use device but is not supplied sterile.

Indications for Use/Intended Use:

CLEARinse CTS is intended to collect and transport clinical nasal wash aspirate specimens that may contain influenza A or influenza B virus, by health care professionals, from the collection site to a laboratory or testing site. CLEARinse CTS specimens are suitable for use with legally marketed lateral flow immunoassays and molecular assays. CLEARinse CTS is for professional in-vitro diagnostic use.

| Device & Predicate

Device(s):	Subject: K221664	Predicate: DEN170029
Device Trade Name	CLEARinse CTS:
Specimen Collection
and Transport System	PrimeStore MTM
General Device
Characteristic Similarities
Intended Use/Indications
For Use	CLEARinse CTS is
intended to collect and
transport clinical nasal
wash aspirate
specimens that may
contain influenza A or
influenza B virus, by
health care
professionals, from the
collection site to a
laboratory or testing
site. CLEARinse CTS	PrimeStore MTM is
intended for the
stabilization,
transportation and
inactivation of
infectious unprocessed
nasal washes suspected
of containing Influenza
a virus RNA.
PrimeStore MTM is
also intended for the
stabilization,

Comparison of Technological Characteristics:

5

| | specimens are suitable
for use with legally
marketed lateral flow
immunoassays and
molecular assays.
CLEARinse CTS is for
professional in-vitro
diagnostic use. | transportation and
inactivation of
infectious unprocessed
sputum samples
suspected of containing
Mycobacterium
tuberculosis DNA from
human samples. |
|----------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Material | Polypropylene | Same |
| General Device
Characteristic Differences | | |
| Specimen Type | Nasal Wash Aspirate
suspected of containing
influenza A or B viruses | Nasal wash suspected
of containing Influenza
A virus. Sputum
samples suspected of
containing MTB. |
| Transport Media
Formulation | 0.9% saline from nasal
wash | Nucleic Acid
Stabilization solution |
| Device Material Supplied | Wash Head and
Transport Container | Molecular Transport
Medium provided in
cryogenic tube |
| Sterility | Sterile | Not sterile |
| Inactivation | No inactivation of
viruses or bacteria | Inactivation of
influenza A and MTB
by Guanidine
thiocyanate |
| Specimen Collection | Collection using the
CLEARinse Pro Handle
and Instructions for Use | Collection using
standard clinical
procedures |

The Aardvark Medical Company CLEARinse CTS Device is substantially equivalent to the legally marketed predicate device. The CLEARinse CTS Device has the same intended use, similar indications for use, and similar technological characteristics for transporting nasal wash specimens to the laboratory as the predicate device. Performance data demonstrates that the CLEARinse CTS Device is as safe and effective.

Performance Data:

Detection Limit

6

Limit of Detection (LoD) testing was conducted to determine the lowest concentration of influenza A and influenza B that contains measurable nucleic acids or measurable antigens. Recovery of target analyte from the transport media, with a greater than 95% accuracy, was conducted by spiking pooled negative clinical nasal wash matrix (NWA and 0.9% saline solution) with various concentrations of influenza nucleic acid or antigen. The contrived samples were then placed into and removed from the Wash Head. The recovered samples are then placed into the workflow for the Cepheid® Xpert® Xpress SARS-CoV-2/Flu/RSV and Princeton BioMeditech Corporation (PBM) BioSign® Flu A+B assays. The results are compared to established LoD for the reference assays, found in their respective Package Inserts (PI).

A. PCR LoD Test Results:

Preliminary LoD testing was initially performed by spiking multiple concentrations of three different strains of influenza into NWA. The three viral concentrations used were 3X, 1X, and 0.5X of the established LoDs of similar influenza strains (Table 1) in the PI for the reference assay. The assay used was the EUA authorized, real-time reverse transcription polymerase chain reaction (PCR) Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV Cartridge using the GeneXpert® Xpress System. Positive and negative results were determined as explained in the PI for the device.

Virus Type	Strain tested with CTS device	Reported LoD of Similar Strain*
Influenza A, H1N1	A/Netherlands/602/2009	$4.0 x 10^{-3}$ TCID50/mL for A/California/7/2009(H1N1)
Influenza A, H3N2	A/Indiana/10/2011	$8.7 x 10^{-2}$ TCID50/mL for A/Victoria/361/2011(H3N2)
Influenza B	B/Florida/07/2004	$4.0 x 10^{-2}$ TCID50/mL for B/Massachusetts/2/2012

Table 1. Proposed test levels for Cepheid PCR testing for preliminary LoD study

*Note: strains used to determine analytical sensitivity (LoDs) for validation of the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV Cartridge

For the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV PCR test, LoD range-finding results indicated that the influenza A (FluA) samples contrived by the sponsor performed similarly to those used by Cepheid to establish the reported LoDs. For both FluA viruses, all three replicates were positive at 1X and 3X the reported LoD (Table 2). At 0.5X the reported LoD, each virus was negative for one or more replicates, indicating that the 1X level was truly near the LoD using the viral stocks listed in Table 1. For the influenza B (FluB), testing at 10-fold lower levels (0.05X - 0.3X) resulted in similar qualitative results: all three replicates positive at 0.1X and 0.3X, and only two of three replicates positive at 0.05X (Table 2).

Table 2. Preliminary PCR LoD estimation results with individual LoDs highlighted in grey.

Flu Type	Test Level	Qualitative Results	Mean Ct*
----------	------------	---------------------	----------

7

	Description	TCID50/mL	# Positive	% Positive
FluA H1N1	3X	1.2E-02	3 of 3	100%	34.9
	1X	4.0E-03	3 of 3	100%	36.8
	0.5X	2.0E-03	2 of 3	67%	37.4
FluA H3N2	3X	2.6E-01	3 of 3	100%	35.6
	1X	8.7E-02	3 of 3**	100%	36.9
	0.5X	4.3E-02	0 of 3	0%	N/A
FluB	0.3X	1.2E-02	3 of 3	100%	36.0
	0.1X	4.0E-03	3 of 3	100%	38.8
	0.05X	2.0E-03	2 of 3	67%	38.1

*Note: Mean Ct for FluA viruses are calculated based on the FluA1 analyte, which produced consistent Ct values.

**One replicate was positive on FluA1 and was negative on FluA2 and was considered below the LoD.

Confirmatory LoD testing was conducted with 20 replicates using contrived samples. The samples for the confirmatory testing were contrived using the sample procedure that was used for the preliminary study. The Ct values for the 20 replicates of the confirmatory tests for each of the three influenza strains are shown in Tables 3-5. Influenza A H1N1 had one Ct value out of acceptance range for analyte FluA1 resulting in 19 out of 20 results within the acceptance range of +/- 3 Ct of the mean. Both influenza A H3N2 and B had 20 out of 20 Ct values for either analyte FluA1 or FluB, respectively, within the acceptance range.

Table 3. PCR LoD confirmation results for influenza A H1N1 with out of acceptance range FluA1 Ct values highlighted in grey.

| Concentration
(1X LoD) | Replicate | FluA1
Result | FluA1 Ct | FluA2 Ct |
|---------------------------|-----------|-----------------|----------|----------|
| 4.00E-03 | 1 | Positive | 35.8 | 36.7 |
| 4.00E-03 | 2 | Positive | 35.2 | 36.4 |
| 4.00E-03 | 3 | Positive | 35.3 | 37 |
| 4.00E-03 | 4 | Positive | 38 | 41.1 |
| 4.00E-03 | 5 | Positive | 35.1 | 36.5 |
| 4.00E-03 | 6 | Positive | 36 | 37.8 |
| 4.00E-03 | 7 | Positive | 35.7 | 38.2 |
| 4.00E-03 | 8 | Positive | 35.9 | 40 |
| 4.00E-03 | 9 | Positive | 36.5 | 37.8 |
| 4.00E-03 | 10 | Positive | 35.6 | 37.2 |
| 4.00E-03 | 11 | Positive | 36.9 | 38.6 |

8

4.00E-03	12	Positive	35.4	36.8
4.00E-03	13	Positive	32.2	34.3
4.00E-03	14	Positive	35.2	36.1
4.00E-03	15	Positive	34.4	35.3
4.00E-03	16	Positive	36	38.6
4.00E-03	17	Positive	34.9	36.7
4.00E-03	18	Positive	36.3	37.8
4.00E-03	19	Positive	35.3	37.2
4.00E-03	20	Positive	35.5	37.3

Table 4. PCR LoD confirmation results for influenza A H3N2 with out of acceptance range
FluA1 Ct values highlighted in grey.

| Concentration
(1X LoD) | Replicate | FluA1
Result | FluA1 Ct | FluA2 Ct |
|---------------------------|--- | 2.60E-01 | 1 | 2.60E-01 | 2 | 2.60E-01 | 3 | 2.60E-01 | 4 | 2.60E-01 | 5 | 2.60E-01 | 6 | 2.60E-01 | 7 | 2.60E-01 | 8 | 2.60E-01 | 9 | 2.60E-01 | 10 | 2.60E-01 | 11 | 2.60E-01 | 12 | 2.60E-01 | 13 | 2.60E-01 | 14 | 2.60E-01 | 15 | 2.60E-01 | 16 | 2.60E-01 | 17 | 2.60E-01 | 18 | 2.60E-01 | 19 | 2.60E-01 | 20 | 2.60E-01 | 21 --------|-----------------|----------|----------|
| Positive | 37.1 | ND |
| Positive | 36.1 | 40 |
| Positive | 37.7 | 39 |
| Positive | 35.1 | 37 |
| Positive | 35.4 | 43 |
| Positive | 34.3 | 37 |
| Positive | 35.3 | ND |
| Positive | 35.5 | 38 |
| Positive | 35.3 | 39 |
| Positive | 35 | 37 |
| Positive | 35.2 | 39 |
| Positive | 35.8 | 38 |
| NA* | NA* | NA* |
| Positive | 35.2 | 38 |
| Positive | 35.6 | 38 |
| Positive | 36 | 39 |
| Positive | 35.3 | 39 |
| Positive | 35.6 | 39 |
| Positive | 35.5 | 38 |
| Positive | 34.9 | 37 |
| Positive | 35.5 | 41 |

*Note: Error. Probe check failed with the output of "NO RESULT – REPEAT TEST."

Table 5. PCR LoD confirmation results for influenza B with out of acceptance range FluB Ct values highlighted in grey.

| Concentration
(1X LoD) | Replicate | FluB
Result | FluB Ct |
|---------------------------|-----------|----------------|---------|
| 4.00E-03 | 1 | Positive | 36.1 |

9

4.00E-03	2	Positive	36.1
4.00E-03	3	Positive	36.1
4.00E-03	4	Positive	36.3
4.00E-03	5	Positive	36.5
4.00E-03	6	Positive	36.7
4.00E-03	7	Positive	36.3
4.00E-03	8	Positive	36.2
4.00E-03	9	Positive	36.9
4.00E-03	10	Positive	36.2
4.00E-03	11	Positive	35.8
4.00E-03	12	Positive	35.9
4.00E-03	13	Positive	35.7
4.00E-03	14	NA*	NA*
4.00E-03	15	Positive	36.3
4.00E-03	16	Positive	36.6
4.00E-03	17	Positive	39.2
4.00E-03	18	Positive	36.4
4.00E-03	19	Positive	35.9
4.00E-03	20	Positive	37.1
4.00E-03	21	Positive	36.4

*Note: Error. Probe check failed with the output of "NO RESULT – REPEAT TEST."

In summary, the testing performed established that for PCR assays 4.0 x10-3 TCIDsolmL is the LoD for both influenza A(H1N1) and B, and that 2.6 x10'' TCID50/mL is the LoD for influenza A(H3N2).

B. LFA LoD Test Results:

Preliminary LoD testing was initially performed by spiking multiple concentrations of three different strains of influenza into NWA. The three viral concentrations used were 3X, 1X, and 0.5X of the established LoDs of similar influenza strains (Table 6) in the PI for the reference assay. The preliminary results indicated that additional antigen concentrations needed to be tested beyond the initially planned levels. The assay used was the PBM BioSign® Flu A+B lateral flow assay (LFA) (K182157). Positive and negative results were determined as explained in the PI for the device.

| Virus Type | Strain tested with CTS
device | Reported LoD of Similar
Strain* |
|----------------------|----------------------------------|-------------------------------------------------|
| Influenza A,
H1N1 | A/Netherlands/602/2009 | 1.1 x 102 TCID50/mL for
A/PR/8/34(H1N1) |
| Influenza A,
H3N2 | A/Indiana/10/2011 | 10 x 101 TCID50/mL for
A/Victoria/3/75(H3N2) |

Table 6. Proposed test levels for PBM BioSign LFA testing for preliminary LoD study

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| Influenza B | B/Florida/07/2004 | $2.0 x 101 TCID50/mL for$
B/Maryland/1/59 |

-------------	-------------------	----------------------------------------------

*Note: strains used to determine analytical sensitivity (LoDs) for validation of the PBM BioSign Flu A+B LFA

For influenza A H1N1, all replicates produced positive results at all test levels, so additional lower levels (0.25X and 0.125X) were tested. For influenza A H3N2 and influenza B, all levels initially tested produced negative results for all three replicates. Thus, higher levels were tested until a test level produced three of three positive results. A summary of levels tested and the results at each level are presented in Table 7.

	Test Level		Qualitative Results
Flu Type	Description	TCID50/mL	# Positive	% Positive
FluA H1N1	0.5X	5.25E+01	3 of 3	100%
FluA H1N1	0.25X	2.63E+01	3 of 3	100%
FluA H1N1	0.125X	1.32E+01	0 of 3	0%
FluA H3N2	27X*	2.65E+03	3 of 3	100%
FluA H3N2	20X	1.99E+03	0 of 3	0%
FluA H3N2	10X	9.95E+02	0 of 3	0%
FluB	20X	3.98E+02	3 of 3	100%
FluB	10X	1.99E+02	0 of 3	0%
FluB	3X	5.97E+01	0 of 3	67%

Table 7. Preliminary LFA LoD estimation results with individual LoDs highlighted in grey.

*Note: LoD is lower than for confirmatory studies below (Table 8) because of an accidental miscalculation in preparation of H3N2 analyte for the range-finding study.

Confirmatory LoD testing was conducted with 20 replicates using contrived samples. The samples for the confirmatory testing were contrived using the sample procedure that was used for the preliminary study. For all three viral test strains the lowest concentration that produced at least 19 positives out of 20 samples (95%) was determined to be the LoD for each test strain (Table 8).

Flu Type	Test Level		Qualitative Results
	Description	TCID50/mL	# Positive	% Positive
FluA H1N1	0.25X	2.63E+01	20 of 20	100%
FluA H3N2	40X*	3.98E+03	20 of 20	100%
FluB	20X	3.98E+02	20 of 20	100%

Table 8. LFA LoD confirmation results

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*Note: Confirmatory testing for FluA strain H3N2 was performed at a higher LoD than the range-finding LoD study.

In summary, the testing performed established that 2.6 x101 TCIDs0/mL is the LoD for influenza A(H3N2), .4.0 x103 TCID50/mL is the LoD for influenza A(H1N1) and 4.0 x102 TCID50/mL is the LoD for influenza B.

Sample Stability

A. Viral Nucleic Acid Stability

Contrived samples containing influenza strains at a concentration of 2.5X LoD were prepared in pooled NWA matrix. Sample stability was evaluated in a study in which each device contained 2 mL of virus inoculum in NWA. The spiked NWA was placed in a CLEARinse CTS Wash Head, sealed in a CLEARinse CTS Transport Container and incubated at 4ºC and 27°C. Testing of the contrived samples was conducted at time point zero to establish a baseline and again at 4 hours, 6 hours, 24 hours, and 48 hours. An aliquot of each contrived sample was tested for influenza using a Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV Cartridge. Each PCR assay was performed in triplicate for each time point and for each storage condition. Samples were not batched, and all testing was completed immediately upon removal of sample from the Wash Head following the instructions in the PI. The acceptance criteria for the stability study included a deviation of no more than +/- 3 Ct for each target at given time point from T = 0

Results of stability testing for each of the three influenza strains are shown below in Table 9.

| Virus and LoD | Storage
Temp | Average Ct value | | | | |
|---------------|-----------------|------------------|------|------|-------|-------|
| | | 0-hr | 4-hr | 6-hr | 24-hr | 48-hr |
| FluA H1N1 | 4°C | NT | 35.6 | 36 | 36 | 36.7 |
| 2.5X LoD | 27°C | 34.6 | 35.8 | 34.8 | 34.9 | 36.9 |
| FluA H3N2 | 4°C | NT | 35.1 | 35.6 | 35.4 | 36 |
| 2.5X LoD | 27°C | 35.4 | 35.6 | 35.8 | 36.1 | 36.4 |
| FluB | 4°C | NT | 36.7 | 36.1 | 37.8 | 37.0 |
| 5X LoD | 27°C | 36.3 | 36.4 | 37.6 | 37.2 | 38.5 |

Table 9. Specimen stability study quantitative PCR results from CTS devices

In summary, these data support the claim that samples that will be used for viral nucleic acid testing are stable when stored for 48 hours at room and refrigerated temperature.

B. Viral Antigen Stability

Contrived samples containing Influenza strains at a concentration of 2.5X LoD were prepared in pooled NWA matrix. Sample stability was evaluated in a study in which each

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device contained 2 mL of virus inoculum in NWA. The spiked NWA was placed in a CLEARinse CTS Wash Head, sealed in a CLEARinse CTS Transport Container and incubated at 4°C and 27°C. Testing of the contrived samples was conducted at time point zero to establish a baseline and again at 4 hours, 6 hours, and 48 hours. An aliquot of each contrived sample was tested for influenza using a PBM BioSign Flu A + B test kit. Each LFA assay was performed in triplicate for each time point and for each storage condition. Samples were not batched, and all testing was completed immediately upon removal of sample from the Wash Head following the instructions in the PI.

Results of stability testing for each of the three influenza strains are shown below in Table 10.

| Virus | Storage
Temp | Number of positive samples out of replicates with valid results | | | | |
|-------|-----------------|-----------------------------------------------------------------|--------|--------|--------|--------|
| | | 0-hr | 4-hr | 6-hr | 24-hr | 48-hr |
| FluA | 4°C | NT | 3 of 3 | 3 of 3 | 3 of 3 | 3 of 3 |
| H1N1 | 27°C | 3 of 3 | 3 of 3 | 3 of 3 | 3 of 3 | 3 of 3 |
| FluA | 4°C | NT | 3 of 3 | 3 of 3 | 3 of 3 | 3 of 3 |
| H3N2 | 27°C | 3 of 3 | 3 of 3 | 3 of 3 | 3 of 3 | 3 of 3 |
| FluB | 4°C | NT | 3 of 3 | 3 of 3 | 3 of 3 | 3 of 3 |
| | 27°C | 3 of 3 | 3 of 3 | 3 of 3 | 3 of 3 | 3 of 3 |

Table 10. LFA Results from CTS Devices at 2.5X LoD

In summary, these data support the claim that samples that will be used for antigen testing are stable when stored for 24 hours at room temperature or 48 hours refrigerated.

Conclusion:

The CLEARinse CTS device does not raise different questions regarding safety and effectiveness as compared to predicate device. The proposed device is as safe, as effective, and performs as well as or better than the predicate device. The information submitted in this premarket notification supports a substantial equivalence decision.