Laboratory Response Network Sentinel Laboratories Elizabeth A. Macias, Ph.D., D(ABMM) Gatekeeper, Air Force LRN Laboratories Air Force Institute for Operational Health Epidemiological Surveillance Division (AFIOH/SDE) Brooks City-Base, TX
Dec 31, 2015
Laboratory Response Network Sentinel
LaboratoriesElizabeth A. Macias, Ph.D., D(ABMM)Gatekeeper, Air Force LRN LaboratoriesAir Force Institute for Operational HealthEpidemiological Surveillance Division
(AFIOH/SDE)Brooks City-Base, TX
Laboratory Response Network (LRN)
• Established in 1999 by the Centers for Disease Control and Prevention (CDC)
• Integrated network of laboratories – state and local public health, hospital, military, veterinary, and international
• Respond quickly to biological and chemical terrorism, as well as emerging infectious diseases and other public health threats
August 2007 - National Laboratory Response Network Policy Letter
• Discusses definition of Basic and Advanced Sentinel laboratories
• “AFMS laboratories will have the CDC technical protocols, notification procedures, and procedures to properly ship clinical samples in place by 1 October 2007…”
AF LRN
If you perform routine diagnostic Microbiology cultures, then you are a Sentinel laboratory.
Minimum requirements:
- Follow BSL-2 guidelines- Plate cultures on blood and chocolate agar- Microscopy capability (Gram stains, wet
mounts)
LRN Sentinel Laboratories
• Recognize, rule-out, and refer to Reference or National laboratories for further testing
LRN Sentinel Laboratories
• Perform testing on clinical specimens, not environmental samples
• Presumptive testing - protocols on American Society for Microbiology (ASM) website http://www.asm.org/Policy/index.asp?bid=6342
LRN Sentinel Labs
Serve as “sentinels” for early detection of an agent that cannot be ruled out as a possible bioterrorism-associated organism
Must utilize standardized testing protocols designed to utilize conventional tests to facilitate the “rule out” or “referral” of suspicious isolates to an LRN Reference lab
ASM website: http://www.asm.org/Policy/index.asp?bid=6342
LRN Sentinel Labs
Sentinel labs should not accept environmental (powders, letters, packages), animal, food, or water specimens for examination, culture, or transport for bioterrorism-associated agents
Such specimens should be submitted directly to the nearest LRN Reference laboratory.
LRN Sentinel Labs
X
Very likely that the lab will not be contacted in advance and informed that one of the potential agents of bioterrorism is suspected in the patients’ specimens
LRN Sentinel Labs – Important Reminders
Essential that appropriate safeguards are taken including:
• All blood cultures should be subcultured in a biosafety cabinet
• Follow flowcharts for suspicious agents
• Always considering the possibility of bioterrorist agents.
LRN Sentinel Labs – Important Reminders
Your lab should know how to assist clinicians in the diagnosis and management of patients who have been overtly or covertly exposed to a BT agent by:
• Promptly providing accurate information on the selection and collection specimens
LRN Sentinel Labs – Important Reminders
• Handle these specimens in a manner that will result in the greatest probability of success in establishing a diagnosis
Your lab must know how to…
- Collect proper specimens- Store and transport specimens at
proper temperatures to ensure stability
LRN Sentinel Labs – Important Reminders
• Minimize exposure of hospital personnel and patients to infectious agents
Your lab must know how to…
- Proper PPE- Lab safety- Proper packaging and transport of
specimens
LRN Sentinel Labs – Important Reminders
In a suspected or confirmed BT event, immediate and effective communication is imperative
You should notify:
• Appropriate institutional and medical personnel
• Designated BT coordinator (usually PHO or Infection Control
LRN Sentinel Labs – Important Reminders
The Sentinel laboratory is NOT responsible for and SHOULD NOT make the decision that a BT event has occurred
That responsibility rests with local, state, and federal health and law enforcement officials
LRN Sentinel Labs – Important Reminders
NOTE: Certain geographic areas are known to have natural human cases of infection due to BT agents. For example:
• Tularemia in Nantucket and Martha’s Vineyard, Massachusetts, as well as Missouri, Oklahoma, and neighboring areas
• Plague in much of the southwestern United States, especially New Mexico
LRN Sentinel Labs – Important Reminders
COLLEGE OF AMERICAN PATHOLOGY PROFICIENCY
TESTING (CAP PT)
2007 “Laboratory Preparedness Survey” (LPS)
2008 “Laboratory Preparedness Exercise”
(LPX)
CAP Laboratory Preparedness PT
• Developed as a collaborative effort between CAP, CDC, and APHL
• Tests the preparedness of labs across the U.S. to handle potential PH emergencies related to BT agents
• Labs are sent live organisms that exhibit characteristics of BT agents and expected to respond following LRN protocols
Excerpt from 2008 CAP PT catalog
• All agents are excluded from the CDC’s select agent list
• May include strains of B. anthracis, Y. pestis, F. tularensis, and B. abortus that have been modified and are safe for testing in a lab that contains a certified, properly functioning Class II Biological Safety Cabinet (BSC) and is capable of handling Category A and B agents
CAP Laboratory Preparedness PT
Excerpt from 2008 CAP PT catalog
Placing an order for the Lab Preparedness PT requires a signature by the Laboratory Director on a “Certificate of Acceptance” form
CAP Laboratory Preparedness PT
• “I have reviewed the list of potential organisms to be provided …”
• “Our facility has a properly functioning, certified Class II BSC and we are capable of handling Category A and B agents….”
LPS – B, Shipped October 2007 Kit Instructions state on page 1, “Biohazard Warning”:
CAP PT – LPS-B 2007
• Your lab must have a properly functioning Class II Biological Safety Cabinet in order to participate in this Survey
• All specimens in this Survey should be handled in a Biological Safety Cabinet with BSL-3 primary barriers and safety equipment
Biohazard Warning (continued):
CAP PT – LPS-B 2007
• These strains are attenuated but they represent potentially dangerous pathogens and should be handled as if they are capable of transmitting disease.
• Participants should wear gloves and protective clothing with a solid-front and perform all manipulations in a Class II BSC
Biohazard Warning (continued):
CAP PT – LPS-B 2007
• Additional information on laboratory safety and agent specific precautions can be found on the CDC website: http://www.cdc.gov/od/ohs/biosfty/biosfty.htm
All five specimens (LPS06 – LPS10) had the following for testing instructions: “Labs are instructed to follow the LRN procedures to rule out or refer potential BT agents….”
CAP PT – LPS-B 2007
• Bottom line: Labs were notified up front that these were potential BT agents
• More often than not, we will not have that happen with actual clinical specimens.
Brucella Exposure Overview
• CAP LPS-B survey sent 15 Oct 2007
• CDC notified on 27 Nov by the New York State Dept of Health (NYSDOH) of potential exposures to the Brucella RB51 strain during the LPS exercise
• Exposure initially occurred after a RB51 specimen was mislabeled as a routine patient specimen and submitted to the NYSDOH lab
Brucella Exposure Overview
• Personnel (24) exposed in the NYSDOH lab
• Survey conducted by NYSDOH of their sentinel labs determined that 17 LPS participating labs did not handle the survey correctly
• As of 14 January, 2008, follow up in labs across the U.S. identified a total of 916 lab workers in 254 labs with potential RB51 exposure
Brucella Exposure Overview
• Improper shipping and handling of isolates• Subculturing of isolates on routine lab
bench• Sniffing subcultures• Setting up susceptibility tests on routine
bench• Spilling blood culture bottles• Aerosol generation from ruptured centrifuge
tubes
Some examples of how the exposures occurred:
• Brucella abortus RB51 is an attenuated veterinary vaccine strain that rarely causes infections in humans
• Risk assessment tools, post-exposure prophylaxis and follow up guidelines were sent to LRN sentinel labs
Brucella Exposure Overview
• Read all PT kit instructions
• Emphasize adherence to biosafety practices
Lessons Learned
Annual biosafety training+ +
Include proper use of biosafety cabinet Frequent spot checks to ensure personnel
are using PPE and safety equipment properly
Perform risk assessments if you isolate a highly pathogenic organism (i.e., Brucella or Francisella)
Lab readiness should include training in the characteristics of particular agents (i.e., Brucella) and the biosafety recommended for handling and testing
Lessons Learned
• For example, if Gram-negative coccobacilli are seen on a Gram stain, Brucella and Francisella should be thought of, especially if the patient has compatible symptoms
Lessons Learned
• Poorly staining• Small gram-negative
coccobacilli (0.5-0.7 x 0.6-1.5 um)• Mostly seen as single
cells and appearing like "fine sand" CDC/PHIL
Brucella spp. Gram stain characteristics:
Lessons Learned
Brucella spp. colony characteristics:
CDC/PHIL
• Fastidious• Usually not visible at 24h• Grows slowly on most
standard laboratory media (e.g. SBA, choc and TSA)
• Pinpoint, smooth, entire translucent, non-hemolytic at 48h
Appendix 4, from the HHS Pandemic Influenza Plan: “Laboratory Biosafety Guidelines for Handling and Processing Specimens or Isolates of Novel Influenza Strains”
Influenza testing
Pandemic Influenza Plans – HHS, DoD, State-specific, WHO, … .
• Commercial antigen detection testing for influenza may be conducted under BSL-2 containment conditions if a Class II biological safety cabinet is used
• Clinical specimens from suspected novel influenza cases may be tested by RT-PCR using standard BSL-2 work practices in a Class II biological safety cabinet for initial processing of patient specimens
Influenza testing (novel strains)
• If a specimen is confirmed positive for influenza A (H5N1) by RT-PCR, additional testing should be performed only under BSL-3 conditions with enhancements
• CDC’s Influenza Branch should be informed immediately by contacting the CDC Director’s Emergency Operations Center (DEOC) at 770-488-7100
Influenza testing (novel strains)
• All clinical labs can potential handle highly pathogenic organisms
• High emphasis must be placed on training and risk management
Lab Safety Summary
Questions?
Elizabeth A. Macias, Ph.D., D(ABMM)
Laboratory Director
Air Force Institute for Operational Health,
Epidemiological Surveillance Division (AFIOH/SDE)
2730 Louis Bauer Drive
Brooks City-Base, TX 78235-5132
COMM: 210.536.1271
DSN: 240.1271
Email: [email protected]