USAFSAM Epidemiology Laboratory Service Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar.

USAFSAMEpidemiology

Laboratory Service

Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10

Team Aerospace Begins Here! 2

USAFSAM “EPI Lab”

SSgt Anthony Lowman

SSgt Rhonda Sullivan

Lucinda Sinclair





Team Aerospace Begins Here!

MOLECULAR/VIROLOGY

4

USAFSAM/ PHE Molecular and Virology Department work hand-in-hand

Flu A and Flu B Results Are CorrelatedActs as a checks and balances system

Increases result confidence

Viral Sample is Received Via Central Operations

1 aliquot goes to Molecular for testing

1 aliquot goes to Virology for testing

remaining aliquots are archived



SEASONAL INFLUENZA

5

Seasonal Influenza (SI) virusesInfluenza A, Subtype H1

Influenza A, Subtype H3

Influenza B

SI Typically Peaks Jan-Feb09’ Molecular Lab-8700 samples

08’ Molecular Lab-12000 samples



Nucleic Acid Extraction Nucleic Acid Extraction

Automated methods M48 (48 specimens)

MDX (96 specimens)

Manual methods QIAamp DNA Blood Mini Kit

RNAqueous-Micro Kit



TEST METHODS

X-TAG RESPIRATORY VIRAL PANEL (RVP)Luminex Platform

13 target real-time multiplex assay

11 viral targets, 1 run control, and 1 internal control



TRADITIONAL RT-PCR

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Traditional Polymerase Chain Reaction (PCR)

specific primer sets for specific targets

used for Flu B, Flu A (H1/H3), and Adenovirus 14



PROCESSING TIMES

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Automated extractions (sample prep to nucleic acid)

M48-approx. 4 hrs. for 48 samples

MDX-approx. 5 hrs. for 96 samples

Traditional PCR (sample prep. to results)

approx. 6 hrs for a full 96 well plate

Luminex X-Tag RVP (sample prep. to results)

approx. 9 hrs for a full 96 well plateDistribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10


OPS TEMPO

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Molecular 2009 1st Quarter Personnel

6 contractors, 4 military, and 1 civilian

Sample # processed prior to H1N1 surge

Jan 09’-4500

Feb 09’-4200

Mar 09’-6000

Work Shifts (Peak)

Two 9 hr. shifts

0700-2100Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10


Enter -H1N1

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H1N1 hits, USAFSAM’s viral sample workload almost TRIPLES.




Normal Virology Operations/ Pre-Surge Testing

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Respiratory Culture Workload

Virology H1N1 Surge Operations



Normal Virology Ops/ Pre-Surge Testing

Receive 10-50 respiratory samples / dayMolecular pulls first Aliquot

Respiratory Sample Testing:Aliquot 3 cryo vials for specimen archiving

Inoculate:1 PMK Tube

1 A-5 Tube

1 PMK Shell Vial

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Normal Ops/ Pre-Surge Testing

Respiratory Sample Testing Cont…Work up Shell Vials on Day 2 (48 hrs)

Read Tubes for CPE average of 5 times

Positive Tubes/SV identify virus by DFA staining

Archive Isolates of Positive samples

Negative Tubes Day 10:

Perform Hemadsorption (HAd) for R/O

<2 yrs old – Resp. Pool DFA

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Respiratory Culture Workload

15

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

FY 09 FY 10



Virology H1N1 Surge Ops

Dropped “Cadillac Method”Utilized frozen ready cells

Read tubes minimum of 3 times

HAd’s only on questionable tubes

Called Suppliers ASAP for overages

Augmented staff w/ techs from local areaTrained on “easy tasks” to free up Viro Techs

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Combined Molecular aliquoting w/ Viro2 step hr process to a 1 step ½ hr process

Upped Saturday OpsReceived/Processed Saturday Samples

Asked WHMC to send courier

Reduced Isolate BacklogAssigned 2 new techs to manage Archiving/Freezer works

Utilized augmentees

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BSL 2 + precautionsCDC requirement

BSL 2 hood w/ additional PPE

N95 respirator maskFit Test requirements

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Virology Lessons Learned

Communication, Communication, Communication!

Logistics, Management, Public Health

Capable of higher Ops than projected300 VS. 200 Samples per day

Surge plan adequate/flexible

Training is key

Utilizing BSL2 Hood space

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USAFSAM’S VIROLOGY LAB

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2009 P H1N1 Surge Plan2009 P H1N1 Surge Plan

Can you spell…SET -UP

How it all started

Surge Strategy20082009

Lessons Learned



WHAT HAD HAPPEN’D WAS

16 & 17 Apr 09 – requests are winding downUnusual subtyping results …..Contact CDC

21 Apr 09CDC-have you heard about MexicoShip Tues…BTW we contacted TDHHS…Gee, thanks

22 Apr 09 - Emergency courier….aaaarrrrr!

Does Brooks have an air strip??25 Apr 09

Test 9 RAFB suspect specimens…Full MOPPRun’s done @ 10:30pm…COOL!; Sorta kinda need you to repeat, tonight….Not Cool!



WHAT ARE WE DOING???WHAT ARE WE DOING???

27 Apr 09 Did you hear….how’re YOU feeling

27 Apr – 1 May 09 All initial unsubtypables:Quarantine RepeatShipment….notify CDCLab Director/PHR250 specimens…1-7500….2 hr test…WHAT DO YOU WANT!!

All stressed out, and no one

to choke!



2008 SURGE PLAN, 200/DAY2008 SURGE PLAN, 200/DAY

Central OPs = 20

CustServiceTeam = 3

Virology Lab = 8

Mole = 11

Personnel from other sections are cross– trained

Suspend other testing

1 Inputs Viro/Mole

Continued focus

Virology Lab = 8

6 trained on 7500

New procedure & processes, cross-training not implemented

Good idea, but ….No need



NEW STRATEGY, 400/DAYNEW STRATEGY, 400/DAY

Testing:New Swine Flu assayOIC ordering from home, new lab assistant

Equipment:Easy Mag - get 2 more3 more 7500s coming

PersonnelTrainingSchedules



LIMITATIONSLIMITATIONS

Laboratory Footprint – Unidirectional FlowProcessing AreaExtraction Area/PCR Set-upMasterMix

Logistics/ Storage- specimens, suppliesWorking Conditions

Full MOPP – lose dexterity, scope of visionAmbient temps – too hot for full MOPP

TrainingDistribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10


WHATEVER THE ROYAL COURT SAYS GOES!!



2009 P H1N1 SURGE PLAN2009 P H1N1 SURGE PLANIMPLEMENTEDIMPLEMENTED

Trained Augmentees-2- WHMC (JBAIDS trained)2- Advanced Tech Center (Mole experienced)Addtn’l Central OPs

Outsourced Specimen Processing-Managed by Immunology – Augmented by USAFSAM Chemistry Div

Commandeered lab space (Bacti)3 Easy Mags 2 hoods for extraction prep

Extended lab coverage – 15 crept up to 24hrStreamlined Testing – Dropped InfB



LESSONS LEARNEDLESSONS LEARNED

Trained Augmentees-

Next time start in-house (Maybe)

Outsourced Specimen Processing-

3-day training…slow down

Lab space (Bacti)

Great!! Could not have done it

Extended lab coverage – 15 crept up to 24hr

Better usage of augmentees

Streamlined Testing – Dropped InfB

Sooner

29 vs 45 specimens/plate...$400 kit/100 testsDistribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar 10


SO, ARE YOU LOOKING FOR SO, ARE YOU LOOKING FOR YOUR SET-UPYOUR SET-UP

Trusted laboratorians/scientist to perform testing

Detected 2nd strain CDC used as reference

Trusted to roll-out DoD training program

Trusted specimens for annual vaccine production

SET -

UP



QUESTIONS?QUESTIONS?


USAFSAM Epidemiology Laboratory Service Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-085, 16 Mar.

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