North Carolina State Laboratory of Public Health Dee Pettit, Assistant Director dee.pettit@dhhs.nc.gov 919-807-8940

Communication and Partnerships Disease Control and Prevention Reference and Specialized Testing Emergency Response Training and Education Environmental Health and Protection Food Safety Public Health-Related Research Laboratory Improvement and Regulation Policy Development Integrated Data Management

Provide medical and environmental laboratory services to promote, protect, and assure the health of citizens

Mission: To maintain an integrated national and international network of laboratories that can respond quickly to acts of chemical or biological terrorism, emerging infectious diseases and other public heath threats and emergencies.

Treat agents B. anthracis Influenza viruses Francisella tularensis MERS-CoV Brucella spp. Ebola Burkholderia spp. Zika virus Yersina pestis Smallpox

National – CDC, USAMRIID, NMRC Reference – State PHLs

Limited Standard Advanced

Sentinel Clinical/Hospital Local PHLs Military Veterinary Agricultural Food Environmental

RULE OUT possibility of Brucella spp. or REFER to a reference LRN laboratory (State PHL)

Brucellosis is the most commonly reported laboratory-associated bacterial infection.

LAIs Inhalation

▪ Sniffing plates

▪ Aerosol generating procedures

Percutaneous exposure

Brucella spp. 96hrs growth

Laboratory leadership ▪ Laboratory Directors

▪ DPH

Medical Consultation Unit

Clinicians, Epidemiologist,

& Public Health Nurses

Development of Guidelines

Laboratory improvement consultants

Physician

Travel history

Consumption of unpasteurized dairy

products

Occupation

Appropriate handling of

potential Brucella specimens

Notification of an Exposure

Event

Post exposure risk assessment

(classification of high and low

risk exposures)

All specimens collected from sterile sites or suspect sites should be worked in Class II, certified, BSC

BSL 3 work practices How to safely conduct tests to r/o Brucella Tape plates of suspected cases

http://www.cdc.gov/brucellosis/laboratories/risk-level.html

http://www.cdc.gov/brucellosis/laboratories/risk-level.html

Daily Monitor Log Worried well

Refuse PEP

Monitor temperature once/day for 28 days

Fever (100.4) or symptoms listed report to your medical provider

**Malaise is described as: general feeling of being unwell, tired, fatigued, low appetite, &/or lack of energy. †Loss of appetite

Internal and Local

EXPOSURE RISK

PROCEDURE

POTENTIAL HAZARD LIKELIHOOD CONSEQUENCE RISK RATING

CONTROL/ PROTECTION

ADDITIONAL INFORMATION

Package receipt and transfer of packages to testing area

Leaking package

Unlikely

Infection, Illness,

Disease, Death

Low

Assess Packaging labels. Place leaking package in plastic bag and transfer to a BSC while using appropriate PPE including nitrile/latex gloves, lab coat, and safety glasses.

Contact RO/ARO/Safety Officer immediately.

Disinfect exterior of sealed plastic bag prior to transfer to testing area.

Unexpected delivery

Moderate

Infection, Illness,

Disease, Death

Low to Moderate

Immediately transfer to BSC and contact RO/ARO/Safety Officer of unexpected delivery.

Notify key staff of expected package delivery.

Deliver specimen in original Category A packaging to testing area.

All Category A packages opened in a Class II BSC with safety blades. Outreach follow-up for all mislabeled packages.

EXPOSURE RISK

PROCEDURE POTENTIAL

HAZARD LIKELIHOOD CONSEQUENCE RISK RATING

CONTROL/ PROTECTION

ADDITIONAL INFORMATION

Decon Following Testing

Contamination of BSC surfaces

Moderate

Infection, Illness,

Disease, Death

Medium

Use plastic- backed bleach soaked surface pads when manipulating sample

Remove PPE following the

Ebola Zaire Virus-Specific

Operational Plan and discard.

Decontaminate BSC with Dispatch, contact time of 10 minutes, followed by 70% Ethanol.

Waste Autoclaving

External contamination

of waste containers

Moderate

Infection, Illness,

Disease, Death

Medium

Disinfect outside of waste containers before removal from BSC and BSL-3, using Dispatch with a contact time of 10 minutes, followed by 70% Ethanol.

Autoclave waste in isolation room. Once biological indicator demonstrates inactivation take materials to pass-through

BSL 3 or Access to the laboratory is restricted to trained personnel when samples are being processed in BSC

Workers trained in use of BSL3 work practices Adequate PPE: gloves, face shield, N-95 respirator, and back-

closing gowns An autoclave is available to successfully inactive pathogens in

laboratory waste. Laboratorians follow ASM Interim Guidance documents to

prepare THIN blood smears for malaria testing. Handle all specimens within a Class II Type A BSC in an isolated

room Remove the stopper from EDTA blood tube with bleach-soaked

gauze Wipe to prevent aerosol formation, and fixing the blood film

with methanol (30 min) and 95°C dry heat (1 hr) to inactivate all pathogens.

Federal and Local Partners

Mosquito-borne emerging arbovirus

Flavivirus - closely related to

dengue, yellow fever, Japanese encephalitis and West Nile viruses

Since 2015: Endemic transmission in Central & South America

Nontraditional transmission Intrauterine Perinatal Sexual

~1 in 5 people infected with Zika virus become ill Symptom onset: 3–12 days after exposure Symptoms resolution: 2–7 days after onset

Symptoms include:

Rash (mostly maculopapular) Non-purulent conjunctivitis Mild fever Headaches Arthralgia Myalgia

Presentation is similar to dengue and chikungunya infection

Severe disease requiring hospitalization and

fatalities are rare

Shinohara, K, Kutsuna, S, Takasaki T, et al. Zika fever imported from Thailand to Japan, and diagnosed by PCR in urine. Journal of Travel Medicine 2016, 1-3

ECDC Rapid Risk Assessment. Microcephaly in Brazil potentially linked to the Zika virus epidemic. 24 November 2015

Brazil 2015: Reports of microcephaly and other poor outcomes in babies of mothers who were infected with Zika virus while pregnant

Brazil current Zika case estimate 440,000 – 1,300,000

Mapped travelers departing from regions with sustained transmission in 2014 2.8 M to US

60% of US population conducive for autochothonous transmission

Brazil home to the 2016 Summer Olympics

Ongoing transmission of multiple arboviruses Isaac Bogoch et. al Lancet. 387: 335-336

1) Arch Gesamte Virusforsch 1973;43(4): 315-9. 2) Simpson DI. Zika virus infection in man. Trans R Soc Trop Med Hyg 1964;58:335-8.

Laboratory Hazards 14 LAIs Percutaneous exposure Bites from experimentally infected mosquito

Risk Reduction BSL 2 facilities and work practices Lab coat and gloves Aerosol generating procedures in a BSC Use of needles, syringes, and other sharp objects should

be strictly limited Open wounds, cuts, scratches, and grazes should be

covered with waterproof dressings. http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/index-eng.php

Laboratory Hazards 42 LAIs Inhalation of CHIKV containing aerosols from blood Percutaneous exposure

Risk Reduction BSL 3 facilities and work practices Solid-front gowns with tight fitting wrists, gloves,

booties, and respiratory protection. Use of needles, syringes, and other sharp objects

should be strictly limited Open wounds, cuts, scratches, and grazes should be

covered with waterproof dressings.

http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/chikungunya-eng.php

Specimen Test Performed Specimen

Volume Shipment

Serum & CSF

Chikungunya RT-PCR & IgM (NCSLPH); Zika and Dengue RT-PCR and virus-specific IgM; Flavivirus PRNT

2 – 5 mL

Refrigerated (4°C), placed on cold packs if shipment is to be received within 72 hrs of collection. For delays exceeding 72 hrs, freeze at -70°C & ship on dry ice. Urine, Saliva, &

Semen

Zika RT-PCR 1 – 3 ml

Amniotic Fluid*

Zika RT-PCR 0.5 – 3 ml Refrigerated (4°C), placed on cold packs if shipment is to be received within 72 hrs of collection. For delays exceeding 72 hrs, freeze at -70°C & ship on dry ice.

Cord Blood Zika RT-PCR & IgM Flavivirus PRNT

0.5 – 3 ml Refrigerated (4°C), placed on cold packs

Placental Tissue Zika RT-PCR Viral Culture

2 – 5 grams Freeze at -70°C & ship on dry ice.

Placental Tissue

and Umbilical Cord

Immunohistochemical Staining and Zika virus RT-PCR

2 – 5 grams of tissue and/or

paraffin blocks

Tissue should be formalin-fixed or paraffin-embedded. Ship specimens at room temperature. Note: Request consultation with NCSLPH for specific instructions.

*Patient and healthcare provider must weigh risks and benefits of testing prior to collection of amniotic fluid

Technology used to conduct testing is based on when the specimen is collected after symptom onset

Specimen Type Days Post-onset Testing Technology

Serum

< 4 RT-PCR

4 -7* RT-PCR, IgM, Flavivirus PRNT

> 7 IgM, Flavivirus PRNT

Urine, Saliva, Semen, & CSF

Currently being evaluated RT-PCR Zika only

* IgM negative specimens collected < 7 days should be repeated > 21 days post-onset

BSL 3 facility with BSL3 work practices due to co-localization of CHIKV

Restriction of pregnant workers

IgM analysis Heat inactivation in BSL3 Specimen testing in BSL2

RT- PCR Nucleic acid extraction BSL 3 Assay set-up BSL 2

Facilities and Equipment

Safety equipment ▪ BSC and thimble duct

▪ Aerosol-barrier rotors

Laboratory facilities ▪ Annual verification of

systems

▪ Autoclave

Mechanical monitoring

Cycle time

Temperature

Pressure

Chemical indicators – autoclave tape

Biological indicators

“Based on our testing and inspections we have verified that the third floor BSL3 laboratory meets or exceeds the requirements and guidelines in the BMBL 5th edition for BSL3 laboratories.”

Executive Summary

100 ͦ

Autoclave operation Bio Bag Cycle 1: 121 ͦͦ C/15 psig for 60

minutes Data logger wrapped in clean PPE (smocks,

shoe covers, gloves) and the bag was tightly tied

Run Data Autoclave tape recorded 122 ͦͦ C for 60

minutes 15 psig for 60 minutes Temperature increased from 30 ͦͦ C to 96 ͦͦ C Biological Indicator – Failed

120 ͦ

120 ͦ

120 ͦ

Chris Goforth John Bunting