Test Directory Table of Contents - NPHL · Test Directory Table of Contents These documents fall outside of the Nebraska Public Health Laboratory document control system; subsequent

9/5/2006

Test Directory Table of Contents

These documents fall outside of the Nebraska Public Health Laboratory document control system; subsequent updates or changes will not automatically be forwarded to

your facility.

Aerobic and Anaerobic Culture Blood……………………………………. Page 1

Aerobic Culture with Gram Stain ………………………………………… Page 2

AFB Mycobacterium Blood Culture ……………………………………… Page 3

AFB Mycobacterium Culture with Smear ………………………………… Page 4

AFB Mycobacterium Identification ………………………………………. Page 5

Anaerobic and Aerobic Culture with Gram Stain ………………………… Page 6

Antibiotic Resistance Confirmation Test …………………………………. Page 7

Bordetella pertussis Culture ………………………………………………. Page 8

Bordetella pertussis DNA Detection ……………………………………… Page 9

Chlamydia/GC DNA Detection …………………………………………… Page 12

NE ipp-lab slip instructions ……………………………………….. Page 16

County F.I.P.S …………………………………………………..… Page 23

Sensitivity and Specificity of CT/GC Testing ……………………. Page 25

New specimen transport requirements ……………………………. Page 26

Chlamydia trachomatis Culture …………………………………………… Page 29

Confirmation of Reportable Disease Isolates ……………………………... Page 30

Diphtheria Culture ………………………………………………………… Page 31

E. coli O157:H7 Culture Confirmation …………………………………… Page 32

Fluorescent Treponemal Antibody IgG …………………………………… Page 33

Fungus Culture Blood ………………………………………………………Page 34

Fungus Dermatophyte, Skin Culture ……………………………………….Page 35

GC Screen Culture ………………………………………………………… Page 36

Giardia and Cryptosporidium Antigen Screen ……………………………. Page 37

Hepatitis B Core Antibody, Total …………………………………………. Page 38

Hepatitis B Surface Antibody ………………………………………………Page 39

Hepatitis B Surface Antigen ………………………………………………. Page 40

Hepatitis C Antibody ……………………………………………….…….. Page 41

Herpes Simplex Culture …………………………………………….…….. Page 42

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NPHL HIV Screening and Confirmation Protocol ………………….……. Page 43

HIV-1 RNA Quantitation Ultrasensitive …………………………….…… Page 47

HIV-1 RNA Quantitation …………………………………………….…… Page 48

HIV 1 and HIV 2 Antibody ………………………………………….…… Page 49

HIV 1 Antibody Confirmation, Western Blot ………………………..…… Page 50

Influenza A Antigen Detection …………………………………….….….. Page 51

LEAD, Blood Screening ……………………………………………….…. Page 52

CDC Classifications for Lead in Children ……………………….. Page 53

Mumps Culture …………………………………………………………… Page 54

Mumps Antibody IgM ……………………………………………………. Page 55

Mumps Antibody IgG …………………………………………………….. Page 56

Mycobacterium tuberculosis complex genotyping ……………………….. Page 57

Mycobacterium tuberculosis DNA Amplified Direct Detection …………. Page 58

Organism Banking ………………………………………………………… Page 59

Ova & Parasite, Stool, Complete, Foreign Travel ………………………… Page 60

QuantiFERON®-TB Gold ………………………………………………… Page 61

Respiratory Syncytial Virus (RSV) Direct Antigen Detection ……………. Page 64

Respiratory Viral Panel ……………………………………………………. Page 65

Nasopharyngeal Washing/ Nasal Swab Collection Procedure ……. Page 66

Rapid Plasma Reagin (RPR) ………………………………………………. Page 68

Rubella Antibody IgG …………………………………………………….. Page 69

Salmonella Serotyping …………………………………………………...... Page 70

Shiga Toxin DNA Detection ……………………………………………… Page 71

Stool Culture ………………………………………………………......……Page 72

Vibrio Culture ………………………………………………………………Page 73

Virus Culture, General …………………………………………………….. Page 74

West Nile Virus Antibody IgG/IgM, Serum for Paired CSF IgM Only ….. Page 75

2006 NHHSS/NPHL West Nile Virus Testing Guidelines ……….. Page 76

West Nile Virus Antibody IgM, CSF ………………………………………Page 81

Yersinia Culture …………………………………………………………… Page 82

If you have questions about proper specimen collection, please call

NPHL Client Services at 402-559-2440 or toll free at 1-866-290-1406.

Aerobic and Anaerobic Culture, Blood Comment: Sites submitting specimens for testing must be approved by the

Epidemiology Program at the Department of Health and Human Services Regulation and Licensure.

Please call NPHL for clarification at 402.559.2440 or 866.290.1406. Comment: A SPECIAL MICROBIOLOGY Requisition or NPHLWeb order must

accompany this specimen. Synonym: BC LISCode: BLDCU, BLDA (Aerobic only) Method: Continuous monitoring system. Standard reference procedures for

identification of aerobic and anaerobic microorganisms and yeast. Availability: Daily; preliminary - no growth at 1 day; final - no growth at 5 days; all

positive blood cultures are reported as soon as detected. Specimen: Blood Collect: Draw aseptically per Blood Culture Collection procedure. Collect blood into a

aerobic and anaerobic bottle. Wipe off top of Blood culture bottle with alcohol wipe and let dry prior to collection of specimen.

Volume: 3.0-10.0 mLs of blood into each aerobic bottle and 3.0-10.0 mLs into each anaerobic bottle. Optimum specimen is 20.0 mL (Bactec Brand bottle). Follow guidelines is less blood is obtained: split the amount of blood drawn equally between bottles, 3.0 mL minimum required for each bottle. For pediatric patients, 1.0-3.0 mL of blood injected into an aerobic culture bottle is sufficient. Pediatric blood culture bottles are available upon request.

Comment: State source of blood if other than peripheral, for example a line draw, on the test request form. No more than 3 blood cultures sets should be drawn within a 24 hour period, unless from multiples lines. Note if patient is suspected of having Brucella, endocarditis or any other unusual organism.

Reference: No growth at 5 days Transport: Room Temperature

Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

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Aerobic Culture with Gram Stain Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: C&S Culture, Aerobic Culture LISCode: AWOCU Method: Standard reference procedures for gram stain, aerobic culture and

identification of potential pathogen; susceptibility performed when indicated. Availability: Daily; results in 24-48 hours, gram stain results same day. Specimen: From: Skin, ear, nasopharyngeal, wound, placenta Collect: In a sterile container or two culterette swabs Comment: Note source of specimen on the lab test request form. Reference: No Growth at 2 days Transport: Room Temperature

Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. Update: 06/03

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AFB Mycobacterium Blood Culture Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Acid fast culture; TB culture. LISCode: AFBBL Method: Culture Availability: Monday - Friday by 0900. Specimen: Blood Collect: Bactec Myco/F lytic bottle. Volume: Adult: 3.0 to 5.0 mL whole blood Pediatric: 1.0 to 3.0 mL whole blood Comment: Collection site should be disinfected using the same sterile technique as the

collection procedure for blood culture collection. Unacceptable condition: EDTA/Lavender tubes or coagulated blood.

Reference: Negative Comment: Negative culture- results in 6 weeks; positive results will be reported as soon

as detected. No smear performed. See AFB culture with smear.

Transport: Room Temperature. Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. Update: 06/03

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AFB Mycobacterium Culture with Smear Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: AFB Culture, TB Culture, Acid fast culture LISCode: AFBCU Method: Standard reference procedures for stain and culture.

Biochemical standard reference procedures are used for rapid growers Availability: Monday - Friday by 0900. Specimen: Sputum, BAL, gastric aspirate, urine, body fluid and tissue. Comment: -Indicate source of specimen on the lab form.

-Include patient's PPD status, BCG immunization history, and prior anti-tuberculosis therapy. -Indicate if Mycobacteria other than tuberculosis (MOTT) are suspected.

Collect: Sputum, collect early morning specimen on each of 3 consecutive days in sterile leak-proof containers. Urine, collect early morning specimens on each of 3 consecutive days in sterile leak-proof containers. Gastric aspirate, collect 8 hours after food ingestion on each of 3 consecutive in sterile leak-proof containers. Gastric lavage specimens must be neutralized with sodium carbonate, if transport to lab is delayed for more than a few hours. Tissue, submit skin lesions or other tissue; keep moistened with sterile saline in a sterile leak-proof container.

Volume: 5-10 mL Reference: Preliminary Culture: Acid fast stain at 24 hours.

Final Culture: Negative at 8 weeks. Positive Cultures: Reported as soon as detected.

Comment: Identification ordered and performed on positives. Susceptibility performed on all initial isolates of M tuberculosis complex. Susceptibility performed on Mycobacterium other than M. tuberculosis complex isolates by request. Susceptibility testing of M.gordonae from sputum is usually inappropriate.

Comment: DNA probes available for M.tuberculosis complex, M. avium-intracellulare complex, M. gordonae and M. kansasii as indicated. Unacceptable conditions: Multiple same-site specimens (more than one in 24 hours), dry material, non-sterile or leaking container, improper volume of sputum or fluids(Less than 5 mLs), material collected and transported on a swab.

Transport: Refrigerated Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. Update: 06/03

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AFB Mycobacterium Identification Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Acid fast identification LISCode: AFBIS Method: Standard method for identification of AFB. DNA probes available for M.

tuberculosis complex, M. avium-intercellular complex, M. gordonae and M. kansasii as indicated. Biochemical procedures are used for rapid growers.

Availability: Monday - Friday by 0900. Specimen: Actively growing isolated organism, in pure culture on Middlebrook 7H10,

7H11, Lowenstein-Jensen agar slants or AFB automated system bottle (ESP, Nactec, Septi-check).

Comment: Indicate source of specimen and any other pertinent information.

Include patient’s PPD status, BCG immunization history, and prior anti-tuberculosis therapy, and growth rate of organism.

Reference: Complete identification of clinically significant isolates. Transport: Room Temperature. Submit organism in NPHL Triple Pack. Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. Update: 06/03

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Anaerobic and Aerobic Culture with Gram Stain Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Abscess or wound culture, anerobic culture LISCode: ANACU Method: Test includes: Gram stain, isolation and identification of potential aerobic and

anaerobic pathogens, and initiation of antibiotic susceptibility tests when indicated.

Availability: Daily; results in 24-72 hours. Culture showing no bacterial growth will be reported after 48 hours. Complete reports of cultures with anaerobic bacteria may take as long as 5 days after receipt of culture, depending upon the nature of the organisms isolated. Final report is at 5 days.

Specimen: Pus tissue or other material properly obtained from an abscess, biopsy, aspirate, drainage, exudate, lesion, or wound. Specimens will also be cultured for aerobic growth.

Collect: Some anaerobes will be destroyed by contact with oxygen for only a few seconds. Overlying and adjacent areas of the wound/abscess must be carefully disinfected to eliminate contamination with normal aerobic flora. Ideally, pus or other fluid obtained by needle aspiration is transported to the lab as soon as possible in a capped syringe. Sampling of open lesions is enhanced by deep aspiration using a sterile catheter. Curettings of base of an open lesion are optimal. If irrigation is necessary, sterile normal saline may be used.

Volume: One anaerobic Culturette and two aerobic Culturettes or 0.5 mL pus or other fluid from aspirated site in syringe with needle removed and replaced with a cap.

Comment: Note suspected organism(s) on the test request form. Specimens not received in anaerobic transport swab or closed syringe or refrigerated are unacceptable. Specimens from sites which have anaerobic bacteria as normal flora will be rejected (e.g., throat, feces, colostomy sites, rectal swabs, bronchial washes, cervical-vaginal muscosal swabs, sputum, skin and superficial wounds, voided or catheterized urine, and decubitus ulcer).

Reference: No aerobic or anaerobic growth. Comment: Culture of specimens from sites harboring endogenous anaerobic organisms

or contaminated by endogenous organisms may be misleading with regard to etiology and appropriate therapy.

Transport: Room Temperature Specimen must be shipped via NPHL ground courier or Federal Express.

Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

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Antibiotic Resistance Confirmation Test Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. LIS Code: BNK Method: Organism tested for antibiotic resistance confirmation. Available: Monday through Friday by 0900. Specimen: Submit actively growing isolated organism in pure culture on agar slant.

Isolates may be requested for confirmation of VRE, MRSA, ESBL, VRSA, and VISA by the Nebraska State Epidemiology Program.

Comment: Indicate source of organism, identification test results, susceptibility testing results and any other pertinent information. Unacceptable conditions: Nonviable organism, mixed culture, leaking container.

Transport: Room Temperature Submit organism in NPHL Triple Pack. Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. Update: 06/03

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Bordetella pertussis Culture Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Pertussis whooping cough culture. LISCode: BPERT Method: Standard reference procedures for B. pertussis culture and identification. Availability: Daily; Results within 7 days. Specimen: Nasopharyngeal swab. Collect: Collect with Amies Charcoal swab. Comment: Unacceptable specimens: specimens not transported in the correct media.

Notification of positive results is provided. Reference: Negative for Bordetella pertussis. Comment: Consult Laboratory for collection/delivery instructions if transport time is

greater than 24 hours. Transport: Room Temperature


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Bordetella pertussis DNA Detection

Comment: Sites submitting specimens for testing must be approved by the Epidemiology Program at the Department of Health and Human Services Regulation and Licensure. Please call NPHL for clarification at 402.559.2440 or 866.290.1406.

Comment: A SPECIAL MICROBIOLOGY Requisition or NPHLWeb order must accompany this specimen.

Synonym: B. Pertussis DNA Detection

LISCode: BPD

Method: DNA Amplification

Availability: MondayFriday by 900. Results within 3 days.

Specimen: Nasopharyngeal wash or nasopharyngeal swab

Collect: Nasopharyngeal wash in sterile container. OrNasopharyngeal swab collected with Amies Charcoal, Dacron or cotton swab. (B. Pertussis culture must be submitted on separate Charcoal swab if ordered.) Avoid swabs made with wooden sticks. Swabs are available from NPHL. See specimen collection protocol below.

Volume: 1.0 mL nasopharyngeal wash/0.5 mL minimum OrOne Swab, dry.

Transport: Nasopharyngeal swab or nasopharyngeal wash refrigerated with in 48 hours of collection. Specimen must be shipped via NPHL ground courier or overnight mail. Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

Reference: No Bordetella species DNA present

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Nasopharyngeal Wash Collection Protocol

The best specimen is a nasal wash, followed by nasal aspirate, and least acceptable is a nasopharyngeal swab, i.e., passing the swab through the mouth and swabbing the nasopharynx. The goal of the nasal wash is to collect cells since respiratory viruses are attached to cells. Therefore, the collection procedure described here is in two parts; first to obtain mucouscontaining cells and secondly then to collect cells from the sidewall of the nasal passages.

EQUIPMENT: 5 or 10 cc syringe Butterfly catheter Normal saline Gloves, gown, mask, eye protection

Cut off the distal end (needle and butterfly) of the butterfly catheter so that about 23 inches of tubing are left attached to the hub. Draw up 2 to 3 mL’s of saline into the syringe. Discard the needle on the syringe. Attach syringe (without needle) to hub of butterfly catheter. Purge tubing with saline. Put on gloves, gown, mask, and eye protection. Gently remove excess mucous from patient’s nose. (If patient is an adult, ask the patient to gently blow nose. For pediatrics, a bulb syringe may be used to remove excess mucous). Position patient in supine position with the head of bed elevated 30 degrees. The patient’s head should be turned to one side. Stabilize the patient’s head and gently place the catheter into the nares. Placement should be in the nares (nasal wall), not the nasopharynx. Depending on the size of the patient, this should be about 1 to 2 cm in adults and 0.5 cm to 1.0 cm in children (0.5 cm in neonates). Instill 1 to2 mL’s (depending on the patient age) of saline into the nares and aspirate back mucous, saline, and epithelial cells. The opposite nare does not need to be occluded while performing the procedure. Repeat this process using the same syringe until sample is cloudy or appears to hold cellular debris. (If the sample is inadequate, the process may be repeated on the opposite nare, using a second sterile syringe and tubing. Usually one nare is sufficient.) There may be some blood streaks in the mucous. This is normal and patients/parents should be told this is expected and will stop in a few minutes. Transfer contents of tubing and syringe into transport media using the following process: Depress syringe plunger and express fluid from syringe and tubing into transport media. Then withdraw media/fluid back into syringe and tubing. Depress syringe plunger again, expressing fluid from syringe and tubing back into transport media.

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Nasal Pharyngeal Swab Collection Procedure

Specimens for B. pertussis culture must be submitted separately on a charcoal swab if a nasopharyngeal swab is the only specimen. Specimens for PCR can be collected with Amies Charcoal, Dacron or cotton swab if a nasopharyngeal swab is the only specimen. Avoid swabs made with wooden sticks.

Collect a nasal swab by gently rubbing the nasopharyngeal mucosa with a minitip culturette swab. Transport dry, refrigerated. Label specimen with patient name, collection date and time, and specimen source. Package the specimen as described in the package and transport instructions.

Update: 10/04

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Chlamydia / G.C. DNA Detection Comment: Sites submitting specimens for sexually transmitted disease screening must be approved by the Sexually Transmitted Disease Program in the Department of Health and Human Services Regulation and Licensure. Please call NPHL for clarification at 402.559.2440 or 866.290.1406. Method: Amplified DNA Probe Test LIS Code: STDSW or STDUR Availability: Monday-Friday, results within 48 hours. Specimen Collection: Female endocervical swab, Male urethral swab, female and male urine Swab: MALE: ProbeTec blue kit for urethral specimen:

• Label transport tube with patient first and last name, collect date and time. • Insert the Mini-tip Culturette Direct Swab 2-4 cm into the urethra. • Rotate for 3-5 seconds. Immediately place swab into transport tube and break

swab off into liquid prior to recapping. • Make sure cap is tightly secured to tube. •

FEMALE: ProbeTec pink kit for endocervical specimen: • Label transport tube with patient first and last name, collect date and time. • Remove excess mucus and blood from the cervical site with large cleaning swab

and discard. • Insert the Culturette Direct Swab into the cervical canal and rotate for 15 – 30

seconds. • Immediately place swab into transport tube and break swab off into liquid prior

to recapping. • Make sure cap is tightly secured to tube.

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Chlamydia / G.C. DNA Detection (Specimen collection continued) Urine: ProbeTec Urine Preservation Transport (UPT) Kit:

• Patient should not urinate for at least 1 hour prior to collection of specimen. • Patient should collect the first 15-20 ml (maximum 60 mL) of voided urine in

sterile preservative-free collection cup. • Prepare the UPT by holding it upright and firmly tap the bottom of the tube on a

flat surface to dislodge any drops from inside the cap. • Label the UPT with patient identification/date/time. • Using the transfer pipette included in the UPT kit, transfer enough urine (2.5mL

to 3.5mL) to fill the UPT between the black lines on the fill window located at the top of the UPT.

• Make sure cap is tightly secured UPT and invert 2 to 3 times. Volume: Swab: 1 ProbeTec swab in transport tube.

Urine: 1 UPT filled to between the black lines on the fill window (2.5mL to 3.5mL). 1 Sterile container with 15-20 ml (maximum 60 mL) of voided urine in sterile preservative-free collection cup (This option must be approved by NPHL in advance of collection).

Transport: Swab: Room Temperature must be received by laboratory within

5 days of collection. Urine: UPT: Room Temperature must be received by laboratory within

5 days of collection. Sterile Container: refrigerate urine within one hour of collection and transport refrigerated. (This option must be approved by NPHL in advance of collection)

Comment: • Specimens collected with wooden swab are not acceptable. • Use only ProbeTec Swab collection kits. • Eye, rectal and throat specimens are not acceptable. • Orange pigmented urine specimens may interfere with testing.

Normal Range: Negative for C. trachomatis / N. gonorrhoeae

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Nebraska Infertility Prevention Project Lab Slip Instructions

May 1, 2003

Nebraska Infertility Prevention Programs:

Douglas County Health Department – 402/444-7750

Eastern Metro-Nebraska Health & Human Services System – 402/444-7750

Lincoln-Lancaster County Health Department – 402/441-8056

Central Area-Kearney Office, Nebraska Health & Human Services System – 308/865-5609

Western Area-North Platte, Nebraska Health & Human Services Systems – 308/535-8134

Northeast Area-Nebraska Health & Human Services System = 402/668-7491

Quality Control Office – Nebraska Health & Human Services System – 308/632-1334

Lincoln-Nebraska Health & Human Services System – Central Office 301 Centennial Mall South

P. O. Box 95007 Lincoln, NE 68509-5007

A cooperative effort between Nebraska STD Control Program, Nebraska Public Laboratory, Nebraska Reproductive Health Program, Region VII, and U. S. Department of Health & Human

Services/Centers for Disease Control and Prevention

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INSTRUCTIONS

PATIENT NAME __________________________________________________________ Last Name First Name Middle Initial Enter the patient’s name. Multiple Race: (Check all that apply.) Ethnicity: 1__ White 1__ Hispanic 2__ African American 2__ Non-Hispanic 3__ American Indian/Alaska Native 3__ Unknown 4__ Asian 5__ Native Hawaiian/Pacific Islander 6__ Other 7__ Primary Race: #___ Fill out both categories. These are separate categories which conform to the U.S. Census format. If not already included in the client’s medical record, ask the client what she/he identifies as. Race: In the Race category, please choose one.

1. White includes persons of European descent. 2. African American includes persons of African descent. 3. American Indian/Alaskan Native: American Indian includes persons having

origins in any of the native people in North America. Alaska Indian, Eskimos, and Aleut are included as Alaskan Native. This box suggests person from either group.

4. Asian includes persons having origins in the Far East, Southeast Asia, or India. 5. Native Hawaiian/Pacific Islander indicates persons having origins in the Pacific

Islands. 6. Other is for people who identify as a member of none of the above groups. 7. Primary Race: The Race that the client most identifies by.

Ethnicity: In the Ethnicity category, only one choice is possible.

(Please note: Hispanic is not a race) 1. Hispanic origin or descent includes Mexican-American, Puerto Rican, Cuban,

Central or South American, and other Spanish-speaking origins. 2. Non-Hispanic includes all other persons. 3. Unknown- self explanatory.

These items are used to determine the location of the client’s residence. Enter the three digits of the County F.I.P.S code (see Appendix A) and two digits of the State F.I.P.S code (see Appendix B), and five digits of the zip code. If client is out of state, put 999 in the County Code space.

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DATE SPECIMEN COLLECTED/SPECIMEN COLLECTION TIME

DATE TIME SPECIMEN COLLECTED SPECIMEN COLLECTED MO DAY YR AM / PM

Enter the date the client was tested for Chlamydia. Enter month, day and year, using two digits for each number. Enter the time the specimen was collected and circle AM or PM. CHART NO. __________ Chart No. Enter the patient’s clinic chart number. ICD-9 CODE: The Nebraska Public Health Laboratory in conjunction with the Nebraska Infertility Program is now able to bill Medicaid for charges incurred by clients who are covered under the Medicaid program. The lab form has been updated to provide a section that needs to be completed in order for the Nebraska Public Health Laboratory to bill Medicaid. If you have a patient who is covered by Medicaid, YOU MUST COMPLETE THIS SECTION OF THE LAB FORM. If you have any questions, please call the UNMC Nebraska Public Health Laboratory billing office at (402)-559-8291. Accession Number: For lab use only Physician/Clinician License Number: Only needed when billing Medicare. Please share this information with all your clinic staff and file this information with your Infertility laboratory instruction manual.

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ENTERING MEDICAID BILLING INFORMATION

1. Infertility Prevention Program requirements (also required for Medicaid: • Patient Name: Enter the patient’s name • Race: Enter the patient’s race • Ethnicity: Enter the patient’s ethnicity • Physician/Clinician Name: Enter clinician’s name • Date of Birth: Enter patient’s date of birth • Sex: Circle m = male or f = female • Address: Enter the patient’s address

2. Patient’s Medicaid Number:

• Prior to providing services, verify the patient is currently a Medicaid client. • Check the patient’s Medicaid card (is it current) or by calling the Nebraska Medicaid

Eligibility System (NMES) (800-642-6092) • Enter the patient’s 11 digit ID Medicaid number or the patient’s 9 digit social security

number. 3. Medicaid ICD-9 Codes:

• The clinician or practitioner must enter the ICD-9 diagnosis code(s) that corresponds with the patient’s visit for that day.

• Enclosed is a list of ICD-9 diagnosis codes. • The V codes are usually adequate documentation in order for the laboratory to bill

Medicaid.

COMMON DIAGNOSIS ICD-9 CODES

VO1.6 EXPOSURE TO: GONORRHEA SYPHILIS VO1.7 EXPOSURE TO: AIDS VIRUS HIV VIRAL DISEASES VO1.9 EXPOSURE TO: CHLAMYDIA V69.2 HIGH RISK SEXUAL BEHAVIOR

a. age (15-24 years) b. new partner (last 90 days) c. multiple partners (last 90 days) d. no contraception used

Questions? Please call UNMC billing for assistance at 402-559-8291.

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Syphilis RPR___ For the test listed above: It is not a part of the Infertility screening program. The facilities that are authorized to have these test processed without cost are aware of this fact. Do not send test samples for the above test unless you are authorized to do so.

Neisseria Gonorrhea Screen ___ Identifies alternative sites that require the use of different tests (i.e., gonorrhea/chlamydia culture for throat and rectum). Other Testing___ The chlamydia/gonorrhea DNA screen is approved for eye specimens. Please indicate specimen source (i.e., eye). Amplified Chlamydia/gonorrhea DNA Screen___ The Nebraska Public Health Laboratory utilizes the Amplified Chlamydia/gonorrhea DNA Screen assay for screening and detection of chlamydia and gonorrhea.

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RISK HISTORY (CHECK ALL THAT APPLY) 1__ Multiple Partners In Last 90 Days 2__ New Partner In Last 90 Days 3__ Contact To A Std 4__ None Of The Above Multiple Partners In Last 90 Days. Client reports she/he has more than one partner. New Partner In Last 90 Days. Last screen. Self explanatory Contact to a STD – Client reports she has been exposed to a STD, especially Chlamydia or Gonorrhea. None of the above – Self explanatory CLINICIAN OBSERVATIONS (CHECK ALL THAT APPLY) 1__ Cervical Friability 8__ Not Examined/Self Collected 3__ PID 9__ None of the Above 4__ Cervicitis/MPC 5__ Urethritis Cervical Friability refers to easily induced bleeding when the swab touches the cervix. PID refers to suspicion of Pelvic Inflammatory Disease, an upper genital tract infection that frequently involves the endometrium *endometritis), fallopian tubes (salpingitis), and pelvic peritoneum (Peritonitis). Symptoms suggestive of PID include abdominal pain, pain with intercourse, vaginal discharge, excessive uterine bleeding, dysuria, onset of pain in association with menses, fever and sometimes nausea and vomiting. Cervicitis/MPC refers to inflammation of the cervix. It can be thought of as the female’s counterpart to male urethritis. Cervicitis is most often caused by HSV, HPV, CT or GC, yet it may be present with benigh metaplasia, mechanical/chemical irritation, post-traumatic repair, neoplasia, or other unknown factors. It is defined as any of the following:

A. Edema, erythema or follicle-like lesions in an area of ectopy (the extension of columnar epithelium onto the ectocervix). OR

B. The presence of cervical mucus with ten or more polymorphonuclear leukocytes

per x1000 microscopic field. Mucopus (MPC) refers to yellow or green mucopurulent discharge from the cervix, with infection.

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APPENDIX B

NEBRASKA COUNTY F.I.P.S CODES

001 ADAMS 085 HAYES 169 THAYER 003 ANTELOPE 087 HITCHCOCK 171 THOMAS 005 ARTHUR 089 HOLT 173 THURSTON 007 BANNER 091 HOOKER 175 VALLEY 009 BLAINE 093 HOWARD 177 WASHINGTON 011 BOONE 095 JEFFERSON 179 WAYNE 013 BOX BUTTE 097 JOHNSON 181 WEBSTER 015 BOYD 099 KEARNEY 183 WHEELER 017 BROWN 101 KEITH 185 YORK 019 BUFFALO 103 KEYA PAHA 021 BURT 105 KIMBALL 023 BUTLER 107 KNOX 025 CASS 109 LANCASTER 027 CEDAR 111 LINCOLN 029 CHERRY 113 LOGAN 031 CHERRY 115 LOUP 033 CHEYENNE 117 MCPHERSON 035 CLAY 119 MADISON 037 COLFAX 121 MERRICK 039 CUMING 123 MORRILL 041 CUSTER 125 NANCE 043 DAKOTA 127 NEMAHA 045 DAWES 129 NUCKOLLS 047 DAWSON 131 OTOE 049 DEUEL 133 PAWNEE 051 DIXON 135 PERKINS 053 DODGE 137 PHELPS 055 DOUGLAS 139 PIERCE 057 DUNDY 141 PLATTE 059 FILLMORE 143 POLK 061 FRANKLIN 145 RED WILLOW 063 FRONTIER 147 RICHARDSON 065 FURNAS 149 ROCK 067 GAGE 151 SALINE 069 GARDEN 153 SARPY 071 GARFIELD 155 SAUNDERS 073 GOSPER 157 SCOTTS BLUFF 075 GRANT 159 SEWARD 077 GREELEY 161 SHERIDAN 079 HALL 163 SHERMAN 081 HAMILTON 165 SIOUX 083 HARLAN 167 STANTON

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APPENDIX A

2

U.S. F.I.P.S CODES

01 ALABAMA 47 TENNESSEE 02 ALASKA 48 TEXAS 04 ARIZONA 49 UTAH 05 ARKANSAS 50 VERMONT 06 CALIFORNIA 51 VIRGINIA 08 COLORADO 53 WASHINGTON 09 CONNECTICUT 54 WEST VIRGINIA 10 DELAWARE 55 WISCONSIN 12 FLORIDA 56 WYOMING 13 GEORGIA 72 PUERTO RICO 15 HAWAII 16 IDAHO 17 ILLINOIS 18 INDIANA 19 IOWA 20 KANSAS 21 KENTUCKY 22 LOUISIANA 23 MAINE 24 MARYLAND 25 MASSACHUSETTS 26 MICHIGAN 27 MINNESOTA 28 MISSISSIPPI 29 MISSOURI 30 MONTANA 31 NEBRASKA 32 NEVADA 33 NEW HAMPSHIRE 34 NEW JERSEY 35 NEW MEXICO 36 NEW YORK 37 NORTH CAROLINA 38 NORTH DAKOTA 39 OHIO 40 OKLAHOMA 41 OREGON 42 PENNSYLVANIA 44 RHODE ISLAND 45 SOUTH CAROLINA 46 SOUTH DAKOTA

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New Screening Method for Chlamydia trachomatis and Neisseria gonorrhoeae Amy Armbrust, MT(ASCP) Beginning January 22, a new test for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae was implemented. The test uses amplified DNA technology to improve sensitivity and allow detection of these organisms from urine as well as swab specimens. Because the collection of urine sample does not require special examination facilities it is expected that more screening can be performed in the population at highest risk, including sexually active males and females under the age of twenty. The establishment of a urine screening program at any clinic requires approval by Phil Medina, the STD Program Coordinator. Clinical studies have shown the value of using an amplified procedure to detect Chlamydia trachomatis and Neisseria gonorrhoeae. The performance characteristics of the Becton Dickinson Probetec assay were abstracted from published studies. (Table 1) The amplified test is more sensitive and specific than either culture or the previous GenProbe assay, but the positive predictive value of the test will vary depending on the prevalence of the organism in the patient population, whether the patient is male or female and the type of specimen collected. Large amounts of blood and mucus may interfere with the assay as well as medications that color the urine orange. Specimens can be submitted from either males or females using the swab collection kit or a voided urine sample in a sterile container. The Chlamydia/Gonorrhea Amplified Probe test will be performed Monday through Friday with results available the same day on specimens received by 6 AM. Specimen requirements are as follows: swabs must be collected with the Probetec, gender specific collection kit. The swab must be labeled with patient identification, date and time of collection. The eyes, throat and rectum are not approved sites and require culture methods for organism recovery. If a legal or criminal action is anticipated, culture is the appropriate method. Swabs can be maintained at room temperature

for up to five days after collection. Urine must be refrigerated and not frozen and also received within five days by the laboratory. The company that provides the Probetec assay is planning on introducing a liquid transport media similar to that used by the GenProbe assay. This change is expected to occur in September and more information will be available in the future.

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Department of Pathology and Microbiology at the University of Nebraska Medical Center

Samuel M. Cohen, M.D., Ph.D., Chairman James L. Wisecarver, M.D., Ph.D., Director, Clinical Laboratory

Steven H. Hinrichs, M.D., Director, Public Health Laboratory Thomas J. Safranek, M.D., Nebraska State Epidemiologist Samuel J. Pirruccello, M.D., Director, Client Services

981180 Nebraska Medical Center Omaha, NE 68198-1180

Phone: (402) 559-2440 Toll Free: 866-290-1406

Fax: (402) 559-9497

Change of Procedure for Transport of GC/Chlamydia Probe Testing The Nebraska Public Health Laboratory is introducing new transport systems for both Chlamydia/GC Swab and Urine specimen collection. The manufacturer's of the DNA Probe test has developed new transportation devices that will improve the stability of the specimen, and eliminate the need to refrigerate the specimens after collection and during transport. This change will be effective the next time collection supplies are ordered. The new transport system does not affect the specificity and sensitivity of the tests. Collection sites will see a difference only in the final step of the collection procedure. Detailed instructions will be included with supply shipments. The following briefly describes the changes. Chlamydia/GC Swab: Use the Wet Swab specimen and collection kit ( swab with plastic screw cap transport tube with green stripe). After collection of a female or male swab specimen, place the swab in the transport tube. Break off the shaft of the swab at the score line. Screw cap on firmly. Mix by inversion 3-4 times. Label tube with patient name and source of specimen. Stability: Room Temperature. Transport to laboratory within 6 days of collection. Chlamydia/GC Urine: Use the Urine Preservative Transport Kit. Open the kit and tap the transport tube (plastic screw cap tube with a blue stripe) on a flat surface to dislodge any large drops of fluid that may have collected in the cap of the transport tube. Using the pipette in the kit, transfer a volume of urine into the transport tube. The correct volume of urine is added when the fluid level is between the black fill lines on the fill window located toward the top of the transport tube. Screw the cap on firmly. Mix transport tube by inversion 3-4 times. Label with the patients name. Stability: Room Temperature. Transport to laboratory within 30 days of collection. Both the swabs and the urine samples may be transported to the laboratory at room temperature. Please check the transport kits expiration date prior to use. Transport kits will have a 3 to 6 month expiration date. Thank you and please contact the Nebraska Public Health Laboratory at 1-866-290-1406 or 402-559-2440 with any questions or concerns.

26





Phone: (402) 559-2440 Toll Free: 866-290-1406

Fax: (402) 559-9497

27





Phone: (402) 559-2440 Toll Free: 866-290-1406

Fax: (402) 559-9497

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Chlamydia trachomatis Culture Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Chlamydia trachomatis LISCode: VCCLM Method: Cell culture Availability: Tuesday by 1200; Results available at 48 hours. Specimen: Cervical, urethral, rectal or eye swab, tissue.

Infant nasopharyngeal swab may be submitted. Collect: Multipurpose viral-chlamydia transport media or Chlamydia Transport media. Comment: Do not collect on cotton swabs with wooden applicator/shaft. Specimens from

discharge or urine are unacceptable. Samples in Amplicor, EOA, GenProbe, LCX STD unacceptable.

Reference: Negative. Transport: Refrigerated Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. Update: 06/03

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Bacterial Organism Identification for Confirmation of Reportable Disease Isolates Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. LIS Code: BNK Method: Standard reference procedures for bacterial identification. Available: Monday through Friday by 0900. Specimen: Submit actively growing isolated organism in pure culture on agar slant. Comment: Indicate source of organism, identification test results, suspected infection

and any other pertinent information. See test “AFB/Mycobacterium Identification” for AFB mycobacterium isolates. See test “E.coli 0157:H7 culture” for confirmation of E. coli 0157:H7 isolates. Unacceptable conditions: Nonviable organism, mixed culture, leaking container.

Reference: Full identification of clinically significant isolates. Transport: Room Temperature Submit organism in NPHL Triple Pack. Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. Update: 06/03

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Diphtheria Culture Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Corynebacterium diphtheriae culture LISCode: DIPCU Method: Standard reference procedure for C.diphtheriae culture and identification. Availability: Daily; results in 72 hours. Specimen: Throat, nasopharynx, wound Collect: A swab of nasopharynx plus throat at the site of membrane or inflammation

site. Swab the base of cleansed wound. Comment: Use culturette swab with Stuart's or Amies medium. Reference: Negative Comment: Unacceptable conditions: Delay of transport.

Refrigerated or frozen specimens. Transport: Room Temperature within 24 hours of collection.

Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. 31

E. coli 0157:H7 Culture/Confirmation Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: E. coli 0157: H7 LISCode: HECCU Method: Standard reference procedure for Hemorrhagic E. coli 0157: H7 by culture

and identification. Availability: Daily; Reported as soon as positive detected or Final: Negative at 2 days. Specimen: Stool Actively growing isolated organism in pure culture on agar slant to rule out E. coli 0157:H7. Collect: Collect in a stool container. Volume: 10.0 mL in Cary-Blair or Enteric Plus transport media. Comment: Notification of positive results is provided.

Unacceptable conditions: Non-sterile or leaking container, multiple specimens (more than 1 in a 24 hour period), dry specimen, delayed transport to lab without use of appropriate preservative. Diapers are not acceptable.

Reference: Negative for E.coli 0157:H7 Transport: Room Temperature.


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Fluorescent Treponemal Antibody IgG Comment: Sites submitting specimens for sexually transmitted disease screening

must be approved by the Sexually Transmitted Disease Program in the Department of Health and Human Services Regulation and Licensure.

Please call NPHL for clarification at 402.559.2440 or 866.290.1406.

Synonym: FTA, FTA-ABS LISCode: FTA Method: IFA Availability: Wednesday by 800; Results same day. Specimen: Blood Collect: One 6.0 mL SST/Red/black tube Volume: 2.0 mL serum or

0.5 mL minimum Reference: Nonreactive Comment: Test Includes: Qualitative measurement of treponemal antibodies by

immunofluorescence. Reactive specimens will be quantitated by RPR. Transport: Room Temperature.

33

Fungus Culture Blood Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Mycology Culture LIS Code: FUNBL Method: Standard reference procedures for culture and identification of mold/yeast.

DNA probes available as indicated. Availability: Daily; negative results available at 7 days and final negative at 30 days;

Positive results will be reported as soon as detected. Specimen: Blood. Collect: Draw aseptically per Blood Culture Collection procedure. Wipe off top of

Blood culture bottle with alcohol wipe and let dry. Collect blood into Bactec Mycolytic/F bottle (red label). Transport to lab immediately at 20-25 oC.

Volume: 3.0-5.0 mL blood for adults; 1.0-3.0 mL blood for pediatrics Comment: Notification of positive results is provided. Unacceptable specimens:

blood collected in EDTA/Lavender tube, Heparin/Green tube and coagulated blood samples.

Reference: No growth at 30 days Comment: For primary isolation of systemic filamentous fungi and yeast including

Malassezia furfur. Yeast will be detected in routine aerobic/anaerobic blood cultures. Add in order comment if particular yeast or mold is suspected. One fungal culture order is recommended per 24 hour period. Bactec Mycolytic/F bottle (red label) is available upon request.

Update: 06/03

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Fungus-Dermatophyte, Skin Culture Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Skin, hair or nails for fungal culture; Dermatophyte culture LIS Code: FUNDCU Method: Standard reference procedure fungal dermatophyte culture. Availability: Daily; Preliminary report at 2 weeks, final report at 4 weeks. Specimen: Hair, nails, or skin scrapings. Collect: In a sterile container or clean envelope. Comment: Indicate suspected organism(s) and specimen site on the test request form.

Additional patient history may be helpful. Include the patient's occupation, history of travel or residence abroad, and any animal contact. Unacceptable conditions: non-sterile or leaking container.

Reference: No fungi isolated. Comment: Notification of positive results for mold is provided. For specimen types

other than hair, nail or skin, see Culture, Fungus. Update: 06/03

35

G.C. Screen Culture Comment: Sites submitting specimens for sexually transmitted disease screening


Please call NPHL for clarification at 402.559.2440 or 800.334. Synonym: GC Screen, Gonococcal Culture LIS Code: GCSCR Method: Standard reference procedure for Neisseria gonorrhoeae culture and

identification. Availability: Daily; preliminary report as soon as found positive, final for negative

results at 3 days. Specimen: Any site or fluid, urethral swab, endocervical swab, rectal swab or throat

swab. Collect: Inoculate Jembec plate of Modified Thayer Martin agar sealed in a plastic

bag with a Co2 generating tablet. Comment: Identification by nucleic acid methodology can be performed on the

genital specimen collected in the GenProbe collection kit. See Chlamydia/GC DNA probe. Note specific site on specimen and test request form.

Reference: Negative for Neisseria gonorrhoeae. Comment: Media is available from NPHL

Unacceptable conditions: Delayed transport of the plates in non-CO2 environment and refrigerated or frozen specimens.

Update: 06/03

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Giardia and Cryptosporidium Antigen Screen Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Acid-fast Stain, Modified; Replaces Cryptosporidium, Giardia Antigen Test. LISCode: OVPSC Method: Enzyme Immunoassay. Availability: Monday, Wednesday, Friday by 0900; results same day. Specimen: Stool. Collect: Collect in Parapak: 10% formalin and PVA vials.

Collect in stool container. Add stool to two separate vials containing 10% formalin and modified PVA (Parapak). Fill each vial to the specimen line with stool and mix. Parapak is provided by NPHL.

Volume: Walnut size stool or 10 mL of stool. Reference: Negative Comment: Test includes: Examination of stool for the presence of Giardia and

Cryptosporidium by EIA assay. Transport: Room Temperature. Stable 7 days

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Hepatitis B Core Antibody, Total Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Antibody to Hepatitis B Core Antigen; Anti-HBc; Core Antibody LISCode: HBCAB Method: EIA Availability: Monday and Thursday by 0900; Results same day. Specimen: Blood Collect: One 6.0 mL SST/Red/black tube or

One 5 mL EDTA/Lavender tube or One 4.5 mL PST/Green/black tube or One 5 mL Heparin/Green tube

Volume: 0.5 mL serum or plasma

0.3 mL minimum Reference: Nonreactive Transport: Room Temperature in NPHL.

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Hepatitis B Surface Antibody Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Antibody to Hepatitis B Surface Antigen; Anti-HBs;

Australian Antigen Antibody LISCode: HBSAB Method: EIA Availability: Monday - Friday BY 09:00; Results same day. Specimen: Blood Collect: One 6.0 mL SST/Red/black or

One 4.5 mL PST/Green/black or One 4.5 mL EDTA/Lavender tube or One 5 mL Heparin/Green/black tube

Volume: 1 ml serum or plasma 0.5 mL minimum

Reference: Nonreactive Transport: Room Temperature.

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Hepatitis B Surface Antigen Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Australian Antigen; HAA; HBsAg; Hepatitis Associated Antigen LISCode: HBSAG Method: EIA Availability: Monday - Friday by 0900; Results same day. Specimen: Blood Collect: One 6.0 mL SST/Red/black tube or

One4.5 mL PST/Green/black tube or One 5 mL EDTA/Lavender tube or One 5 mL Heparin/Green tube

Volume: 2 mL serum or plasma

1 mL minimum Reference: Nonreactive Transport: Room Temperature.

40

Hepatitis C Antibody Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: HCV Antibody LISCode: HCAB Method: EIA Availability: Monday, Wednesday, and Friday by 0900; Results same day. Specimen: Blood Collect: One 6.0 ml SST/Red/black tube or

One 5 mL EDTA/Lavender tube or One 4.5 mL PST/Green/black tube or One 5 mL Heparin/Green tube

Volume: 0.5 mL serum or plasma

0.3 mL minimum Reference: Nonreactive Transport: Room Temperature.

41

Herpes Simplex Culture Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Herpes Culture; Herpes Simplex 1 and 2 Culture; HSV Culture LISCode: VCHSV Method: Cell culture Availability: Daily by 1300. Specimen: Vesicle fluid and cells from lesion or Blood. Collect: Specimen in Viral Transport media.

Collect blood in Sodium Heparin tube Volume: Adequate specimen for culture.

Blood: 5.0 mL for Adults, 2.0 ml children Comment: Culture held for 7 days Reference: No CPE detected at 7 days. Comment: Special Instructions: Place specimen in viral transport medium. Viral

Culturette or other commercially available viral transport systems are satisfactory. Do not use Calgiswabs.

Transport: Refrigerated Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

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Information Package on the Nebraska Public Health Laboratory

Screening and Confirmation for the Human Immunodeficiency Virus

Testing for the presence of HIV may be complex in certain clinical situations. The following is intended to provide background information on the laboratory approach to this problem. HIV 1 and 2 Antibody Screen The screening of an individual for HIV is determined in the laboratory by a combination ELISA method, which detects antibodies directed against HIV1 and HIV2. The result of this screen is either negative or positive. Since this is a screening test, a positive result is considered a “presumptive positive” only and requires a second level of testing for confirmation. This second level test is for the detection of HIV 1 Antibody by Western Blot.

Fig. 1, HIV Western Blot Please contact Steven Hinrichs, M.D., Director for questions on a specific patient or client.

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HIV 1 Antibody Detection by Western Blot. The interpretation of an HIV 1 Western Blot is made by looking for bands on an immuno blot, a nylon strip showing the presence or absence of bands as shown in figure 1 above. In most situations, two bands need to be present to be positive confirmation test. The bands of importance (named according to their size), are: p 24, gp 40-42, gp 120, or gp160. The confirmation test is interpreted as negative if no bands are seen on the blot. At the NPHL, we also review the ELISA result to make sure it is consistent with the Western blot result. Indeterminate Western Blot When only one band, such as p24 is seen, the HIV 1 western blot is interpreted as “indeterminate” which means it is neither negative nor positive. Additionally, an HIV 1 western blot result is sometimes unreadable due to blotchiness of the stain caused by the presence of a non-specific antibody and is interpreted as “indeterminate due to non-specific staining”. The approach to an indeterminate result may vary depending on the clinical situation. In certain cases a molecular based assay is appropriate. (See discussion below) Qualitative HIV 1 DNA Detection The HIV1 DNA DetectRtm is used to determine whether a patient has HIV DNA within their white blood cells. The result is reported as positive or negative. Because the report states negative or no HIV DNA detected, the test provides more clarity through the quantitative result and may help resolve previously ambiguous test results. HIV 2 Western Blot If the HIV 1-2 antibody screen is positive but the HIV 1 western blot is negative, the serum should be evaluated for presence of antibodies to HIV 2. If there is a positive patient history for foreign travel in Africa or exposure to someone who has traveled in Africa, a HIV 2 Western Blot confirmation may be considered. Confirmation of an indeterminate HIV 2 western blot is complex and requires specific consultation.

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Quantitative HIV RNA Detection A HIV RNA quantitative or viral load determination is ordered as part of a treatment plan for the HIV positive patient. This determination aids in the monitoring of anti-viral therapy, and is obtained shortly after the initial diagnosis of HIV infection is made. As with all quantitative tests, the level of sensitivity is important, some tests are able to detect as little as 50 copies of the virus. The report may indicate the specimen has less than 400 copies of virus, for example.

HIV Antibody Specimen Requirements

Routine HIV Antibody Screening:

HIV 1 and 2 Antibody Screen 5.0 mL whole blood in clot or SST tube. Ship at ambient temperature.

Testing performed at NPHL. HIV 1 Western Blot

5.0 mL whole blood in clot of SST tube. Ship at ambient temperature. Testing performed at NPHL. Indeterminate Western Blot Confirmation:

HIV 1 DNA DetectRtm Qualitative 5.0 mL EDTA whole blood.

Ship at ambient temperature. Specimen must arrive at NPHL with in 24 hours of collection. Do not collect on Fridays or Weekends. Specimen tested at Specialty Laboratories, Santa Monica, California.

Viral Load Testing:

HIV RNA Quantitation 5.0 mL EDTA whole blood.

Centrifuge and separate sample from cells within 6 hours of collection. Transfer plasma to a clean tube and freeze. Ship frozen EDTA plasma

Testing performed at NPHL.

HIV-1 RNA Quantitation Ultrasensitive 5.0 mL EDTA whole blood. Centrifuge and separate sample from cells within 6 hours of collection. Transfer plasma to a clean tube and freeze. Ship frozen EDTA plasma

Testing performed at NPHL. Other Testing:

HIV 2 Western Blot 5.0 mL whole blood in clot of SST tube. 45

Ship at ambient temperature. Testing performed at ARUP Laboratories, Salt Lake City, Utah.

HIV-2 Proviral DNA, Qualitative, PCR 5.0 mL EDTA whole blood.

Ship at ambient temperature. Testing performed at FOCUS Laboratories, Cypress, California.

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HIV1 RNA Quantitation Ultrasensitive Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: HIV Viral Load Ultrasensitive LISCode: HIVUS Availability: Test performed once/week; Results within 1 week. Specimen: Blood Collect: One 5 mL EDTA/Lavender tube Volume: 2.0 mL plasma or

1.0 mL minimum Reference: Number of viral copies per mL.

Upper limit of assay=75,000 copies/ml Lower limit of assay=50 copies/mL

Comment: Indications: Monitoring anti-viral therapy by measurement of viral burden in

patients with known low viral loads. This test is not designed as a diagnostic tool however a 5 fold change in copies/mL may be significant.

Transport: Frozen. Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

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HIV-1 RNA Quantitation Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: HIV Viral Load LISCode: HIVDQ Availability: Assay performed once/week; Results within 1 week. Specimen: Blood Collect: One 5.0 mL EDTA/Lavender tube Volume: 2.0 mL plasma or 1.0 mL minimum Comment: Centrifuge and separate sample from cells within 6 hours of collection.

Transfer plasma to a clean tube and freeze. Reference: Number of viral copies per mL.

Upper limit of assay = 750,000 copies/mL Lower limit of assay = 400 copies/mL

Comment: Monitoring anti-viral therapy by measurement of viral burden.

This test is not designed as a diagnostic tool however a 1 Log (10-fold) change in copies/mL may be significant.

Transport: Frozen. Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

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HIV 1 and HIV 2 Antibody Comment: Sites submitting specimens for HIV screening must be approved by the

HIV Prevention Program at the Department of Health and Human Services.

Please call NPHL for clarification at 402.559.2440 or 866.290.1406. Comment: A HIV SCREENING Requisition or NPHLWeb order must accompany

this specimen. Synonym: HIV ELISA Screen LISCode: HIV12 Method: EIA Availability: Monday - Friday by 0900; Results - same day by 1700. Specimen: Blood Collect: One 6.0 mL SST/Red/black tube or 4.5 mL PST/Green/black tube or

5.0 mL EDTA/Lavender tube Volume: 0.5 mL serum or plasma or 0.05 mL minimum Reference: Nonreactive Comment: All Reactive HIV ELISA screens will be confirmed by Western Blot. Transport: Room Temperature.

49

HIV 1 Antibody Confirmation, Western Blot Comment: Sites submitting specimens for HIV screening must be approved by the

HIV Prevention Program at the Department of Health and Human Services.

Please call NPHL for clarification at 402.559.2440 or 866.290.1406. Comment: A HIV SCREENING Requisition or NPHLWeb order must accompany

this specimen. Synonym: HIV Confirmation, HIV Western Blot LISCode: HIVC1 Method: Western Blot Availability: Wednesday by 0800; Results within 24 hours.. Specimen: Blood Collect: One 6.0 mL SST/Red/black tube Volume: 2 mL serum or 0.5 mL minimum Comment: This test is intended to confirm the HIV ELISA Screen. Order this assay only

when a specimen is repeatedly reactive for HIV 1 or HIV 1-2 antibodies. Reference: Negative Comment: Test includes HIV antibody detection to specific HIV proteins and

glycoproteins (p17, p24, p31, gp41, p51, p55, p65, gp120, and gp160). Transport: Room Temperature.

50

Influenza A Antigen Detection Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Flu A LISCode: FLUAD Method: EIA Availability: Daily; 0900, 1400, 2000. Specimen: Nasal wash, nasal aspirate and nasal swabs. Collect: Place in viral transport media. Volume: 3.0 mL wash or aspirate

2.0 mL minimum Comment: Slides smears and BAL specimens are not acceptable. Reference: Negative. Transport: Refrigerated Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

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LEAD, Blood Screening Comment: Sites submitting specimens for blood lead screening must be approved by

the Childhood Lead Poisoning and Prevention Program at the Department of Health and Human Services Regulation and Licensure.

Please call NPHL for clarification at 402.559.2440 or 866.290.1406. Comment: A Blood Lead Analysis Requisition or NPHLWeb order must accompany

this specimen. Synonym: Pb LISCode: LEAD Method: Anodic Stripping Voltammetry Availability: Monday through Friday by 1400; Results within 72 hours. Specimen: Blood, venous or capillary Collect: Whole blood EDTA/Lavender microtainer. Collection Comment: Invisible traces of lead dust on a child’s skin can contaminate the

sample and cause results to be elevated. For capillary samples the child’s hands should be thoroughly washed with soap and then dried with a clean, low lint towel. Plain, unprinted, non-recycled towels are best. If water is unavailable, foam soaps can be used without water. If desired, a brush can be used for cleaning the finger; brushing during washing can increase blood circulation in the finger. Once washed, the finger must not be allowed to come into contact with any surface, including the child’s other fingers.

Volume: 0.250 mL, minimum Reference: < 15 years of age: <10.0 mcg/dL

> 15 years of age: <25.0 mcg/dL Critical Range: >70.0 mcg/dL Results: > 25.0 mcg/dL will be called to the submitting site.

Comment: This test has a Communicable Disease and Poisoning Reporting Requirement: NPHL will Report the information on this form and the blood lead analysis results to the Nebraska Department of Health and Human Services Regulation and Licensure. Physicians do not have to make a separate report.

Transport: Room Temperature.

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CDC Classifications for Blood Lead Concentration Screening in Children

Table 1. CDC classifications of lead concentrations in children (CDC, 1991)

Classification [Pb] (ug/dL) Interpretation I < or equal 9 Not Considered to be Lead-poisoned (Negative) IIA 10-14 May Need to be Rescreened More Frequently

(Positive) IIB 15-19 Nutritional and Educational Intervention and More

Frequent Screening. If Persists, Environmental Investigation and Intervention

III 20-44 Environmental Evaluation, Remediation and Medical Evaluation. May need Pharmacologic (Succimer) Treatment

IV 45-69 Medical and Environmental Intervention, Including Chelation Therapy

V > or equal 70 Medical Emergency

References

1. MMWR, October 11, 1991 / 40(40);695 http://www.cdc.gov/mmwr/preview/mmwrhtml/00015325.htm

2. CDC. Preventing lead poisoning in young children, 1991. Atlanta: US

Department of Health and Human Services, Public Health Service, 1991. Notice to Readers Statement on Preventing Childhood Lead Poisoning On October 7, 1991, CDC released an updated statement on the prevention of childhood lead poisoning. The statement provides guidelines to pediatric health-care providers, public health programs, and others about childhood lead screening, case management for lead-poisoned children, and primary prevention of childhood lead poisoning. Copies of the statement, Preventing Lead Poisoning in Young Children, 1991 (1), are available free of charge from Publication Activities, Office of the Director, National Center for Environmental Health and Injury Control, Mailstop F-29, CDC, 1600 Clifton Road, NE, Atlanta, GA 30333.

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http://www.cdc.gov/mmwr/preview/mmwrhtml/00015325.htm

Mumps Viral Culture Comment: Sites submitting specimens for mumps virus testing must be approved by the Epidemiology Program at the Department of Health and Human Services Regulation and Licensure. Please call NPHL for clarification at 402-559-2440 or 866-290-1406. Comment: A SPECIAL MICROBIOLOGY Requisition or ELIRT order must accompany this specimen. Requisition must have written comments that states “Rule-out Mumps Virus.” Laboratory: Microbiology Method: Cell Culture, (Immunofluorescence Stain – if needed to confirm isolates) Availability: Monday through Sunday Specimen: Throat Culture/Stenson Duct (Parotid Gland duct) within 9 days of symptom onset. Massage the

parotid (salivary) glands for 30 seconds prior to swabbing the cheek area of the Stensen’s duct orifice (which is level with the upper 2nd molar-see picture).

Urine should be collected within 9 days of symptom onset Collect: Urine: clean catch, in screw-cap, sterile container. Store and ship cold. If transport is delayed >24

hours, place 2.0 mL of urine in viral transport media (urine should be added in a 1-to1 ratio with media).

Stenson Duct (Parotid gland duct): Swab. Place swab in viral transport medium and do not remove.

(M5 viral media can be used)

Volume: Urine - 2.0 mL minimum Transport: Urine and Stenson Duct specimens must be stored and shipped cold, do not freeze samples. Comment: Viral transport media is available from Regional Pathology Services. Dry swabs are unacceptable

for culture. Reference Range: No CPE detected at 14 days LIS Code: VCGVI CPT Code: NA

54

Mumps Antibody IgM Comment: Sites submitting specimens for mumps virus testing must be approved by the Epidemiology Program at the Department of Health and Human Services Regulation and Licensure. Please call NPHL for clarification at 402-559-2440 or 866-290-1406. Comment: A SPECIAL MICROBIOLOGY Requisition or ELIRT order must accompany this specimen. Requisition must have written comments that states “Rule-out Mumps Virus.” Testing Lab: ARUP Methodology: Enzyme-Linked Immunosorbent Assay Performed: Mon, Wed, Fri; Results reported: 1-6 days Specimen: 3.0 mL serum (minimum) Transport: Refrigerated Remarks: Separate serum from cells ASAP. Rejection Criteria: Severely lipemic, hemolyzed, heat-inactivated, or contaminated samples. Stability: After separation from cells: Ambient: 2 days; Refrigerated: 2 weeks; Frozen: 1 year (avoid repeated freeze/thaw cycles) Reference Range: 0.90 IV or less: Negative - No significant level of detectable IgM antibody to mumps virus. 0.91-1.09 IV: Equivocal - Repeat testing in 10-14 days may be helpful. 1.10 IV or greater: Positive - Presence of IgM antibody to mumps virus detected, which may indicate a current or recent infection. However, low levels of IgM antibodies may occasionally persist for more than 12 months post-infection or immunization. CPT Code: 86735

55

Mumps Antibody IgG Comment: Sites submitting specimens for mumps virus testing must be approved by the Epidemiology Program at the Department of Health and Human Services Regulation and Licensure. Please call NPHL for clarification at 402-559-2440 or 866-290-1406. Comment: A SPECIAL MICROBIOLOGY Requisition or ELIRT order must accompany this specimen. Requisition must have written comments that states “Rule-out Mumps Virus.” Methodology: Enzyme-Linked Immunosorbent Assay Availability: Monday through Sunday Specimen: 3.0 mL serum (minimum) Transport: Frozen Remarks: Separate serum from cells ASAP. Comment: Acute and convalescent samples must be labeled as such; parallel testing is preferred and acute samples will be stored frozen by NPHL until convalescent sample is collected. Collect convalescent sample at 2 to 4 weeks from acute sample collection. Please mark samples plainly as "acute" or "convalescent." Rejection Criteria: Severely icteric, hemolyzed, heat-inactivated, or contaminated samples. Stability: After separation from cells: Ambient: 2 days; Refrigerated: 2 weeks; Frozen: 1 year (avoid repeated freeze/thaw cycles) Reference Range: 0.89 IV or less: Negative - No significant level of detectable IgG mumps virus antibody. 0.90-1.09 IV: Equivocal - Repeat testing in 10-14 days may be helpful. 1.10 IV or greater: Positive - IgG antibody to mumps virus detected, which may indicate a current or past exposure/immunization to mumps virus. Positive IgG antibody levels in the absence of current clinical symptoms may indicate immunity. Interpretive Data: The best evidence for current infection is a significant change on two appropriately timed specimens, where both tests are done in the same laboratory at the same time. CPT Code: 86735

56

Mycobacterium tuberculosis complex genotyping Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Tuberculosis genotyping Lab: Microbiology/Virology Method: PCR genotyping methods: spoligotyping and mycobacterium interspersed

repetitive units (MIRU); with optional IS 6110-based restriction fragment length polymorphism (RFLP) analysis

Availability: Sent to CDC for testing Specimen: One isolate of M tuberculosis complex per patient Volume: Total volume required is 2 mls of positive broth (e.g., MGIT, Bactec, converted

blood culture instrument) in a screw- top vial with installed o-ring (e.g.,cryovial), screw-top securely fastened, taped with adhesive tape ( two 1 ml vials acceptable); or LJ slant with viable growth, securely closed and taped with adhesive tape.

Transportation: Room temperature. Comment: Specimens sent for Tb genotyping require submission with NPHL Special

Microbiology requisition. Please notify NPHL if requisition is needed. Specimens must be packaged in Infectious Shipping containers, available from NPHL client services at 866-290-1406. More information can be found on the internet at www.nphl.org.

Reference range: By report LIS Code: TBGEN

57

Mycobacterium tuberculosis DNA Amplified Direct Detection Comment: Sites submitting specimens for testing must have prior approval by the

Tuberculosis Control Program at the Department of Health and Human Services Regulation and Licensure, 402.471.2937.

Comment: A SPECIAL MICROBIOLOGY Requisition or NPHLWeb order must

accompany this specimen. LIS Code: TBAPR Method: Transcription mediated amplification and Hybridization Protection

(Genprobe) Available: Monday through Friday by 0900. Testing sent to reference laboratory. Specimen: Submit sputum or bronchial lavage in sterile, leak proof container.

Collection of early morning specimens of sputum on each of three consecutive days is optimum. Please indicate source of specimen.

Comment: Test recommended for AFB smear positive respiratory specimens for

patient highly indicative of M. tuberculosis. Unacceptable conditions: Non-respiratory specimens.

Reference: Negative Transport: Refrigerated Submit organism in NPHL Triple Pack. Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. Update: 06/03

58

Organism Banking Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. LIS Code: BNK Method: Organism frozen for NPHL epidemiology studies. Availability: Daily

Specimen: Submit actively growing isolated organism in pure culture on agar slant.

Isolates accepted by NPHL include from sterile sites: Salmonella species Shigella species Camplylobacter species e.coli 017:H7 Listeria monocytogenes VISA VRSA Neisseria meningitides Haemophilus influenza Other isolates may be requested to be submitted for banking by the Nebraska State Epidemiologist.

Comment: Indicate source of organism. Unacceptable conditions: Nonviable organism Mixed culture Leaking container Transport: Room Temperature. Update: 06/03

59

Ova & Parasite, Stool, Complete, Foreign Travel Comment: Sites submitting specimens for testing must be approved by the

Epidemiology Program at the Department of Health and Human Services Regulation and Licensure. Please call NPHL for clarification at 402.559.2440 or 866.290.1406.

Comment: A SPECIAL MICROBIOLOGY Requisition or NPHLWeb order must

accompany this specimen. LISCode: OVPAR Method: Concentration technique and trichrome stain by microscopic examination,

gross appearance description. Availability: Monday - Friday; results next day. Specimen: Stool, preserve in Proto-fix vial. Collect: Collect in stool container. If transport > 2 hours, preserve in a Proto-fix vial for

transport. Add stool to fill line marked on Proto-fix vial, seal and shake vigorously. Add bloody, watery portions of stool if present. Proto-fix is provided by Regional Pathology Services.

Volume: Walnut size stool specimen or10.0 mL of stool Comment: Indicate suspected parasites and patient history if applicable. Do not send more

than one stool specimen per day. Three stool specimens collected over a 10 day period are optimal. Specimens tested to determine the efficacy of treatment should be collected three to four weeks after completion of therapy. Order this test if the patient has had foreign travel or continued symptoms. See Giardia/Cryptosporidium Antigen Test on stool for O&P routine screening. If Cyclospora/Isospora is suspected, order Ova & Parasites, stool for Cyclospora & Isospora stain. One Proto-fix vial can be submitted for all Ova and Parasite tests except Pinworm. Unacceptable conditions: Dry specimen, leaking container, specimen contaminated with oil, barium, or urine, multiple specimens in a 24 hour period, delayed transport.

Transport: Room Temperature in Proto-fix vial Reference: No ova or parasites seen by concentration procedure and trichrome stain. Updated 11/22/04

60

TB Interferon (QuantiFERON®-TB Gold) Comment: Sites submitting specimens for testing must be approved by the Epidemiology Program at the Department of Health and Human Services Regulation and Licensure. Please call NPHL for clarification at 402.559.2440 or 866.290.1406. Comment: A SPECIAL MICROBIOLOGY Requisition or ELIRT order must accompany this specimen. Synonym: TB Interferon Antigen Response, QuantiFERON®-TB Gold Lab Defined: Microbiology Method: ELISA Availability: Monday, resulted in 24 hours. Comment: Samples are processed Monday through Thursday, except holidays. Sample must be received in the laboratory by12:00 Noon for 1:00 P.M. processing, Monday through Thursday. (Sample must be no more than12 hours post collection at 1P.M.) Do not collect sample earlier that 1:00A.M. TB Interferon only performed on Mondays, if six or more samples have been received for testing. Specimen: Whole blood Comment: Unacceptable conditions: Specimen received greater than 12 hours collection time, frozen or refrigerated samples, centrifuged samples. Collect: One 7.0 mL (two 5.0 mL) Sodium or Lithium Heparin (Green) Tube PST tubes are acceptable but must not be centrifuged Volume: 7.0 mL heparinized whole blood Transport: Room Temperature Comment: LIVE LYMPHOCYTES REQUIRED. Critical Room Temperature, Specimen must not be refrigerated, frozen, or centrifuged. Reference Range: Negative Additional Info: This assay is intended to assist in the evaluation of tuberculosis disease and latent tuberculosis infection in patients and health care workers. Since prior vaccination with BCG does not cause the TB interferon test to become positive, it can also be used as a test for tuberculosis in people who have been vaccinated with BCG. Additional information regarding QuantiFERON®-TB Gold is available at www.cellestis.com. LIS Code: TBINT

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http://www.cellestis.com/



1

Steven H. Hinrichs, M.D., Director, Public Health Laboratory Thomas J. Safranek, M.D., Nebraska State Epidemiologist


Phone: (402) 559-2440 Toll Free: 866-290-1406

Fax: (402) 559-9497

Additional QuantiFERON®-TB Gold Information : This assay is intended to assist in the evaluation of tuberculosis disease and latent tuberculosis infection in patients and healthcare workers. Since prior vaccination with BCG does not cause the TB interferon test to become positive, it can also be used as a test for tuberculosis in people who have been vaccinated with BCG. The test approved by the FDA in November, 2001 and marketed under the name “QuantiFERON®-TB Gold”, is an in vitro test utilizing peripheral blood, and tests for the production of interferon by lymphocytes. Two Mycobacterium tuberculosis antigens are added to heparinized peripheral blood containing antigen presenting cells and T lymphocytes. T lymphocytes, if exposed previously to M. tuberculosis, produce interferon-γ (IFN-γ) in response to addition of the antigens and subsequent immune response. The quantity of IFN-γ is assayed using a single step enzyme-linked immunosorbant assay (ELISA). In unvaccinated individuals without reported risk for M. tuberculosis infection, clinical trials have shown a specificity of 99.8%, compared to 99.1% for tuberculin skin test (TST). In culture confirmed infected individuals, TB interferon testing demonstrated a sensitivity of 91.3 %, compared to 79.2% with TST. In BCG vaccinated individuals, specificity with TB interferon testing was 98.1%, compared to 68.1% with TST. The utility of this test is being studied in children and immunosuppressed patients, including HIV positive individuals, and is currently not appropriate for these populations. Indeterminate test results may occur, and are believed to be due to a high background of interferon production or the lack of response to antigen stimulation. This test was evaluated in our facility with 15 TST positive individuals who were believed to be clinically negative, 16 TST negative individuals, and 6 BCG vaccinated individuals. Three of the TST positive individuals had a positive TB interferon result; all three had negative chest x-rays. This data suggests the TB interferon assay will reduce the number of individuals treated for a false positive TST. 16 TST negative cases were negative with the TB interferon assay. Five of 6 BCG vaccinated individuals tested negative, and one was indeterminate. The TB interferon test is appropriate to screen those individuals who have received BCG vaccination or the evaluation of health care workers who test positive by the tuberculin skin test. Cost savings are expected from decreased need for treatment of skin-test positive individuals who test negative with TB interferon, and elimination of repeat skin-testing in individuals who have consistently positive skin-tests.

62



2

Steven H. Hinrichs, M.D., Director, Public Health Laboratory Thomas J. Safranek, M.D., Nebraska State Epidemiologist


Phone: (402) 559-2440 Toll Free: 866-290-1406

Fax: (402) 559-9497

Specimen collection consists of two green-top heparinized (sodium heparin or lithium heparin) tubes (5 mL each). Other anticoagulants (EDTA, Citrate dextrose) interfere with the assay and should not be used. The specimen must be processed within 12 hours of collection. Specimens will be accepted Monday through Thursday from 7:30 am to 1:00 pm. The assay will be performed weekly dependant on volume. Further information can be found at www.cellestis.com and in the Center for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (MMWR), December 16th, 2005, volume 54.

63

http://www.cellestis.com/

Respiratory Syncytial Virus Direct Antigen Detection Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: RSV Direct LIS Code: RSVAD Method: EIA Availability: Daily by 0900, 1400, 2000. Specimen: Nasal wash, nasal aspirate, nasal swab Collect: Place specimen in viral transport media. Volume: 2.0 mL minimum wash or aspirate. Reference: Negative Additional Info: Slide smears and BAL specimens are not

acceptable. Update: 06/03

64

Respiratory Viral Panel Comment: Sites submitting specimens for testing must be approved by the

Epidemiology Program at the Department of Health and Human Services Regulation and Licensure. Please call NPHL for clarification at 402.559.2440 or 866.290.1406.

Comment: A SPECIAL MICROBIOLOGY Requisition or NPHLWeb order

must accompany this specimen.

Synonym: Respiratory Panel, Respiratory Culture Test Code: VCRRP Method: Immunofluorescence and cell culture. Availability: Monday - Saturday by 1300. Specimen: Nasopharyngeal washings or Nasopharyngeal swab, both preferred;

Bronchial alveolar lavage (BAL)

Collect: Nasopharyngeal washings with normal saline and/or nasopharyngeal swab. Place in viral transport media. Transport refrigerated, must be received in lab within 72 hours.

Click HERE for Nasopharyngeal Washing/ Nasal Swab Collection Procedure.

Volume: 2-3 ml nasopharyngeal washings or BAL; nasopharyngeal swab

Transport: Refrigerated Comment 1: Preliminary report of culture with 1 and 2 day staining for Adenovirus,

Influenza A and B, Parainfluenza 1, 2, 3 and RSV. Final Culture report at 14 days.

Comment 2: Patient history requested: Date of onset, Travel history, Antiviral therapy,

influenza vaccine status. Reference: No CPE detected at 14 days. CPT: 87252, 87253, 87254 Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up. Updated November 2004

65

http://www.nphl.org/documents/Nasopharyngealwashing-nasalswabProcedure.pdf

NASOPHARYNGEAL WASHINGS/Swab (virus only)

Washing:

1. Cut off the distal end of the butterfly catheter (needle and butterfly) catheter extension set so that about 23 inches of tubing are left attached to the hub.

2. Draw up 23 mls of saline into a syringe.

3. Attach syringe to hub of butterfly catheter. Purge tubing with saline.

4. Put on gloves, gown, mask and eye protection.

5. Gently remove excess mucous from patient's nose. (If patient is an adult, ask the patient to gently blow nose. For pediatrics, a bulb syringe may be used to remove excess mucous.)

6. Position patient in supine position with the head of bed up 30°. The head should be turned to one side and tilted slightly backward.

7. Stabilize the patient's head and gently place the catheter into the nare. Placement should be in the nare (nasal wall), not the nasopharynx. Depending on the size of the patient, this should be about 12 cm in adults and 0.5 cm to 1.0 cm in children (0.5 cm in neonates). See Figure 1.

Figure 1

8. Instill .5 2 mls saline (.5 1 mls for infants and children, 1 2 mls for adults) into the nare and aspirate back mucous, saline and epithelial cells.

9. Repeat this process using the same syringe until the sample is cloudy or appears to hold cellular debris. (If the sample is inadequate, the process may be repeated on the opposite nare, using a second sterile syringe and tubing. Usually one nare is sufficient.) NOTE: There may be some blood streaks in the mucous. This is normal and patients/parents should be told this is expected and will stop in a few minutes.

10. Transfer contents of tubing and syringe into transport media using the following process: Depress syringe plunger and express fluid from syringe and tubing into transport media. Then withdraw media/fluid back into syringe and tubing. Depress syringe plunger again, expressing fluid from syringe and tubing back into transport media. NOTE: This is necessary to recover any cells or virus adhering to the tubing or syringe.

11. Transport refrigerated. Specimen must be received at NPHL within 72 hours of collection.

66

NASOPHARYNGEAL WASHINGS/Swab (virus only) continued

Nasal Swab

1. Insert a minitip culturette swab into the same nares from which the wash was performed approximately 3 cm and gently rub the mucosa.

2. Place the swab back into transport media containing aspirated material. See Figure 2. NOTE: Combining the aspirate and the swab enhances viral recovery and reduces cost to the patient.

3. Transport refrigerated. Specimen must be received at NPHL within 72 hours of collection.

Figure 2

Updated November 2004

67

RPR Rapid Plasma Reagin Comment: Sites submitting specimens for sexually transmitted disease screening


Please call NPHL for clarification at 402.559.2440 or 866.290.1406. Comment: A STD and SEROLOGY Requisition or NPHLWeb order must

accompany this specimen. Synonym: Test for Syphilis, Syphilis Screening Test LISCode: RPR Method: Agglutination Availability: Monday-Friday by 800; Results same day Specimen: Blood Collect: One 6.0 mL SST/Red/black tube Volume: 2.0 mL serum or

0.5 mL minimum Reference: Nonreactive Comment: Reactive specimens will be tested by FTA. Transport: Room Temperature.

68

Rubella Antibody IgG Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Rubella IgG LISCode: RUBG Method: Axsym Availability: Monday and Thursday by 0900; Results same day Specimen: Blood Collect: One 6.0 mL SST/Red/black tube or

One 5.0 mL EDTA/Lavender tube Volume: 2.0 mL serum or heparinized, EDTA plasma

0.2 mL minimum Reference: Immune Transport: Room Temperature.

69

Salmonella Serotyping Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Salmonella serotyping LISCode: SLMS Availability: Daily, Monday-Friday, by 0900. Specimen: Organisms isolated from routine cultures. Submitted on media slant. Comment: Send identification and test method used. Reference: Serogrouping report. Comment: Test Includes: Serogrouping and banking of referred organism. Transport: Room Temperature Update: 06/03

70

Shiga Toxin DNA Detection Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. LISCode: SHIGT Method: DNA Amplification Availability: Monday-Friday; results within 3 days. Specimen: Stool Collect: Sterile container Volume: 1.0 mL of stool minimum Reference: No Shiga Toxin DNA Transport: Refrigerated Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

71

Stool Culture Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Enteric pathogens, Routine Stool, Feces Culture LISCode: STOCU Method: Standard reference procedures for Salmonella, Shigella and Campylobacter

culture and identification. Availability: Daily; positive results reported as soon as detected, negative results at 2 days. Specimen: Stool Collect: Collect in a stool container. Volume: 10.0 mL stool in Cary-Blair media. Comment: Indicate suspected organisms and available patient history, especially travel.

Notification of positive results is provided. Reference: Negative for Salmonella, Shigella and Campylobacter. Comment: Unacceptable conditions: Nonsterile or leaking container, multiple specimens

(> 1 in a 24 hour period), dry specimen, delayed transport to lab without use of appropriate preservative. Diapers are not acceptable.

Transport: Room Temperature

Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

72

Vibrio Culture Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. LIS Code: VIBCU Method: Standard reference procedure for Vibro culture and identification Availability: Daily; Final negative report at 2 days. Specimen: Stool Collect: Stool container Volume: 1.0-5.0 fresh stool; 10 mL in Cary-Blair media Comment: Indicate suspected organisms and available patient history, especially any

recent travels, on the test request form. Notification of positive results is provided.

Reference: Negative for Vibrio species. Comment: Unacceptable conditions: Nonsterile or leaking container, multiple

specimens (>one in 24 hours), dry specimens or delayed transport to lab in inappropriate preservative. Diapers are not acceptable.

Update: 06/03

73

Virus Culture, General Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Virus Isolation, Viral Culture LISCode: VCGVI Method: Cell Culture Availability: Daily by 1300. Specimen: Cerebral spinal fluid, Eye, Nasal wash/aspirate, Stool, Throat swab, Tissue,

Lesion swab, Tracheal aspirate, Urine, Bronchoalveolar lavage (BAL) and Blood.

Collect: Swabs, nasal wash and aspirates and tissue submitted in commercial viral transport medium. Urine, Cerebral spinal fluid, stool and BAL in sterile containers. Blood in Sodium Heparin tube.

Volume: CSF, 0.5 mL minimum Nasal wash /aspirate, 2.0 mL minimum Urine and BAL, 2.0 mL minimum Blood, 5.0 mL Adult/ 2.0 ml Children

Comment: Dry swabs, samples in EIA and Gen-Probe transport media are unacceptable. Reference: No CPE detected at 14 days Comment: Viral transport medium is available from NPHL. Transport: Refrigerated Specimen must be shipped via NPHL ground courier or Federal Express. Call NPHL at 402.559.2440 or 866.290.1406 for pick up.

74

West Nile IgG/IgM Ab Screen, Serum for Paired CSF IgM Only Comment: This serum test is only available with a paired CSF specimen. The Nebraska State Department of Epidemiology will not pay

for WNV serum only screening. Sites submitting specimens for testing must be approved by the Epidemiology Program at the Department of Health and Human Services Regulation and Licensure.


accompany this specimen. Syn: West Nile Virus IgG/IgM, Serum Lab: Microbiology/Virology Method: ELISA Availability: Testing is performed on Thursday, results reported next day.

Additional testing days available in peak season.

Specimen: Serum Collect: 6.0 mL SST/ red/black clot tube Volume: 2.0 mL serum or 0.5 ml minimum Comment: If transport of sample to the lab is not the same day as collected, aliquot the serum.

To aliquot: Centrifuge the sample and pour off the serum into a clean tube. Transport: Refrigerate specimen.

If transport delayed > 2 weeks, freeze specimen. Reference: IgG IgM

Negative: <1.30 Index Negative: <0.9 Index Equivocal: ≥1.30-<1.5 Index Equivocal: ≥0.9 - ≤ 1.1 Index Positive: ≥1.5->15.0 Index Positive: > 1.1 – >15.0 Index

LIS code: WNAB Comment: Testing is available only by IgG/IgM panel and only with a paired CSF.

75





Phone: (402) 559-2440 Toll Free: 866-290-1406

Fax: (402) 559-9497

July 2006 2006 NHHSS/NPHL West Nile Virus Testing Guidelines

The Nebraska Health and Human Services System is covering the costs for certain West Nile Virus specimens collected June 1 through October 31, 2006. The costs for the following tests are covered by Nebraska Health and Human Services System:

1. All West Nile Virus CSF IgM testing OR

2. West Nile Virus CSF Serum IgM and IgG testing if accompanied by a CSF sample for IgM. **Serum submitted without a CSF sample will not be paid for by NHHSS.

TEST: West Nile Antibody IgM (Cerebral Spinal Fluid) Method: ELISA Availability: Testing is performed on Thursday, results reported next day. Specimen: CSF Collect: 1.5 mL CSF in a sterile tube. Volume: 1.5 mL (1.2 mL minimum) Transport: Refrigerated. If assay not performed within 48 hours of collection, freeze and ship frozen

on dry ice. Reference Range: CSF: IgM Negative: <0.90 IV* Equivocal: >0.90 to <1.10 IV Positive: >1.10 IV * IV = Index Value TEST: West Nile Antibody IgG, IgM (Serum) Method: ELISA Availability: Testing is performed on Thursday, results reported next day. Specimen: Blood Collect: 6.0 mL SST tube (Gold). Volume: Centrifuge the sample and transfer 2.0 mL serum (1.0 mL minimum) of serum into a clean transport tube. Transport: Refrigerated. Comment: If assay not performed within 48 hours of collection, freeze and transport sample frozen on dry Ice. Reference Range: Serum IgG Negative: <1.30 IV* Equivocal: >1.30 IV to <1.50 IV Positive: >1.50 IV

Serum IgM Negative: <0.90 IV Equivocal: >0.90 IV to <1.10 IV Positive: >1.10 IV

* IV = Index Value Please see the following HAN message sent 7-3-06 for more information. Also included is a NPHL Special Microbiology Requisition that should be used when submitting specimens. Please call NPHL Client Services (toll free, 866-290-1406) if you have any questions.

76

Nebraska Health and Human Services System P.O. Box 95007 Lincoln, NE 68509-5007

Epidemiology Reports are available on the Nebraska HHS Website at: http://www.hhs.state.ne.us/epi/epiindex.htm

TO: Nebraska Healthcare Providers

FROM: Thomas J. Safranek, M.D., State Epidemiologist, 402-471-2937 DATE: July 3, 2006 RE: Human Surveillance for West Nile Virus, Nebraska, 2006 Arthropod-borne virus (“arbovirus”) season is upon us. The most important arbovirus infection in Nebraska is West Nile virus. Between 2002 and 2005, public health officials received annual WNV reports on 174, 2177, 54, and 188 patients, respectively. Health care providers can expect to see this disease in Nebraska residents this summer, and should consider this diagnosis in patients with symptoms consistent with WNV infection. For about 80% of humans infected with WNV, the condition is asymptomatic. For the 20% of WNV-infected persons who develop symptomatic illness, the vast majority develop WNV fever. Less than 1% develop encephalitis, meningitis, and other less common clinical syndromes. The spectrum of WNV illness includes: WNV Fever: A syndrome which may persist for several weeks manifesting as a febrile illness of sudden onset, often accompanied by skin rash, fatigue, malaise, anorexia, nausea, vomiting, eye pain, headache, and myalgia. Meningitis/encephalitis: Neurologically invasive WNV is clinically comparable to other viral meningitis/encephalitis and manifests as meningeal inflammation (headache plus nuchal rigidity, photo/phonophobia, and pleocytosis). Encephalitis manifests with objective neurologic deficits, ranging from focal neurologic signs (e.g., cranial nerve abnormalities, abnormal reflexes) to more global neurologic dysfunction (e.g., disorientation, confusion, coma, etc). Other: Additional clinical scenarios associated with WNV include acute flaccid paralysis, severe muscle weakness, and Guillain-Barre syndrome. There are several experimental treatment regimens that should be considered for persons with severe and progressive WNV infection. Contact my office for information

77

regarding treatment options for such patients. In addition, researchers at the University of Nebraska Medical Center are enrolling persons with WNV infection in a genetic study designed to identify cause of variation in severity of illness following WNV infection. Nebraska residents are invited to participate in this study. Human Surveillance and Testing We estimate that the background seropositivity for WNV in Nebraskans from exposure during the past four summers may range as high as 10%, depending on the region of the state. The majority of these infections were asymptomatic, and are likely to remain seropositive by IgG antibody test. Physicians who order and interpret WNV tests should follow these guidelines:

1) Order serum IgM AND IgG antibodies. If WNV meningitis or encephalitis is suspected, in addition to serum antibodies, order a spinal fluid IgM antibody. Costs for WNV testing in persons with suspected neuroinvasive disease will be covered by Nebraska Health & Human Services, provided the specimens are collected between June 1-October 31, 2006 and tested through the NE Public Health Laboratory using an NPHL requisition (http://www.hhss.ne.gov/wnv)

2) Because serum IgM antibody can persist for up to 16 months in some patients, when a patient tests positive for both IgM and IgG antibodies, a “convalescent” serum (collected at least 14 days following the initial specimen) should be obtained. A stable antibody titer on acute and convalescent specimens is suggestive of infection in the distant past. Rising IgM and IgG titers between the acute and the convalescent specimens are consistent with acute infection.

3) Serum which tests positive for IgM and negative for IgG is consistent with acute WNV infection. CSF which tests positive for IgM is consistent with acute meningitis/encephalitis. A positive IgG and a negative IgM antibody test is consistent with infection in the distant past.

4) Because the serology test for WNV is non-specific and can cross-react with other Flavivirus infections, the Nebraska Public Health Laboratory will send positive WNV specimens obtained early in the season to the CDC for confirmatory testing (microsphere-based immunoassay or plaque-reduction neutralization test). If WNV infection becomes more widespread, as was the case in 2003, the MAC-ELISA serology would suffice to make the diagnosis.

Please report any positive WNV tests results to your local health department as shown on the attached map. Contact NHHSS for additional assistance at fax number 402-471-3601 or by phone 402-471-0935. Additional information on WNV can be found in the following references: 1) http://www.cdc.gov/ncidod/EID/vol11no08/05-0289b.htm2) http://www.cdc.gov/ncidod/dvbid/westnile/index.htm

78

http://www.cdc.gov/ncidod/EID/vol11no08/05-0289b.htm

http://www.cdc.gov/ncidod/dvbid/westnile/index.htm

Panhandle Public Health Department

308-487-3600North Central District

Health Department402-336-2406

Loup Basin Public Health Department

308-346-5795

Southwest Nebraska Public Health Department

308-345-4223

Public Health

Solutions402-826-3880

West Central District Health Department

308-696-1201

Two Rivers Public Health Department

308-995-4778

Four Corners Health Department402-362-2621

Southeast District Health Department

402-274-3993

East Central District Health Department402-563-9224

South Heartland District Health

Department402-462-6211

Central District Health Department

308-385-5175

Northeast Nebraska Public Health Department402-375-2200

Elkhorn Logan Valley Public Health Department

402-529-2233

Three Rivers Public Health Department

402-727-5396

Scotts Bluff County Health


Lincoln-Lancaster County Health


Sarpy Cass Department of

Health & Wellness402-339-4334

Douglas County Health Department

402-444-7214

Dakota County Health Department402-987-2164

Cherry

Custer

Sioux

Lincoln

Sheridan

Keith

Dawes

HallBuffalo York

Frontier

OtoeDawson

Cheyenne

Hayes

Polk

Furnas

Saline

Harlan Thayer

Phelps

Howard

Fillmore

Hitchcock Jefferson

Sherman

Red Willow

Hamilton

Holt

MorrillGarden

Rock

GageDundy

Chase

Grant

Clay

Cedar

PlatteArthur

Burt

Perkins

Blaine Loup

Box Butte

Cass

Boone

Butler

Hooker

Valley

Pierce

Logan

Thomas

Lancaster

Dixon

Dodge

Saunders

McPherson

Deuel

Cuming

Seward

Greeley

Garfield

Nance

MadisonWheeler

Nuckolls

Merrick

Colfax

Gosper

Scotts Bluff

Wayne

Kearney

Stanton

Thurston

Douglas

Dakota

Washington

Knox

Brown

Kimball

Boyd

Banner

Antelope

Adams

Franklin

Keya Paha

Webster Pawnee Richardson

NemahaJohnson

Sarpy

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NEBRASKA PUBLIC HEALTH LABORATORY UNIVERSITY OF NEBRASKA MEDICAL CENTER

BOX 981180 600 SOUTH 42ND STREET OMAHA NEBRASKA 68198-1180 PHONE: (402) 559-2440 FAX: (402) 559-9497

SPECIAL MICROBIOLOGY REQUISITION

PATIENT LAST NAME FIRST NAME MI | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

DATE OF BIRTH AGE SEX

SUBMITTED BY: / / M / F ADDRESS APT

|_ | | | | | | | | | | | | | | | | | | | CITY STATE ZIP | | | | | | | | | | | | | | | | | | | COUNTY CODE STATE CODE SURVEILLANCE SITE | | | | | | | | | | | | | | |

Name : ________________________ Address: _____________________ _____________________ Phone: (____)____-________ Fax: (____)____-________ UPIN No.: ____________

PHYSICIAN’S NAME PHONE # | | | | | | | | | | | | | | | | | | |

COLLECTION DATE COLLECTION TIME / / AM / PM

ID / CHART NUMBER (NUMBER WILL APPEAR ON REPORT) Test approved by: Dennis Leschinsky Thomas Safranek (EPI) v. 2006

| | | | | | | | | | | | | | | | | | | Clinical Diagnosis:____________________________________________________________________ ICD 9 Code:_______________________________ Race ___White ___Black ___Native American Ethnicity ____Hispanic ___Non-Hispanic

___Asian/Pacific Islander ___Unknown ___Other______________ ____Unknown

Source:_____Bronchial Aspirate _____CSF _____Genital _____Nasopharyngeal _____Sputum _____Stool _____Throat _____Urine _____Blood _____Other ____________________________________________

Bacteriology ____Enteric Pathogen Culture ____Escherichea coli O157:H7 Culture ____Bordetella pertussis Culture ____Bordetella pertussis DFA ____Corynebacterium diphtheria Culture ____Group A Streptococcus Culture

____Legionella Culture ____Legionella DFA ____Clostridium difficile Toxin

Mycobacteriology____AFB Culture and Smear, Initial ____AFB Culture and Smear, Follow-up ____AFB Susceptibility Testing

Mycology ____Fungus Culture ___Cryptococcus Antigen

Virology _____West Nile Virus IgG/IgM Capture ELISA (serum) _____West Nile Virus IgM Capture ELISA (CSF)

Serum must be accompanied by CSF to be run at public health expense.

Parasitology Recent Travel: ____No _____Yes, specify _______________________________________________________

____Ova and Parasites ____Giardia _____Tick Identification _____Worm Identification _____Other:________________

Source: _____Bronchial Aspirate _____CSF _____Genital _____Nasopharyngeal _____Sputum _____Stool _____Throat _____Urine _____Blood _____Other__________________________________________

Date of Isolation:_________________________________________ Recovery medium:________________________________________ Transport medium:___________________________________________ Preliminary Identification (Gram stain, morphology, biochemical tests performed):

____Confirmation / Identification ____Escherichia coli O157:H7 ____Salmonella species ____Shigella species ____Campylobacter species ____Haemophilus ____Neisseria species ____Mycobacterium species ____Other___________________________

____ Antibiotic Resistance Confirmation _____MRSA _____VRE _____ESBL _____Other_________________________ ____ Serotyping/Serogrouping _____Salmonella species _____ Shigella species _____H. influenzae _____ N. meningitidis

____ Organism Banking Organism identified as:____________________________ OR

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West Nile IgM Antibody Screen, CSF Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Syn: West Nile Virus IgM, CSF Lab: Microbiology/Virology Method: ELISA Availability: Testing is performed on Thursday, results reported next day.

Additional testing days available in peak season.

Specimen: CSF Collect: CSF in sterile container. Volume: 0.5 mL CSF, minimum Transport: Refrigerate specimen.

If transport delayed > 2 weeks, freeze specimen. Reference: IgM

Negative: <0.9 Index Equivocal: ≥0.9 - ≤ 1.1 Index Positive: > 1.1 – >15.0 Index

Comment: Testing is available through the state for IgM only on CSF. LIS code: WNIGMC

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Yersinia Culture Comment: Sites submitting specimens for testing must be approved by the



accompany this specimen. Synonym: Yersinia culture LIS Code: YERCU Method: Standard reference procedures for Yersinia culture and identification. Availability: Daily; Final negative report at 2 days. Specimen: Stool Volume: 1.0-5.0 mL fresh stool; 10.0 mL in Cary-Blair media. Comment: Indicate suspected organisms and available patient history, especially any

recent travels, on the test request form. Notification of positive results is provided.

Reference: Negative for Yersinia Comment: Unacceptable conditions: Nonsterile or leaking container, multiple

specimens (> one in 24 hours), dry specimens or delayed transport to lab in inappropriate preservative. Diapers are not acceptable.

Update: 06/03

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Documents

Test Directory Table of Contents - NPHL · Test Directory Table of Contents These documents fall outside of the Nebraska Public Health Laboratory document control system; subsequent