USAFSAM Epidemiology Laboratory Service

USAFSAMEpidemiology

Laboratory Service

Distribution Statement A: Approved for Public release; distribution is unlimited. 311 ABG/PA No. 10-084, 12 Mar 2010

Team Aerospace Begins Here!

Microbiology• Virology• Bacteriology• Parasitology

Immunodiagnostics• HIV, Hepatitis• Infectious Disease Serology

Molecular DiagnosticsLIS

• CST (Customer Service Team)• LIS (Lab Information Systems)• COPS (Central Operations)

Programs• Influenza Surveillance• USAF HIV Testing/Repository• USAF Recruit Health Testing• Clinical Infections Disease Testing

• LRN Reference Lab

DoD’s only Clinical Reference Laboratory

220+ DoD Customers

2.0+ Million Tests per Year

USAFSAM “EPI Lab”


Laboratory Information Systems

Customer Service Team (CST)

Lab Information Systems (LIS)

Central Operations (COPS)

Personnel = 3 CST, 3 LIS, 20 COPS

Handle customer/specimen problems

Customer newsletters

Customer satisfaction surveys

Generate customer feedback reports

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Team Aerospace Begins Here! 4


Central Operations

Boxes arrive in lab Boxes opened, specimens sorted

Information verifiedAccessioned into CHCSSpecimens delivered to sections


Receive ~ 5000 specimens/ 8 hr day (~2.0 million/year)

Could easily ramp up to ~ 3x that volume by adding shifts

Boxes usually arrive at ~ 0800

Delivered to testing sections in batches every half hour

Central Operations


EpiLab Web site

https://kx.afms.mil/epi/

Shipping Instructions

Shipping Material Ordering Information

Lab Guide

Import certificate

CLIP and CAP certificates

List of tests

Training videos


EpiLab Web site


BIOPLEX 2200

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Immunodiagnostics

Tests Performed:

ANA – Positive Screen Reflexes to SSA, SSB, Sm, RNP, dsDNA, and Centromere

Syphilis – Reactives Sent to IFA Section for Confirmation by VDRL and FTA-ABS

EBV IgG, IgM, EBNA IgG - No Reflex or Confirmation Testing Performed

NEW: HSV-1 & HSV-2 IgG (Moved to Bioplex on 22 Dec 2009)


EIAHelicobacter pylori IgG –Discontinue serum test replacing with stool test 1April 10

Cytomegalovirus (CMV) IgG, IgM

Lyme Disease (Borrelia burgdorferi)

Mumps IgG

Measles (Rubeola) IgG

Varicella IgG DSX instrumentManual tests include:

Cardiolipin IgG, IgM – Discontinued test 1 Oct 09

Coccidioides Immunodiffusion Test


IFA & MANUAL

Autoantibody Profile (AMA, ASMA, APCA)

Mycoplasma pneumoniae IgM

Cytomegalovirus (CMV) IgM

Lyme Disease (Borrelia burgdorferi) IgG, IgM Western Blot

Rickettsia IgM

Q Fever (Coxiella burnetti) IgG, IgM

VDRL Slide Test

FTA-ABS Double Stain (performed on non-reactive VDRL’s)

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HIV

Tests Performed:

HIV 1/2/O

HIV Type 1 Western Blot (manual)

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Siemens Centaur XP


Total HIV ScreensJAN 35999FEB 31858

MAR 34502APR 35803MAY 32275JUN 33686JUL 33842

AUG 29410SEP 32169OCT 31004NOV 25054DEC 30004

TOTALS385606

Positive Screens

580Screen

Positivity Rate0.15%

Positive Western Blots

131WB Positivity

Rate0.03%

Western Blot Average Percentage RateNegative 70.2%

Indeterminate 7.2%Positive 14.7%

Prev/Conf 7.9%


Hepatitis Testing

Tests Performed:

Hep A Virus AB IgM (HAV-M)

Hep A Virus AB Total (HAV-T)

Hep B Total Core AB (HBcAb-T)

Hep B Core AB IgM (HBcAb-IgM)

Hep C (HCV) AB

Hep B Surface AG (HBsAg)

AB to Hep B Surface AG(HBsAb)

Hepatitis B Envelope Ab, Ag (manual test)

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Siemens ADVIA

Centaur


Immunodiagostics

Additional tests performed on the Centaur:

Rubella IgG, IgM

Toxoplasma IgG, IgM

Thyroid Panel

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Changes in Immunodiagnostics

Tests moving to Bioplex 2200 pending FDA approval:

Mumps IgG

Measles (Rubeola) IgG

Varicella IgG

Cytomegalovirus (CMV) IgG, IgM

Rubella IgG, IgM

Toxoplasma IgG, IgM

Lyme Disease (Borrelia burgdorferi)

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TAT-HIV

Days


TAT-Hepatitis

0

0.5

1

1.5

2

2.5

3

Jan Feb Mar Apr May Jun July Aug Sept Oct Nov DEC

CY08 CY09

Days


TAT-EIA

Days


Parasitology

Manual testing

Specimen = Stool

Ova & Parasites• Trichrome Stains• Concentrations• Turn-around- time – 9 hours

Worm Identification• Turn-around-time < 24 hours

Trichuris trichiura ova

Schistosoma haematobium ova


Parasitology

Enzyme immunoassay (EIA) for:• Giardia Specific Antigen• Crytosporidium Specific Antigen• Turn around time – 9 hours

Acid Fast Stain for:• Cyclospora species• Isospora species• Turn around time – 9 hours

Pinworm Identification• Turn around time – 9 hours

Giardia lamblia (trophozoite)

Enterobius vermicularis (ova)

E. vermicularis (adult worm)


Virology

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Herpes Simplex Virus testing - ELVIS

Enzyme Linked Virus Inducible System A culture-based test for HSV only

ELVIS results in ~ 17 hrs


Virology

Routine clinical specimens for viral detection

Tissue culture and fluorescent antibody stains

TAT = 2-14 days

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Influenza virus AInfluenza virus BAdenovirusParainfluenza virus 1-3Respiratory Syncytial VirusEnterovirus

TAT = 2-10 days

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Detection in tissue culture

Confirming by FA stain

Positive influenza isolates sent to Molecular Diagnostics for sequencing

Respiratory Viral Cultures


The “Swine Flu” Team to the Rescue

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Chlamydia/GC Testing

Nucleic Acid Amplification Testing (NAAT)

Three TIGRIS walk away instruments

(Gen-Probe, Inc.)

~18,000 month (36,000 reportable results)

All positives confirmed by a supplemental test that detects a different target

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Days

TAT – GC/Chlamydia


Molecular DiagnosticsMolecular Diagnostics

Nasal wash specimens preferred:

Allows for concurrent molecular and culture analysis

Allows for enough leftover specimen for archiving - additional testing may be requested by the CDC

Also, original specimens may be requested by the CDC for use as potential seed virus for influenza vaccine production


Automated: easyMAG

Off board lysis (safer)

Excellent in side by side comparisons with other automated extractors (especially with stool)

Manual: RNA Ambion

Nucleic Acid Extraction Nucleic Acid Extraction


Target Detection Target Detection

Real time RT PCR

- 7500 DX (New Norovirus)

Traditional RT PCR

- 9700 (for Sequencing)

Multiplex PCR (xTag RVP)

- Luminex (not currently utilized)


Strain AnalysisStrain Analysis

Sanger Sequencing

Pyrosequencing


Influenza Surge Testing


Currently, limited bacteriology service

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Helicobacter pylori stool antigen test

Bacteriology


H. pylori: Introduction

Isolated by Warren and Marshall from gastric biopsies in 1983

Gram-negative organism, produces urease

Prevalence varies depending on age, socioeconomic class, issues related to sanitation and hygiene, and country of origin

Causes 75% to 80% of peptic ulcer disease

Approximately 20% of people under 40 and 50% of people over 60 are infected


H. pyloriDisease Overview

DISEASE CONTRIBUTORY ROLE FOR H. PYLORI?

EFFECT OF H. PYLORI ERADICATION

Peptic ulcer disease Yes Reduces ulcer recurrence rate

Gastric adenocarcinoma Yes Uncertain

MALT lymphoma Yes Partial or complete remission in more than half of patients

Uninvestigated dyspepsia Yes, in some patients Symptom improvement in some

Iron-deficiency anemia Likely May lead to anemia resolution when H. pylori is the cause

Idiopathic thrombocytopenic purpura Yes, in some patients Platelet count improves after eradication

Nonulcer dyspepsia Controversial Little effect, if any

NSAID-induced ulcer Controversial; perhaps only in naïve NSAID users

May reduce ulcer incidence in Asian naïve NSAID users

GERD Unlikely, at least for most patients; H. pylori may protect against GERD

Uncertain

Pancreatic cancer Uncertain Unknown

Coronary artery disease Unlikely Probably none


* Assuming a 20% H. pylori prevalence

ACG Guidelines

The AGA released new guidelines for managing dyspepsia in 2005… and the American College of Gastroenterology revised their guidelines in 2007.

In 2007, the American College of Gastroenterology revised their guidelines to include:

"Patients 55 years of age or younger without alarm features should receive H. pylori test and treatment followed by acid suppression if symptoms remain. H. pylori testing is optimally performed by a stool antigen test or 13C urea breath test."

The test and treatment strategy for H. pylori infection is a proven management strategy for patients with uninvestigated dyspepsia who are under the age of 55 yr and have no "alarm features“.


Both AGA and ACG now recommend that serology testing no longer be performed to test for H. pylori because it only tests for the antibody and does not test for “active” infection

The AGA and ACG guidelines do recommend using Stool Antigen Test or Urea Breath Test for the detection of H. pylori

50% of patients that have a positive serology test do not have “active” infection (false positive for active infection)

ACG Guidelines


Why Not Serology?

Serology does not test for “active” infection - tests for antibody not antigenA patient with a false positive serology test or with positive serology but an inactive infection can lead to:

• Unnecessary treatment (and expense)• Increased antibiotic resistance• Increased incidence of side effects from

treatment• Increased patient anxiety over implications of

a positive test


H. pylori Antigen Test

Freeze unpreserved stool specimens immediately store upon receipt at -20 C and ⁰ship frozen

Minimum volume: 5gms/5mL

Order in CHCS - Helicobacter pylori Ag

Validation contact – Ms. Annette Compton (DSN 240- 6622)

Turnaround time – 24 hours


BRAC

Seamless transition to customers

Relocation of Immunodiagnostics first

Phase 1 – ADVON team (June & Oct 2010)

Phase 2 – December 2010

Phase 3 – January 2011

Complete relocation: May-Sep 2011


BRAC

Upfront plans completed prior to relocation

Interop CHCS test files

Contracts – Equipment (new and reagent rental, Personnel, Supplies)

Accreditations (CAP, CDC, etc.)

OIs/SOPs, Policies, Procedures


BRAC

Lab – Open construction of entire lab space

Design facilitates movement of specimens

Lab work areas are moveable for mission flexibility


USAFSAM EPI Lab


Questions?

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United States School of Aerospace MedicineEpidemiology Laboratory Service(USAFSAM/PHE)2730 Louis Bauer DriveBrooks City-Base, TX 78235-5132

EPI Lab Customer Service TeamDSN: 240-8378Commercial: 210.536.8378Email: [email protected]: https://kx.afms.mil/epi/

Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 09-062, 12 Feb 2009

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USAFSAM Epidemiology Laboratory Service